Self-Trephination in Cranial Excoriation Disorder.

BACKGROUND AND IMPORTANCE: Trephination is a procedure in which a small hole is made in the skull. Rare cases of self-trephination by individuals seeking medical benefit have been reported. Excoriation disorder is a compulsive skin-picking condition in which an individual self-inflicts cutaneous lesions. Left untreated, severe excoriation disorder can pose significant health risks. CLINICAL PRESENTATION: Here, we describe 5 patients who presented with self-trephination due to a severe form of compulsive cranial excoriation at 2 neighboring academic medical centers over a 4-year period. We review the clinical presentation of self-trephination in cranial excoriation disorder and associated risk factors, surgical and nonsurgical interventions, complications of the disease, treatments, and mortality. Defining clinical characteristics include repetitive self-induced destruction of the scalp and skull with entry into the intracranial compartment, frequent psychiatric comorbidities, infection or injury of the brain with consequent neurological morbidity or mortality, and frequent treatment failures because of poor adherence. CONCLUSION: Self-trephination in cranial excoriation disorder is a severe neuropsychological disorder and neurosurgical emergency that exposes the brain and is often life-threatening. Appropriate therapy requires antibiotics, surgical debridement and repair of the wound, and concomitant effective psychiatric management of the underlying compulsion, including the use of antidepressants and behavioral therapy.

High-resolution detection of copy number alterations in single cells with HiScanner.

Improvements in single-cell whole-genome sequencing (scWGS) assays have enabled detailed characterization of somatic copy number alterations (CNAs) at the single-cell level. Yet, current computational methods are mostly designed for detecting chromosome-scale changes in cancer samples with low sequencing coverage. Here, we introduce HiScanner (High-resolution Single-Cell Allelic copy Number callER), which combines read depth, B-allele frequency, and haplotype phasing to identify CNAs with high resolution. In simulated data, HiScanner consistently outperforms state-of-the-art methods across various CNA types and sizes. When applied to high-coverage scWGS data from human brain cells, HiScanner shows a superior ability to detect smaller CNAs, uncovering distinct CNA patterns between neurons and oligodendrocytes. For 179 cells we sequenced from longitudinal meningioma samples, integration of CNAs with point mutations revealed evolutionary trajectories of tumor cells. These findings show that HiScanner enables accurate characterization of frequency, clonality, and distribution of CNAs at the single-cell level in both non-neoplastic and neoplastic cells.

Evaluating mortality and 6-month functional outcomes of patients with dural venous sinus thrombosis in traumatic brain injury.

OBJECTIVE: Patients with dural venous sinus thrombosis (DVST) in select populations following traumatic brain injury (TBI), including those with blunt mechanism or depressed skull fractures, have been shown to have an increased risk of mortality. The purpose of this study was to assess these findings in a mixed population of head trauma patients. METHODS: The authors performed a case-control study using propensity score matching by reviewing 17 years (2004-2021) of data from their institutional trauma registry. Patients with imaging-confirmed DVST were matched to a control group of TBI patients without identified DVST based on age, sex, postresuscitation Glasgow Coma Scale (GCS) score, and Injury Severity Score. All age groups and injury mechanisms were included with a head Abbreviated Injury Scale score ≥ 3. Data on demographics, injury and radiographic characteristics, and patient outcomes were collected. Multivariable logistic regression was performed to identify predictors of inpatient mortality. An additional subgroup analysis of patients with concurrent DVST and blunt cerebrovascular injury (BCVI) was planned a priori. RESULTS: The authors identified 9875 patients who presented to their institution over the study period with TBIs, with a 1.64% incidence of DVST. Concurrent BCVI was diagnosed in 23.5% of patients with a DVST. Following matching, the presence of DVST itself was not significantly associated with inpatient mortality (OR 0.68, 95% CI 0.24-1.88). On regression analysis, penetrating injuries (8.19, 95% CI 1.21-80.0) and lower postresuscitation GCS scores (0.69, 95% CI 0.53-0.84) were independently associated with inpatient mortality for patients with traumatic DVST. Significantly worse functional outcomes were observed in those with DVST at 3 months, with no significant difference at 6 months. CONCLUSIONS: The authors observed a prevalence of traumatic DVST of 1.64% in a mixed population of head-injured patients, with 23.5% of patients with DVST having concurrent BCVI. Traumatic DVST alone was not associated with a significantly increased risk of inpatient mortality.

A Systematic Review and Meta-Analysis of 3-Dimensional Morphometric Parameters for Cerebral Aneurysms.

BACKGROUND: Imaging modalities with increased spatial resolution have allowed for more precise quantification of cerebral aneurysm shape in 3-dimensional (3D) space. We conducted a systematic review and meta-analysis to assess the correlation of individual 3D morphometric measures with cerebral aneurysm rupture status. METHODS: Two independent reviewers performed a PRISMA (preferred reporting items of systematic reviews and meta-analysis)-guided literature search to identify articles reporting the association between 3D morphometric measures of intracranial aneurysms and rupture status. RESULTS: A total of 15,122 articles were identified. After screening, 39 studies were included. We identified 17 3D morphometric measures, with 11 eligible for the meta-analysis. The meta-analysis showed a significant association with rupture status for the following measures: nonsphericity index (standardized mean difference [SMD], 0.66; 95% confidence interval [CI], 0.53-0.79; P < 0.0001; I2 = 55.2%), undulation index (SMD, 0.55; 95% CI, 0.26-0.85; P = 0.0017; I2 = 68.1%), ellipticity index (SMD, 0.53; 95% CI, 0.29-0.77; P = 0.0005; I2 = 70.8%), volume (SMD, 0.18; 95% CI, 0.02-0.35; P = 0.0320; I2 = 82.3%), volume/ostium ratio (SMD, 0.43; 95% CI, 0.16-0.71; P = 0.0075; I2 = 90.4%), elongation (SMD, -0.94; 95% CI, -1.12 to -0.76; P = 0.0005; I2 = 0%), flatness (SMD, -0.87; 95% CI, -1.04 to -0.71; P = 0.0005; I2 = 0%), and sphericity (SMD, -0.62; 95% CI, -1.06 to -0.17; P = 0.0215; I2 = 67.9%). A significant risk of publication bias was estimated for the ellipticity index (P = 0.0360) and volume (P = 0.0030). CONCLUSIONS: Based on the results of a meta-analysis containing 39 studies, the nonsphericity index, undulation index, elongation, flatness, and sphericity demonstrated the most consistent correlation with rupture status.

A role for mutations in AK9 and other genes affecting ependymal cells in idiopathic normal pressure hydrocephalus.

Idiopathic normal pressure hydrocephalus (iNPH) is an enigmatic neurological disorder that develops after age 60 and is characterized by gait difficulty, dementia, and incontinence. Recently, we reported that heterozygous CWH43 deletions may cause iNPH. Here, we identify mutations affecting nine additional genes (AK9, RXFP2, PRKD1, HAVCR1, OTOG, MYO7A, NOTCH1, SPG11, and MYH13) that are statistically enriched among iNPH patients. The encoded proteins are all highly expressed in choroid plexus and ependymal cells, and most have been associated with cilia. Damaging mutations in AK9, which encodes an adenylate kinase, were detected in 9.6% of iNPH patients. Mice homozygous for an iNPH-associated AK9 mutation displayed normal cilia structure and number, but decreased cilia motility and beat frequency, communicating hydrocephalus, and balance impairment. AK9+/- mice displayed normal brain development and behavior until early adulthood, but subsequently developed communicating hydrocephalus. Together, our findings suggest that heterozygous mutations that impair ventricular epithelial function may contribute to iNPH.

Post-traumatic Middle Meningeal Artery Pseudoaneurysm Treated With Endovascular Coil Embolization.

Pseudoaneurysms of the middle meningeal artery are rare events following head trauma. Given the potential for significant morbidity and mortality associated with pseudoaneurysm rupture, it is recommended that they be treated early. Endovascular embolization is a viable alternative to open surgical intervention. Here, we describe a case of an incidentally found middle meningeal artery pseudoaneurysm in a patient with a carotid-cavernous fistula after head injury. The pseudoaneurysm was treated with endovascular coil embolization.

Preincisional Localization: An Overlooked Contribution by Ralph Bingham Cloward.

Preincisional localization has become ubiquitous within spinal neurosurgery and has served as the foundation for modern minimally invasive surgery techniques. Dr. Ralph Bingham Cloward, renowned for his contributions to the field of spinal fusion, was a strong advocate and early adopter of diskography. In fact, Cloward credited cervical diskography for inspiring his anterior approach to the cervical disk. In his landmark 1958 article on what is now known as anterior cervical diskectomy and fusion, Cloward commented on a case of wrong-level surgery that motivated him to implement a standardized technique for spinal level localization with the patient under anesthesia in the operating room before skin incision. We trace the origins of the use of preincisional radiographs to localize the pathologic level at the time of diskectomy and highlight this original contribution by Cloward.

Heterozygous FOXJ1 Mutations Cause Incomplete Ependymal Cell Differentiation and Communicating Hydrocephalus.

Heterozygous mutations affecting FOXJ1, a transcription factor governing multiciliated cell development, have been associated with obstructive hydrocephalus in humans. However, factors that disrupt multiciliated ependymal cell function often cause communicating hydrocephalus, raising questions about whether FOXJ1 mutations cause hydrocephalus primarily by blocking cerebrospinal fluid (CSF) flow or by different mechanisms. Here, we show that heterozygous FOXJ1 mutations are also associated with communicating hydrocephalus in humans and cause communicating hydrocephalus in mice. Disruption of one Foxj1 allele in mice leads to incomplete ependymal cell differentiation and communicating hydrocephalus. Mature ependymal cell number and motile cilia number are decreased, and 12% of motile cilia display abnormal axonemes. We observed decreased microtubule attachment to basal bodies, random localization and orientation of basal body patches, loss of planar cell polarity, and a disruption of unidirectional CSF flow. Thus, heterozygous FOXJ1 mutations impair ventricular multiciliated cell differentiation, thereby causing communicating hydrocephalus. CSF flow obstruction may develop secondarily in some patients harboring FOXJ1 mutations. Heterozygous FOXJ1 mutations impair motile cilia structure and basal body alignment, thereby disrupting CSF flow dynamics and causing communicating hydrocephalus.

Peritrigeminal Safe Entry Zone Access to Anterolateral Pons Using the Presigmoid Retrolabyrinthine Suprameatal Approach: A Cadaveric Morphometric Study.

BACKGROUND AND OBJECTIVES: Access to the anterolateral pontine lesions can be achieved through the peritrigeminal and supratrigeminal safe entry zones using Kawase, retrosigmoid, or translabyrinthine approaches. However, these approaches entail shallow extensive dissection, tangential access, and compromise vestibulocochlear function. We aimed to investigate infratentorial presigmoid retrolabyrinthine approach to access pontine lesions through the peritrigeminal zone. METHODS: We performed 10 presigmoid retrolabyrinthine suprameatal approach dissections in 5 cadaveric heads. Anatomic-radiological characteristics and variations were evaluated. Six morphometric parameters were measured and analyzed to predict surgical accessibility. RESULTS: The pontine infratrigeminal area was accessible in all patients. The mean exposed area of the anterolateral pontine surface was 98.95 cm 2 (±38.11 cm 2 ). The mean length of the exposed trigeminal nerve was 7.9 cm (±2.9 cm). Preoperative anatomic-radiological parameters may allow to select patients with favorable anatomy that offers appropriate surgical accessibility to the anterior pontine cavernoma through a presigmoid retrolabyrinthine corridor. CONCLUSION: Anterolateral pontine lesions can be accessed through a minimally invasive infratentorial presigmoid retrolabyrinthine approach by targeting the infratrigeminal safe entry zone. Further clinical studies should be conducted to evaluate the viability of this technique for treating these complex pathologies in real clinical settings.

The effects of aneurysmal subarachnoid hemorrhage on cerebral vessel diameter and flow velocity.

BACKGROUND: Transcranial Doppler flow velocity is used to monitor for cerebral vasospasm following aneurysmal subarachnoid hemorrhage. Generally, blood flow velocities appear inversely related to the square of vessel diameter representing local fluid dynamics. However, studies of flow velocity-diameter relationships are few, and may identify vessels for which diameter changes are better correlated with Doppler velocity. We therefore studied a large retrospective cohort with concurrent transcranial Doppler velocities and angiographic vessel diameters. METHODS: This is a single-site, retrospective, cohort study of adult patients with aneurysmal subarachnoid hemorrhage, approved by the UT Southwestern Medical Center Institutional Review Board. Study inclusion required transcranial Doppler measurements within 1.1, R2>0.9). Furthermore, velocity and diameter changed (P<0.033) consistent with the signature time course of cerebral vasospasm. CONCLUSIONS: These results suggest that middle cerebral artery velocity-diameter relationships are most influenced by local fluid dynamics, which supports these vessels as preferred endpoints in Doppler detection of cerebral vasospasm. Other vessels showed less influence of local fluid dynamics, pointing to greater role of factors outside the local vessel segment in determining flow velocity.

Complex Morphologic Analysis of Cerebral Aneurysms Through the Novel Use of Fractal Dimension as a Predictor of Rupture Status: A Proof of Concept Study.

BACKGROUND: Aneurysm morphology has been correlated with rupture. Previous reports identified several morphologic indices that predict rupture status, but they measure only specific qualities of the morphology of an aneurysm in a semiquantitative fashion. Fractal analysis is a geometric technique whereby the overall complexity of a shape is quantified through the calculation of a fractal dimension (FD). By progressively altering the scale of measurement of a shape and determining the number of segments required to incorporate the entire shape, a noninteger value for the dimension of the shape is derived. We present a proof-of-concept study to calculate the FD of an aneurysm for a small cohort of patients with aneurysms in 2 specific locations to determine whether FD is associated with aneurysm rupture status. METHODS: Twenty-nine aneurysms of the posterior communicating and middle cerebral arteries were segmented from computed tomography angiograms in 29 patients. FD was calculated using a standard box-counting algorithm extended for use with three-dimensional shapes. Nonsphericity index and undulation index (UI) were used to validate the data against previously reported parameters associated with rupture status. RESULTS: Nineteen ruptured and 10 unruptured aneurysms were analyzed. Through logistic regression analysis, lower FD was found to be significantly associated with rupture status (P = 0.035; odds ratio, 0.64; 95% confidence interval, 0.42-0.97 per FD increment of 0.05). CONCLUSIONS: In this proof-of-concept study, we present a novel approach to quantify the geometric complexity of intracranial aneurysms through FD. These data suggest an association between FD and patient-specific aneurysm rupture status.

A proposed classification system for presigmoid approaches: a scoping review.

OBJECTIVE: The "presigmoid corridor" covers a spectrum of approaches using the petrous temporal bone either as a target in treating intracanalicular lesions or as a route to access the internal auditory canal (IAC), jugular foramen, or brainstem. Complex presigmoid approaches have been continuously developed and refined over the years, leading to great heterogeneity in their definitions and descriptions. Owing to the common use of the presigmoid corridor in lateral skull base surgery, a simple anatomy-based and self-explanatory classification is needed to delineate the operative perspective of the different variants of the presigmoid route. Herein, the authors conducted a scoping review of the literature with the aim of proposing a classification system for presigmoid approaches. METHODS: The PubMed, EMBASE, Scopus, and Web of Science databases were searched from inception to December 9, 2022, following the PRISMA Extension for Scoping Reviews guidelines to include clinical studies reporting the use of "stand-alone" presigmoid approaches. Findings were summarized based on the anatomical corridor, trajectory, and target lesions to classify the different variants of the presigmoid approach. RESULTS: Ninety-nine clinical studies were included for analysis, and the most common target lesions were vestibular schwannomas (60/99, 60.6%) and petroclival meningiomas (12/99, 12.1%). All approaches had a common entry pathway (i.e., mastoidectomy) but were differentiated into two main categories based on their relationship to the labyrinth: translabyrinthine or anterior corridor (80/99, 80.8%) and retrolabyrinthine or posterior corridor (20/99, 20.2%). The anterior corridor comprised 5 variations based on the extent of bone resection: 1) partial translabyrinthine (5/99, 5.1%), 2) transcrusal (2/99, 2.0%), 3) translabyrinthine proper (61/99, 61.6%), 4) transotic (5/99, 5.1%), and 5) transcochlear (17/99, 17.2%). The posterior corridor consisted of 4 variations based on the target area and trajectory in relation to the IAC: 6) retrolabyrinthine inframeatal (6/99, 6.1%), 7) retrolabyrinthine transmeatal (19/99, 19.2%), 8) retrolabyrinthine suprameatal (1/99, 1.0%), and 9) retrolabyrinthine trans-Trautman's triangle (2/99, 2.0%). CONCLUSIONS: Presigmoid approaches are becoming increasingly complex with the expansion of minimally invasive techniques. Descriptions of these approaches using the existing nomenclature can be imprecise or confusing. Therefore, the authors propose a comprehensive classification based on the operative anatomy that unequivocally describes presigmoid approaches simply, precisely, and efficiently.

External Validation of an Extreme Gradient Boosting Model for Prediction of Delayed Cerebral Ischemia After Aneurysmal Subarachnoid Hemorrhage.

BACKGROUND: Delayed cerebral ischemia (DCI) may significantly worsen the functional status of patients with aneurysmal subarachnoid hemorrhage (aSAH). Several authors have designed predictive models for early identification of patients at risk of post-aSAH DCI. In this study, we externally validate an extreme gradient boosting (EGB) forecasting model for post-aSAH DCI prediction. METHODS: A 9-year institutional retrospective review of patients with aSAH was performed. Patients were included if they underwent surgical or endovascular treatment and had available follow-up data. DCI was diagnosed as new-onset neurologic deficits at 4-12 days after aneurysm rupture, defined as worsening Glasgow Coma Scale score for ≥2 points, and new ischemic infarcts at imaging. RESULTS: We collected 267 patients with aSAH. At admission, median Hunt-Hess score was 2 (range, 1-5), median Fisher score 3 (range, 1-4), and median modified Fisher score 3 (range, 1-4). One-hundred and forty-five patients underwent external ventricular drainage placement for hydrocephalus (54.3%). The ruptured aneurysms were treated with clipping (64%), coiling (34.8%), and stent-assisted coiling (1.1%). Fifty-eight patients (21.7%) were diagnosed with clinical DCI and 82 (30.7%) with asymptomatic imaging vasospasm. The EGB classifier correctly predicted 19 cases of DCI (7.1%) and 154 cases of no-DCI (57.7%), achieving sensitivity of 32.76% and specificity of 73.68%. The calculated F1 score and accuracy were 0.288% and 64.8%, respectively. CONCLUSIONS: We validated that the EGB model is a potential assistant tool to predict post-aSAH DCI in clinical practice, finding moderate-high specificity but low sensitivity. Future research should investigate the underlying pathophysiology of DCI to allow the development of high-performing forecasting models.

Environmental DNA as an emerging tool in botanical research.

Over the past quarter century, environmental DNA (eDNA) has been ascendant as a tool to detect, measure, and monitor biodiversity (species and communities), as a means of elucidating biological interaction networks, and as a window into understanding past patterns of biodiversity. However, only recently has the potential of eDNA been realized in the botanical world. Here we synthesize the state of eDNA applications in botanical systems with emphases on aquatic, ancient, contemporary sediment, and airborne systems, and focusing on both single-species approaches and multispecies community metabarcoding. Further, we describe how abiotic and biotic factors, taxonomic resolution, primer choice, spatiotemporal scales, and relative abundance influence the utilization and interpretation of airborne eDNA results. Lastly, we explore several areas and opportunities for further development of eDNA tools for plants, advancing our knowledge and understanding of the efficacy, utility, and cost-effectiveness, and ultimately facilitating increased adoption of eDNA analyses in botanical systems.

The history of antibiotic irrigation and prophylaxis in operative neurotrauma: perpetuation of military care in civilian settings.

The benefit of antibiotic irrigation for prophylaxis against wound infections, not only for traumatic cranial injuries but also in elective neurosurgical care, has recently been called into question. Several articles have cast doubt on the utility of topical antibiotics, and recently, bacitracin irrigation was made unavailable in some US markets. The pervasive nature of antibiotic irrigation, considering the lack of evidence supporting its use, led the authors to question when and how neurosurgeons started using antibiotic irrigation in cranial neurosurgery. Through a review of historical literature, they highlight the adoption of antibiotic irrigation as it began in battlefield surgical practice, gradually leading to the modern concept of antibiotic prophylaxis in civilian and military care.

The Effects of the COVID-19 Pandemic on Penetrating Neurotrauma at a Level 1 Trauma Center.

BACKGROUND/OBJECTIVE: The COVID-19 pandemic has had a profound impact on the global delivery of health care. Recent data suggest a possible impact of the pandemic on patterns of neurotrauma. The aim was to assess the impact of the pandemic on the incidence of neurotrauma, with a focus on cranial gunshot wounds (cGSWs) at a large Midwestern level 1 trauma center. METHODS: We conducted a retrospective review of our trauma registry from March through September 2020 and compared it to the same months in 2019. Odds ratios were utilized to assess for differences in patient demographics, injury characteristics, rates of neurotrauma, and rates of cGSWs. RESULTS: A total of 1188 patients presented with neurotrauma, 558 in 2019 and 630 in 2020. The majority of patients were male (71.33% in 2019; 68.57% in 2020) and Caucasian (78.67% in 2019; 75.4% in 2020). Patients presented with cGSWs more frequently in 2020 (n = 49, 7.78%) than in 2019 (n = 25, 4.48%). The odds of suffering a cGSW in 2020 was 73.6% higher than those in 2019 (95% confidence interval = [1.0871, 2.7722]; P = 0.0209). The etiology of such injury was most commonly assault (n = 16, 21.62% in 2019; n = 34, 45.95% in 2020), followed by self-inflicted injury (n = 4, 5.41% in 2019; 12, 16.22% in 2020). CONCLUSIONS: Despite the government-mandated shutdown, we observed an increase in the number of neurotrauma cases in 2020. There was a significant increase in the incidence cGSWs in 2020, with an increase in assaults and self-inflicted injuries. Further investigation into socioeconomic factors for the observed increase in cGSWs is warranted.

An independent, external validation and component analysis of the Surviving Penetrating Injury to the Brain score for civilian cranial gunshot injuries.

OBJECTIVE: The Surviving Penetrating Injury to the Brain (SPIN) score utilizes clinical variables to estimate in-hospital and 6-month mortality for patients with civilian cranial gunshot wounds (cGSWs) and demonstrated good discrimination (area under the receiver operating characteristic curve [AUC] 0.880) in an initial validation study. The goal of this study was to provide an external, independent validation of the SPIN score for in-hospital and 6-month mortality. METHODS: To accomplish this, the authors retrospectively reviewed 6 years of data from their institutional trauma registry. Variables used to determine SPIN score were collected, including sex, transfer status, injury motive, pupillary reactivity, motor component of the Glasgow Coma Scale (mGCS), Injury Severity Score (ISS), and international normalized ratio (INR) at admission. Multivariable logistic regression analysis identified variables associated with mortality. The authors compared AUC between models by using a nonparametric test for equality. RESULTS: Of the 108 patients who met the inclusion criteria, 101 had all SPIN score components available. The SPIN model had an AUC of 0.962. The AUC for continuous mGCS score alone (0.932) did not differ significantly from the AUC for the full SPIN model (p = 0.26). The AUC for continuous mGCS score (0.932) was significantly higher compared to categorical mGCS score (0.891, p = 0.005). Use of only mGCS score resulted in fewer exclusions due to missing data. No additional variable included in the predictive model alongside continuous mGCS score was a significant predictor of inpatient mortality, 6-month mortality, or increased model discrimination. CONCLUSIONS: Given these findings, continuous 6-point mGCS score may be sufficient as a generalizable predictor of inpatient and 6-month mortality in patients with cGSW, demonstrating excellent discrimination and reduced bias due to missing data.

A Rational Approach to the Management of Cerebral Arteriovenous Malformations.

OBJECTIVE: Cerebral arteriovenous malformations (AVMs) typify the delicate balance cerebrovascular specialists face in weighing the treatment risk against the natural history of a pathologic lesion. The goal of our review was to provide an overview of the current evidence for the treatment of cerebral AVMs and describe a contemporary approach to developing a treatment strategy according to individual AVM characteristics. METHODS: A review of the contemporary literature on the natural history and treatment of cerebral AVMs was completed through the PubMed and Google Scholar databases. The studies were reviewed for original advances in the characterization and treatment of cerebral AVMs. RESULTS: The overall risk of hemorrhage for cerebral AVMs is 2%-4% per year. Individual AVM characteristics, including small size, exclusive deep venous drainage, deep or posterior fossa location, venous ectasia, and the presence of a flow-associated aneurysm, appear to confer a greater risk of presentation with rupture. A diverse array of modalities have been developed to achieve the goal of complete lesion obliteration, including microsurgery, endovascular therapy, and radiosurgery. Advances in treatment strategies and technology have continued to decrease the morbidity associated with lesion obliteration. CONCLUSIONS: Microsurgical or multimodal treatment strategies are often required to achieve complete obliteration; however, it remains critical that each treatment approach is individualized by the specific AVM characteristics.

Delivering Therapeutics to Glioblastoma: Overcoming Biological Constraints.

Glioblastoma multiforme is the most lethal intrinsic brain tumor. Even with the existing treatment regimen of surgery, radiation, and chemotherapy, the median survival time is only 15-23 months. The invasive nature of this tumor makes its complete removal very difficult, leading to a high recurrence rate of over 90%. Drug delivery to glioblastoma is challenging because of the molecular and cellular heterogeneity of the tumor, its infiltrative nature, and the blood-brain barrier. Understanding the critical characteristics that restrict drug delivery to the tumor is necessary to develop platforms for the enhanced delivery of effective treatments. In this review, we address the impact of tumor invasion, the molecular and cellular heterogeneity of the tumor, and the blood-brain barrier on the delivery and distribution of drugs using potential therapeutic delivery options such as convection-enhanced delivery, controlled release systems, nanomaterial systems, peptide-based systems, and focused ultrasound.

Bacterial translocation as a cause of ventriculoperitoneal shunt infection: A case report.

Bacterial translocation as a mechanism of distal catheter infection may play a larger role in ventriculoperitoneal shunt infections than previously recognized.