Coexistent Vestibular Schwannoma and Creutzfeldt-Jakob Disease: Recognition and Infection Control.

OBJECTIVES: We describe the first known case of coexistent vestibular schwannoma (VS) and Creutzfeldt-Jakob disease (CJD). Our objectives are to use this case as a general lesson for the subspecialist otolaryngologist to remain vigilant to alternative diagnoses, and to specifically improve understanding of the diagnosis and management of CJD as relevant to the practice of otolaryngology and skull base surgery. METHODS: Retrospective case review performed in June 2016 at an academic, tertiary, referral center. RESULTS: A 55-year-old man presents with one month of worsening disequilibrium and short-term memory loss. Magnetic resonance imaging (MRI) (T1, T2) identified a 4 mm left VS which was then surgically resected. Postoperatively, his neurological status decline continued, and subsequent MRI identified patterns of FLAIR hyperintensity and diffusion restriction consistent with CJD. While CSF analysis (tau and 14-3-3) and EEG was inconclusive, serial imaging and the clinical course were highly suggestive of CJD. A probable diagnosis was made, surgical instruments quarantined, and infection control involved to minimize transmission risk. The patient died 6 months after symptom onset. CONCLUSIONS: Patients with CJD may initially present with otolaryngologic symptoms. MRI signal abnormality in the basal ganglia on diffusion weighted imaging and FLAIR sequences in conjunction with physical findings and clinical course may help make a probable diagnosis CJD. Prions are resistant to traditional sterilization and additional measures must be taken to prevent iatrogenic transmission. LEVEL OF EVIDENCE: Level 4-Case series.

Validation of the unruptured intracranial aneurysm treatment score: comparison with real-world cerebrovascular practice.

OBJECTIVE The purpose of this study was to compare the unruptured intracranial aneurysm treatment score (UIATS) recommendations with the real-world experience in a quaternary academic medical center with a high volume of patients with unruptured intracranial aneurysms (UIAs). METHODS All patients with UIAs evaluated during a 3-year period were included. All factors included in the UIATS were abstracted, and patients were scored using the UIATS. Patients were categorized in a contingency table assessing UIATS recommendation versus real-world treatment decision. The authors calculated the percentage of misclassification, sensitivity, specificity, and area under the receiver operating characteristic (ROC) curve. RESULTS A total of 221 consecutive patients with UIAs met the inclusion criteria: 69 (31%) patients underwent treatment and 152 (69%) did not. Fifty-nine (27%) patients had a UIATS between -2 and 2, which does not offer a treatment recommendation, leaving 162 (73%) patients with a UIATS treatment recommendation. The UIATS was significantly associated with treatment (p < 0.001); however, the sensitivity, specificity, and percentage of misclassification were 49%, 80%, and 28%, respectively. Notably, 51% of patients for whom treatment would be recommended by the UIATS did not undergo treatment in the real-world cohort and 20% of patients for whom conservative management would be recommended by UIATS had intervention. The area under the ROC curve was 0.646. CONCLUSIONS Compared with the authors' experience, the UIATS recommended overtreatment of UIAs. Although the UIATS could be used as a screening tool, individualized treatment recommendations based on consultation with a cerebrovascular specialist are necessary. Further validation with longitudinal data on rupture rates of UIAs is needed before widespread use.

What Is the Safety and Efficacy of Chemical Venous Thromboembolism Prophylaxis Following Vestibular Schwannoma Surgery?

OBJECTIVE: The benefit of routine chemical prophylaxis use for venous thromboembolism (VTE) prevention in skull base surgery is controversial. Chemical prophylaxis can prevent undue morbidity and mortality, however there are risks for hemorrhagic complications. STUDY DESIGN: Retrospective case-control. METHODS: A retrospective chart review of patients who underwent surgery for vestibular schwannoma from 2011 to 2016 was performed. Patients were divided by receipt of chemical VTE prophylaxis. Number of VTEs and hemorrhagic complications (intracranial hemorrhage, abdominal hematoma, and postauricular hematoma) were recorded. RESULTS: One hundred twenty-six patients were identified, 55 received chemical prophylaxis, and 71 did not. All the patients received mechanical prophylaxis. Two patients developed a deep vein thrombosis (DVT) and one patient developed a pulmonary embolism (PE). All patients who developed a DVT or PE received chemical prophylaxis. There was no difference in DVT (p = 0.1886) or PE (p = 0.4365) between those who received chemical prophylaxis and those who did not. Five patients developed a hemorrhagic complication, two intracranial hemorrhage, three abdominal hematoma, and zero postauricular hematoma. All five patients with a complication received chemical prophylaxis (p = 0.00142). The relative risk of a hemorrhagic complication was 14.14 (95% CI = 0.7987-250.4307; p = 0.0778). CONCLUSION: There was a significant difference between the number of hemorrhagic complications but not between numbers of DVT or PE. Mechanical and chemical prophylaxis may lower the risk of VTE but in our series, hemorrhagic complications were observed. These measures should be used selectively in conjunction with early ambulation.

The Use of Semitranslucent Rubber Pledgets During Microsurgical Dissection of Cerebellopontine Angle Tumors: Technical Note.

BACKGROUND AND IMPORTANCE: Dissection of cerebellopontine angle (CPA) tumors that abut or adhere to the brainstem or cranial nerves can be a challenging surgical endeavor. We describe the use of semitranslucent latex rubber pledgets in the tumor-brain interface as a method to improve visualization and protection of vital tissue during microsurgical dissection of CPA masses. The rubber pledgets are fashioned by cutting circular discs out of the cuff portion of talc-free, partially opaque latex gloves. These pledgets provide a semitranslucent, nonadherent membrane that can be placed between vital neural tissues and a tumor capsule to minimize trauma during dissection. The semitranslucent latex enables visualization of the underlying anatomical structures while also providing a protective surface onto which a suction device can be rested to facilitate clearance of the surgical field. CLINICAL PRESENTATION: A 56-yr-old woman with left ear tinnitus presented with a 3-cm CPA meningioma. During microsurgical dissection, rubber pledgets were used to preserve the interface between the brain stem, cranial nerves, and tumor capsule. The use of the rubber pledgets appeared to secure the interface between to tumor and the brain while at the same time protecting the cranial nerves, brainstem, and cerebellum. CONCLUSION: Semitranslucent rubber pledgets may facilitate microsurgical dissection of CPA tumors.

Computer-aided design/computer-aided manufacturing skull base drill.

The authors have developed a simple device for computer-aided design/computer-aided manufacturing (CAD-CAM) that uses an image-guided system to define a cutting tool path that is shared with a surgical machining system for drilling bone. Information from 2D images (obtained via CT and MRI) is transmitted to a processor that produces a 3D image. The processor generates code defining an optimized cutting tool path, which is sent to a surgical machining system that can drill the desired portion of bone. This tool has applications for bone removal in both cranial and spine neurosurgical approaches. Such applications have the potential to reduce surgical time and associated complications such as infection or blood loss. The device enables rapid removal of bone within 1 mm of vital structures. The validity of such a machining tool is exemplified in the rapid (< 3 minutes machining time) and accurate removal of bone for transtemporal (for example, translabyrinthine) approaches.

Factors influencing management of unruptured intracranial aneurysms: an analysis of 424 consecutive patients.

OBJECTIVE The choice between treating and observing unruptured intracranial aneurysms is often difficult, with little guidance on which variables should influence decision making on a patient-by-patient basis. Here, the authors compared demographic variables, aneurysm-related variables, and comorbidities in patients who received microsurgical or endovascular treatment and those who were conservatively managed to determine which factors push the surgeon toward recommending treatment. METHODS A retrospective chart review was conducted of all patients diagnosed with an unruptured intracranial aneurysm at their institution between January 1, 2013, and January 1, 2016. These patients were dichotomized based on whether their aneurysm was treated. Demographic, geographic, socioeconomic, comorbidity, and aneurysm-related information was analyzed to assess which factors were associated with the decision to treat. RESULTS A total of 424 patients were identified, 163 who were treated surgically or endovascularly and 261 who were managed conservatively. In a multivariable model, an age < 65 years (OR 2.913, 95% CI 1.298-6.541, p = 0.010), a lower Charlson Comorbidity Index (OR 1.536, 95% CI 1.274-1.855, p < 0.001), a larger aneurysm size (OR 1.176, 95% CI 1.100-1.257, p < 0.001), multiple aneurysms (OR 2.093, 95% CI 1.121-3.907, p = 0.020), a white race (OR 2.288, 95% CI 1.245-4.204, p = 0.008), and living further from the medical center (OR 2.125, 95% CI 1.281-3.522, p = 0.003) were all associated with the decision to treat rather than observe. CONCLUSIONS Whereas several factors were expected to be considered in the decision to treat unruptured intracranial aneurysms, including age, Charlson Comorbidity Index, aneurysm size, and multiple aneurysms, other factors such as race and proximity to the medical center were unanticipated. Further studies are needed to identify such biases in patient treatment and improve treatment delineation based on patient-specific aneurysm rupture risk.

C2-C3 Anterior Cervical Fusion: Technical Report.

STUDY DESIGN: Retrospective review of patients at a university hospital. OBJECTIVE: To describe the anterior approach for cervical discectomy and fusion (ACDF) at C2-C3 level and evaluate its suitability for treatment of instability and degenerative disease in this region. SUMMARY OF BACKGROUND DATA: The anterior approach is commonly used for ACDF in the lower cervical spine but is used less often in the high cervical spine. METHODS: We retrospectively reviewed a database of consecutive cervical spine surgeries performed at our institution to identify patients who underwent ACDF at the C2-C3 level during a 10-year period. Demographic data, clinical indications, surgical technique, complications, and immediate results were evaluated. RESULTS: Of the 11 patients (7 female, 4 male; mean age 46 y) identified, 7 were treated for traumatic fractures and 4 for degenerative disk disease. Three patients treated for myelopathy showed improvement in mean Nurick grade from 3.6 to 1.3. Pain was significantly improved in all patients who had preoperative pain. Solid bony fusion was achieved in 5 of 7 patients at 3-month follow-up. Complications included dysphagia in 4 patients (which resolved in 3), aspiration pneumonia, mild persistent dysphonia, and construct failure at C2 requiring posterior fusion. One patient died of a pulmonary embolism 2 weeks postoperatively. CONCLUSIONS: ACDF at the C2-C3 level is an option for the treatment of high cervical disease or trauma but is associated with a higher rate of approach-related morbidity. Familiarity with local anatomy may help to reduce complications. ACDF at C2-C3 appears to have a fusion rate similar to ACDF performed at other levels.

Rerupture of a Blister Aneurysm After Treatment With a Single Flow-Diverting Stent.

BACKGROUND AND IMPORTANCE: As the use of flow-diverting stents (FDSs) for intracranial aneurysms expands, a small number of case reports have described the successful treatment of blister aneurysms of the internal carotid artery with flow diversion. Blister aneurysms are uncommon and fragile lesions that historically have high rates of morbidity and mortality despite multiple treatment strategies. We report a case of rebleeding after treatment of a ruptured blister aneurysm with deployment of a single FDS. CLINICAL PRESENTATION: A 29-year-old man presented with subarachnoid hemorrhage and a ruptured dorsal variant internal carotid artery aneurysm. Despite a technically successful treatment with a single FDS, a second catastrophic hemorrhage occurred during the course of his hospitalization. CONCLUSION: This case highlights the risk of hemorrhage during the period after deployment of a single FDS. Ruptured aneurysms, especially of the blister type, are at risk for rehemorrhage while the occlusion remains incomplete after flow diversion. ABBREVIATIONS: FDS, flow-diverting stentICA, internal carotid arterySAH, subarachnoid hemorrhage.

Executive Summary: 2016 Infectious Diseases Society of America (IDSA) Clinical Practice Guideline for the Treatment of Coccidioidomycosis.

It is important to realize that guidelines cannot always account for individual variation among patients. They are not intended to supplant physician judgment with respect to particular patients or special clinical situations. Infectious Diseases Society of America considers adherence to these guidelines to be voluntary, with the ultimate determination regarding their application to be made by the physician in the light of each patient's individual circumstances.Coccidioidomycosis, also known as San Joaquin Valley fever, is a systemic infection endemic to parts of the southwestern United States and elsewhere in the Western Hemisphere. Residence in and recent travel to these areas are critical elements for the accurate recognition of patients who develop this infection. In this practice guideline, we have organized our recommendations to address actionable questions concerning the entire spectrum of clinical syndromes. These can range from initial pulmonary infection, which eventually resolves whether or not antifungal therapy is administered, to a variety of pulmonary and extrapulmonary complications. Additional recommendations address management of coccidioidomycosis occurring for special at-risk populations. Finally, preemptive management strategies are outlined in certain at-risk populations and after unintentional laboratory exposure.

Surgical Treatment of Vestibular Schwannoma: Does Age Matter?

OBJECTIVE: For older patients (>65 years) who undergo surgical treatment of vestibular schwannoma (VS), the reported rates of facial nerve preservation, hearing preservation, and complications are inconsistent. Many surgeons believe that older patients have worse outcomes than their younger counterparts and advise against surgical treatment. We analyzed a consecutive series of patients with VS treated with surgery to determine whether age was a factor in outcome. METHODS: We retrospectively reviewed all patients treated for VS at our institution from January 1, 2000, to July 1, 2012. We examined how sex, age (≥65 years and <65 years), race, tumor size, tumor laterality, body mass index, Charlson Comorbidity Index, smoking status, surgical approach, and preoperative hearing and symptoms were associated with outcomes. RESULTS: Two-hundred forty-three patients underwent resection of VS, including 23 patients ≥65 years (mean 68 ± 4 years) and 220 patients <65 years (mean 47 ± 11 years). The average tumor size was 16.5 mm. Older patients had a significantly lower body mass index of 26.6 vs. 29.8 (P = 0.03) and were more likely to have a CCI ≥2 (52.2% vs. 18.2%, P ≤ 0.00, preoperative facial numbness (34.8% vs. 10.1%, P = 0.03), and dizziness (78.3% vs. 49.3%, P = 0.03). There were no significant differences after surgery in facial nerve outcome, hearing preservation outcome, or general surgical complications between the 2 cohorts. CONCLUSIONS: With no difference in surgical complications, facial nerve outcome, or hearing preservation rates between older and younger patients in our series, age alone may not be an absolute contraindication to surgical management of VS.

2016 Infectious Diseases Society of America (IDSA) Clinical Practice Guideline for the Treatment of Coccidioidomycosis.

It is important to realize that guidelines cannot always account for individual variation among patients. They are not intended to supplant physician judgment with respect to particular patients or special clinical situations. Infectious Diseases Society of America considers adherence to these guidelines to be voluntary, with the ultimate determination regarding their application to be made by the physician in the light of each patient's individual circumstances.Coccidioidomycosis, also known as San Joaquin Valley fever, is a systemic infection endemic to parts of the southwestern United States and elsewhere in the Western Hemisphere. Residence in and recent travel to these areas are critical elements for the accurate recognition of patients who develop this infection. In this practice guideline, we have organized our recommendations to address actionable questions concerning the entire spectrum of clinical syndromes. These can range from initial pulmonary infection, which eventually resolves whether or not antifungal therapy is administered, to a variety of pulmonary and extrapulmonary complications. Additional recommendations address management of coccidioidomycosis occurring for special at-risk populations. Finally, preemptive management strategies are outlined in certain at-risk populations and after unintentional laboratory exposure.

Direct C2 Pedicle Screw Fixation for Axis Body Fracture.

BACKGROUND: Acute complex C2 vertebral body fracture specifically does not involve the odontoid process or C2 pars interarticularis. External stabilization can be effective but may prolong healing and increase morbidity. Many traditional surgical techniques can achieve internal stabilization at the expense of normal cervical motion. We describe direct surgical C2 pedicle screw fixation as an option for managing acute complex C2 vertebral body fracture. CASE DESCRIPTION: Three patients were treated with direct pedicle screw fixation of acute traumatic complex C2 vertebral body fractures. All fractures were coronally oriented Benzel type 1. None of the patients sustained neurological injury. Stereotactic navigation with intraoperative computed tomography scanning was used for each procedure. Surgery provided immediate internal orthosis and stability, as judged by intraoperative dynamic fluoroscopy. Rigid cervical collar bracing was used for 1 month after surgery when the patients were out of bed. Initial radiographs showed acceptable screw placement and fracture alignment. Dynamic radiographs at 3 months showed structural stability at the fracture site and adjacent levels, and complete bony union was confirmed with late computed tomography scanning (>1 year) in each case. Each patient reported resolution of trauma-related and postsurgical pain at 30-day follow-up. Postoperative Neck Disability Index questionnaires for each patient suggested no significant disability at 1 year. CONCLUSIONS: Direct pedicle screw fixation of acute complex C2 vertebral body fracture appeared to be safe and effective in our 3 patients. It may provide a more-efficient and less-morbid treatment than halo brace or cervical collar immobilization in some patients.

Middle Fossa Approach for Vestibular Schwannoma: Good Hearing and Facial Nerve Outcomes with Low Morbidity.

OBJECTIVE: The middle fossa approach (MFA) is not used as frequently as the traditional translabyrinthine and retrosigmoid approaches for accessing vestibular schwannomas (VSs). Here, MFA was used to remove primarily intracanalicular tumors in patients in whom hearing preservation is a goal of surgery. METHODS: A retrospective chart review was performed to identify consecutive adult patients who underwent MFA for VS. Demographic profile, perioperative complications, pre- and postoperative hearing, and facial nerve outcomes were analyzed with linear regression analysis to identify factors predicting hearing outcome. RESULTS: Among 78 identified patients (mean age, 49 years; 53% female; mean tumor size, 7.5 mm), 78% had functional hearing preoperatively (American Academy of Otolaryngology-Head and Neck Surgery class A/B). Follow-up audiologic data were available for 60 patients overall (mean follow-up, 15.1 months). The hearing preservation rate was 75.5% (37/49) at last known follow-up for patients with functional hearing preoperatively. Other than preoperative hearing status (P < 0.001), none of the factors assessed, including demographic profile, size of tumor, and fundal fluid cap, predicted hearing preservation (P > 0.05). Good functional preservation of the facial nerve (House-Brackmann class I/II) was achieved in 90% of patients. The only operative complications were 3 wound infections (3.8%). CONCLUSIONS: Preliminary results from this single-center retrospective study of patients undergoing MFA for resection of VS showed that good hearing preservation and facial nerve outcomes could be achieved with few complications. These results suggest that resection via the MFA is a rational alternative to watchful waiting or stereotactic radiosurgery.

Bedside Treatment of Chronic Subdural Hematoma: Using Radiographic Characteristics to Revisit the Twist Drill.

BACKGROUND AND STUDY AIMS: Conventional treatment strategies for the management of symptomatic chronic subdural hematoma (cSDH) in the elderly include observation, operative burr holes or craniotomy, and bedside twist drill drainage. The decision on which technique to use should be determined by weighing the comorbidities and symptoms of the patient with the potential risks and benefits. The goal of this study was to identify radiographic characteristics on computed tomography scan that might be used to guide surgical decision making in terms of operative versus bedside removal of cSDH. METHODS: We retrospectively reviewed clinical and radiographic features in patients who underwent bedside twist drill evacuation of a cSDH and those for a cohort of patients who underwent operative intervention via burr holes. RESULTS: We did not identify any clinical features or preoperative imaging characteristics to suggest an advantage of one procedure over the other. Additionally, complete radiographic resolution of cSDH on postoperative imaging is not required to relieve patient symptoms. CONCLUSION: Although bedside twist drill evacuation may avoid operating room costs and anesthetic complications in an elderly patient population and allow earlier resumption of anticoagulation treatment if necessary, there is also a risk of morbidity if uncontrolled bleeding is encountered or the patient is unable to tolerate the bedside procedure. However, bedside twist drill craniostomy is a reasonable and effective option for the treatment of subacute/chronic SDH in patients who may not be optimal surgical candidates.

Epidemiology of Traumatic Brain Injury After Small-Wheeled Vehicle Trauma in Utah.

BACKGROUND: Recreational use of small-wheeled vehicles (SWVs), which include skateboards, longboards, nonmotorized scooters, ice skates, and roller skates or rollerblades, results in numerous injuries in the United States. OBJECTIVE: To describe the nature and severity of traumatic brain injuries (TBIs) that result from the use of SWVs in Utah. METHODS: Patients who were admitted to any Utah hospital after a SWV-related injury from 2001 through 2010 were identified from the Utah State Trauma Registry. Patients who sustained TBI were identified by International Classification of Diseases, Ninth Revision, codes. RESULTS: Of 907 patients admitted with SWV injury, 392 (43%) had a TBI (85% male). Their mean age was 19.8 ± 0.5 years, including 234 (60%) aged ≤18 and 119 (30%) aged 19 to 29. Most patients sustained TBI while using a skate- or longboard (87%). Mean Glasgow Coma Scale score in the emergency department was 12.8 ± 0.2. Thirty-nine percent were admitted to an intensive care unit, and 6% (23) underwent emergent neurosurgical intervention. Thirty-three (8.4%) patients had a concussion; the rest had nonoperative intracranial hemorrhage. Among patients for whom helmet use data were available, 8 out of 291 (2.7%) patients with TBI were wearing a helmet, whereas 24 out of 190 (12.6%) non-TBI patients were wearing helmets (P < .001). Overall mortality was higher in TBI patients than in non-TBI patients (2.3% vs 0.2%, P = .003). CONCLUSION: Young people, especially males, who ride SWVs in Utah are at risk for serious TBI, admission to the intensive care unit, neurosurgical intervention, and death. Helmet use in these patients is likely rare, but may reduce the risk of TBI and death. ABBREVIATIONS: ED, emergency departmentSWV, small-wheeled vehicleTBI, traumatic brain injury.

Comparison of ferromagnetic induction and bipolar electrosurgery and suction in corticotomies in pig cerebrum.

INTRODUCTION: The effects of newer energy-based surgical dissection and coagulation modalities on cerebral tissue have not been investigated. Several instruments have been developed to address the limitations of traditional electrosurgical instruments in the nervous system. We compared the effects of standard bipolar electrocautery and suction (BPS) with those of a new ferromagnetic induction (FMI) device in corticotomies of pig cerebral tissue as assessed by magnetic resonance imaging (MRI) and histological analysis. METHODS: Three adult pigs underwent bilateral corticotomies (3 cm long×1 cm deep) using both FMI and BPS. The acute cerebral tissue edema created by each method was measured on coronal volumetric T2-weighted MRI sequences immediately after surgery. A lateral thermal "damage index" was calculated by dividing the width of the visible T2 tissue edema by the measured depth. The radiographic damage indices with each method were compared statistically. Histological analysis of each incision was conducted to compare the extent of tissue damage. RESULTS: MRI showed that the mean radiographic damage index of each corticotomy was significantly lower with the FMI (0.30 ± 0.02 (0.28-0.32)) than with the BPS method (0.54 ± 0.11 (0.42-0.64)) (p = 0.02). Histological analysis suggested a correlation with the radiographic findings as the FMI tissue samples demonstrated less adjacent tissue damage than BPS. CONCLUSIONS: FMI appeared to cause less adjacent tissue damage than the BPS method in pig cerebral tissue based on quantitative radiographic and qualitative histological analysis. Future studies are needed to investigate the clinical implications of energy-based surgical dissection on cerebral tissue.

Comparison of tissue effects in rabbit muscle of surgical dissection devices.

While some energy-based surgical dissection and coagulation modalities may offer excellent cutting and coagulation abilities, the impact on healing may differ among devices. We compared the tissue effects of three of these modalities with those of the standard surgical scalpel in rabbit muscle at 24 h and 14 days after surgery by evaluating radiographic and histological data. Linear incisions were made with each device in the dorsal lumbar musculature of rabbits using monopolar electrocautery in cut mode (MPE-Cut) and coagulation mode (MPE-Coag), a ferromagnetic induction loop (FMI), and a traditional scalpel. Magnetic resonance imaging scans and histological sampling were done at 24 h and 14 days. Subjective cutting and coagulation characteristics for each device were also recorded during surgery. The scalpel and FMI appeared to cause the least tissue damage adjacent to the incisions in rabbit dorsal lumbar musculature. The scalpel showed the best healing, while the FMI and MPE-Cut demonstrated good healing. The MPE-Coag showed the worst tissue healing. The scalpel, FMI, and MPE-Cut all exhibited favorable subjective characteristics during surgery. It appears that the FMI may be a better choice for surgical dissection and coagulation in muscle tissue than the MPE coagulation mode because it shows less tissue damage and offers better tissue healing.