Cervical Spine Research Society-Cervical Stiffness Disability Index (CSRS-CSDI): Validation of a Novel Scoring System Quantifying the Effect of Postarthrodesis Cervical Stiffness on Patient Quality of Life.

STUDY DESIGN: Cross-sectional study. OBJECTIVE: The aim was to create and validate a novel patient-reported outcome measure (PROM) focusing on stiffness-related patient functional limitations after cervical spine fusion. SUMMARY OF BACKGROUND DATA: Cervical arthrodesis is a common treatment for myelopathy/radiculopathy, however, results in increased neck stiffness as a collateral outcome. No current PROM exists quantifying the impact of postoperative stiffness on patient function. METHODS: The Cervical Spine Research Society-Cervical Stiffness Disability Index (CSRS-CSDI) was created through a modified Delphi process. The resultant 10-item questionnaire yields a score out of 100 with higher scores indicating increased functional difficulty related to neck stiffness. Cross-sectional study of control and postoperative patients was completed for CSRS-CSDI validation. Retest reliability (intraclass correlation coefficient), internal consistency (Cronbach alpha), responsiveness (levels fused vs. CSRS-CSDI scores), and discriminatory validation (CSRS-CSDI vs. neck disability index) scores) were completed. RESULTS: Fifty-seven surgical and 24 control patients completed the questionnaire. Surgical patients underwent a variety of procedures: 11 (19%) motion preserving operations, nine (16%) subaxial 1-2 level fusions, seven (12%) subaxial 3-5 level fusions, five (9%) C1-subaxial cervical spine fusions, 20 (35%) C2-upper thoracic spine fusions, five (9%) occiput-subaxial or thoracic spine fusions. The questionnaire demonstrated high internal consistency (Cronbach alpha=0.92) and retest reliability (intraclass correlation coefficient=0.95, P <0.001). Good responsiveness validity with a significant difference between fusion cohorts was found ( P <0.001, rs =0.63). Patient CSRS-CSDI scores also correlated with neck disability index scores recorded ( P <0.001, r =0.70). CONCLUSION: This is the first study to create a PROM addressing the functional impact of cervical stiffness following surgical arthrodesis. The CSRS-CSDI was a reliable and valid measure of postoperative stiffness impact on patient function. This may prove useful in counseling patients regarding their expected outcomes with further investigation demonstrating its value in a prospective fashion.

Complications in the Elderly Population Undergoing Spinal Deformity Surgery: A Systematic Review and Meta-Analysis.

STUDY DESIGN: Systematic Review and Meta-Analysis. OBJECTIVES: The elderly have an increased risk of perioperative complications for Adult Spinal Deformity (ASD) corrections. Stratification of these perioperative complications based on risk type and specific risk factors, however, remain unclear. This paper will systematically review perioperative risk factors in the elderly undergoing ASD correction stratified by type: medical, implant-related, proximal junctional kyphosis (PJK), and need for revision surgery. METHODS: A systematic review was performed using the PRISMA guidelines. A query of PubMed was performed to identify publications pertinent to ASD in the elderly. Publications included in this review focused on patients ≥65 years old who underwent operative management for ASD to assess for risk factors of perioperative complications. RESULTS: A total of 734 unique citations were screened resulting in ten included articles for this review. Pooled incidence of perioperative complications included medical complications (21%), implant-related complications (16%), PJK (29%), and revision surgery (13%). Meta-analysis calculated greater preoperative PT (WMD 2.66; 95% Cl .36-4.96; P = .02), greater preoperative SVA (WMD 2.24; 95% Cl .62-3.86; P = .01), and greater postoperative SVA (WMD .97; 95% Cl .03-1.90; P = .04) to significantly correlate with development of PJK with no evidence of publication bias or concerns in study heterogeneity. CONCLUSIONS: There is a paucity of literature describing perioperative complications in the elderly following ASD surgery. Appropriate understanding of modifiable risk factors for the development of medical and implant-related complications, proximal junctional kyphosis, and revision surgeries presents an opportunity to decrease morbidity and improve patient outcomes.

The lexicon of multirod constructs in adult spinal deformity: a concise description of when, why, and how.

The use of multirod constructs in the setting of adult spinal deformity (ASD) began to prevent rod fracture and pseudarthrosis near the site of pedicle subtraction osteotomies (PSOs) and 3-column osteotomies (3COs). However, there has been unclear and inconsistent nomenclature, both clinically and in the literature, for the various techniques of supplemental rod implantation. In this review the authors aim to provide the first succinct lexicon of multirod constructs available for the treatment of ASD, providing a universal nomenclature and definition for each type of supplementary rod. The primary rod of ASD constructs is the longest rod that typically spans from the bottom of the construct to the upper instrumented vertebrae. The secondary rod is shorter than the primary rod, but is connected directly to pedicle screws, albeit fewer of them, and connects to the primary rod via lateral connectors or cross-linkers. Satellite rods are a 4-rod technique in which 2 rods span only the site of a 3CO via pedicle screws at the levels above and below, and are not connected to the primary rod (hence the term "satellite"). Accessory rods are connected to the primary rods via side connectors and buttress the primary rod in areas of high rod strain, such as at a 3CO or the lumbosacral junction. Delta rods span the site of a 3CO, typically a PSO, and are not contoured to the newly restored lordosis of the spine, thus buttressing the primary rod above and below a 3CO. The kickstand rod itself functions as an additional means of restoring coronal balance and is secured to a newly placed iliac screw on the side of truncal shift and connected to the primary rod; distracting against the kickstand then helps to correct the concavity of a coronal curve. The use of multirod constructs has dramatically increased over the last several years in parallel with the increasing prevalence of ASD correction surgery. However, ambiguity persists both clinically and in the literature regarding the nomenclature of each supplemental rod. This nomenclature of supplemental rods should help unify the lexicon of multirod constructs and generalize their usage in a variety of scientific and clinical scenarios.

The Number of Organ System Injuries Is a Predictor of Intrahospital Mortality in Complete Cervical Spinal Cord Injury.

OBJECTIVE: We sought to determine the extent to which polytrauma significantly impacts intrahospital mortality among patients with complete cervical spinal cord injury (cSCI) and to assess whether an organ system-based approach would be appropriate as a mortality predictor as compared with conventional standards to help guide prognosis and management. METHODS: We retrospectively reviewed patient medical records and assessed the type of associated trauma at presentation. We then reviewed its correlation with mortality in patients who were admitted at our institution between 2012 and 2021. Types of associated trauma were classified under the following: traumatic brain injury, abdominal injury, thoracic injury, orthopedic injury, craniofacial injury, genitourinary injury, and vascular injury. RESULTS: Thirty patients with complete cSCIs were identified. Increased organ system-based polytrauma had a statistically significant increase in intrahospital mortality (P = 0.01). Using the logistic regression model, for each additional gain in organ system-based trauma, patients had a 2.455 odds ratio of mortality (P = 0.03, 95% confidence interval 1.171-6.348). Zero other organ system injuries in the setting of cSCI provided a predictive mortality probability of 6.6%. One organ system-based trauma provided a 14.8% intrahospital mortality probability, 2 traumas provided a 29.9% mortality probability, 3 traumas provided a 51.1% mortality probability, and 4 other organ-system traumas provided a 72.0% mortality probability. The predictive prognostic accuracy of using number of organ system-based trauma to predict mortality probability was quantified at area under the curve = 0.8264 (95% confidence interval 0.6729-0.9799, P = 0.01). CONCLUSIONS: Our research shows that an increased number of organ system injuries is associated with greater intrahospital mortality in polytrauma patients with complete cSCI.

The Intradiscal Osteotomy: An Alternative Technique for Adult Spinal Deformity Correction.

Adult spinal deformity (ASD) correction has changed considerably since the initial description of a Smith-Petersen osteotomy (SPO), including pedicle subtraction osteotomies (PSO), and more minimally invasive techniques. Here, we introduce and describe the intradiscal osteotomy (IDO), a novel variation of Schwab type 3 and 4 osteotomies allowing pedicle and vertebral body preservation, and its advantages and disadvantages. After pedicle screw placement, the posterior elements (except pedicles) are removed from the appropriate vertebrae, including the superior/inferior articulating processes, laminae, and spinous processes. An osteotome is used to remove the posterior aspect of the superior and inferior endplate, followed by the entire disc, creating more working room for eventual cage insertion. After the careful release of the annulus, an intradiscal distractor is used to distract the endplates and allow interbody cage insertion as anteriorly as possible. Pedicle and vertebral body preservation allow increased fixation and endplate cage support, which lengthens the anterior column and acts as a fulcrum when compressing posteriorly to restore lordosis. By allowing for anterior and posterior column release, the IDO technique provides a feasible, all-posterior approach for the correction of fixed or flexible kyphoscoliotic curves. This technical report introduces and describes the IDO as an alternative method for thoracic and/or lumbar ASD correction. More studies are required to fully elucidate its outcome vs. complication profile compared to other deformity correction techniques.

The Central Cord Score: A Novel Classification and Scoring System Specific to Acute Traumatic Central Cord Syndrome.

BACKGROUND: Acute traumatic central cord syndrome (ATCCS) is the most common form of spinal cord injury in the United States. Treatment remains controversial, which is a consequence of ATCCS having an inherently different natural history from conventional spinal cord injury, thus requiring a separate classification system. We devised a novel Central Cord Score (CCscore), which both guides treatment and tracks improvement over time with symptoms specific to ATCCS. METHODS: Medical records of patients with a diagnosis of ATCCS were retrospectively reviewed at a single institution. The CCscore was devised based on signs, symptoms, and imaging findings we believed to be critical in assessing severity of ATCCS. Numeric values were assigned for distal upper extremity motor strength, upper extremity sensation, ambulatory status, magnetic resonance imaging cord signal, and urinary retention. RESULTS: We identified 51 patients with follow-up data; there were 17 cases of mild injury (CCscore 1-5), 23 moderate cases (CCscore 6-10), and 11 severe cases (CCscore 11-15). Patients treated surgically had significantly greater improvement in upper extremity motor scores and total CCscore only up to 3 months. In terms of timing of surgery, patients treated <24 hours after injury had significantly improved upper extremity motor scores and overall CCscores at last follow-up of ≥3 months. CONCLUSIONS: Based on these data and their alignment with past literature, the CCscore is able to objectively and specifically categorize the severity and outcome of ATCCS, which represents a step forward in the quest to determine the ultimate efficacy and timing of surgery for ATCCS.

Spinal Cord Injury Clinical Classification Systems: What Is Available and a Proposed Alternative.

Spinal cord injury (SCI) remains a challenging disease in terms of surgical decision-making and improving neurologic outcome. As we have now entered a new era founded on routine "big data" capture, more advanced and meaningful yet simplified SCI classification systems and outcome measurement tools would be helpful to determine the efficacy of potential therapeutics in future clinical trials and registries. The proposed classification herein focuses on gross sensorimotor, sacral function below the injured level via an easy-to-use scoring system yielding grades 1 to 4 of injury severity. Such an optimized SCI scoring system would enhance real-time analytics and offer superior outcomes modeling.

Foraminal Ligaments Tether Upper Cervical Nerve Roots: A Potential Cause of Postoperative C5 Palsy.

Background Nerve root tethering upon dorsal spinal cord (SC) migration has been proposed as a potential mechanism for postoperative C5 palsy (C5P). To our knowledge, this is the first study to investigate this relationship by anatomically comparing C5-C6 nerve root translation before and after root untethering by cutting the cervical foraminal ligaments (FL). Objective The aim of this study is to determine if C5 root untethering through FL cutting results in increased root translation. Methods Six cadaveric dissections were performed. Nerve roots were exposed via C4-C6 corpectomies and supraclavicular brachial plexus exposure. Pins were inserted into the C5-C6 roots and adjacent foraminal tubercle. Translation was measured as the distance between pins after the SC was dorsally displaced 5 mm before and after FL cutting. Clinical feasibility of FL release was examined by comparing root translation between standard and extended (complete foraminal decompression) foraminotomies. Translation of root levels before and after FL cutting was compared by two-way repeated measures analysis of variance. Statistical significance was set at 0.05. Results Significantly more nerve root translation was observed if the FL was cut versus not-cut, p = 0.001; no difference was seen between levels, p = 0.33. Performing an extended cervical foraminotomy was technically feasible allowing complete FL release and root untethering, whereas a standard foraminotomy did not. Conclusion FL tether upper cervical nerve roots in their foramina; cutting these ligaments untethers the root and increases translation suggesting they could be harmful in the context of C5P. Further investigation is required examining the value of root untethering in the context of C5P.

Antibiotic-impregnated polymethylmethacrylate strut graft as a treatment of spinal osteomyelitis: case series and description of novel technique.

OBJECTIVE: The surgical treatment of osteomyelitis and discitis of the spine often represents a challenging clinical entity for a multitude of reasons, including progression of infection despite debridement, development of spinal deformity and instability, bony destruction, and seeding of hardware. Despite advancement in spinal hardware and implantation techniques, these aforementioned challenges not uncommonly result in treatment failure, especially in instances of heavy disease burden with enough bony endplate destruction as to not allow support of a modern titanium cage implant. While antibiotic-infused polymethylmethacrylate (aPMMA) has been used in orthopedic surgery in joints of the extremities, its use has not been extensively described in the spine literature. Herein, the authors describe for the first time a series of patients treated with a novel surgical technique for the treatment of spinal osteomyelitis and discitis using aPMMA strut grafts with posterior segmental fusion. METHODS: Over the course of 3 years, all patients with spinal osteomyelitis and discitis at a single institution were identified and included in the retrospective cohort if they were surgically treated with spinal fusion and implantation of an aPMMA strut graft at the nidus of infection. Basic demographics, surgical techniques, levels treated, complications, and return to the operating room for removal of the aPMMA strut graft and placement of a traditional cage were examined. The surgical technique consisted of performing a discectomy and/or corpectomy at the level of osteomyelitis and discitis followed by placement of aPMMA impregnated with vancomycin and/or tobramycin into the cavity. Depending on the patient's condition during follow-up and other deciding clinical and radiographic factors, the patient may return to the operating room nonurgently for removal of the PMMA spacer and implantation of a permanent cage with allograft to ultimately promote fusion. RESULTS: Fifteen patients were identified who were treated with an aPMMA strut graft for spinal osteomyelitis and discitis. Of these, 9 patients returned to the operating room for aPMMA strut graft removal and insertion of a cage with allograft at an average of 19 weeks following the index procedure. The most common infections were methicillin-sensitive Staphylococcus aureus (n = 6) and methicillin-resistant S. aureus (n = 5). There were 13 lumbosacral infections and 1 each of cervical and thoracic infection. Eleven patients were cured of their infection, while 2 had recurrence of their infection; 2 patients were lost to follow-up. Three patients required unplanned return trips to the operating room, two of which were for wound complications, with the third being for recurrent infection. CONCLUSIONS: In cases of severe infection with considerable bony destruction, insertion of an aPMMA strut graft is a novel technique that should be considered in order to provide strong anterior-column support while directly delivering antibiotics to the infection bed. While the active infection is being treated medically, this structural aPMMA support bridges the time it takes for the patient to be converted from a catabolic to an anabolic state, when it is ultimately safe to perform a definitive, curative fusion surgery.

Intraoperative Ischemic Stroke in Elective Spine Surgery: A Retrospective Study of Incidence and Risk.

STUDY DESIGN: . Retrospective study. OBJECTIVE: . To determine incidence, risk factors, complications, and early postoperative outcome in patients with intraoperative ischemic stroke during elective spine surgery. SUMMARY OF BACKGROUND DATA: . Overall, stroke is the fifth leading cause of death in the United States and the second leading cause of death worldwide. It can be a catastrophic event and the main cause of neurological disability in adults. METHODS: . A retrospective review of the electronic medical records of patients who underwent elective spine surgery between January 2016 and November 2018 at a larger tertiary referral center was conducted. Patients with infection and neoplastic disease were excluded. Patient demographics, pre- and postoperative neurological status, surgical treatment, surgical time, blood loss, intraoperative abnormalities, risk factors, history of stroke, medical treatment, diagnostics, hospital stay, complications, and mortality were collected. RESULTS: . Out of 5029 surgically treated patients receiving elective spine surgery, a total of seven patients (0.15%) were identified who developed an ischemic stroke during the surgical procedure. Patients were predominantly females (n = 6). Ischemic pontine stroke occurred in two patients. Further distributions of ischemic stroke were: left caudate nucleus, left posterior inferior cerebellar artery, left external capsule, left middle cerebral artery, and acute ischemic supratentorial spots. The main risk factors identified for intraoperative ischemic stroke include hypertension, diabetes, smoking, dyslipidemia, and possibly major intraoperative CSF leak. Three patients (43%) had neurological deficits which did not improve during hospital stay. Two patients recovered fully and two patients died. Therefore, in-hospital mortality rate of this subset of patients was 29%. CONCLUSION: . With the increase of spinal procedures, it is important to identify patients at risk for having an ischemic stroke and to optimize their comorbidities preoperatively. Patients with intraoperative ischemic stroke carry a higher risk for morbidity and mortality during the index hospitalization. LEVEL OF EVIDENCE: 4.

Factors Associated With C5 Palsy Following Cervical Spine Surgery: A Systematic Review.

STUDY DESIGN: Systematic review. OBJECTIVES: C5 palsy (C5P) is a not uncommon and disabling postoperative complication with a reported incidence varying between 0% and 30%. Among others, one explanation for its occurrence includes foraminal nerve root tethering. Although different risk factors have been reported, controversy about its causation and prevention persists. Inconsistent study findings contribute to the persistent ambiguity leading to an assumption of a multifactorial nature of the underlying C5P pathophysiology. Here, we report the results of a systematic review on C5P with narrow inclusion criteria in the hope of elucidating risk factors for C5P due to a common pathophysiological mechanism. METHODS: Electronic databases from inception to March 9, 2019 and references of articles were searched. Narrow inclusion criteria were applied to identify studies investigating demographic, clinical, surgical, and radiographic factors associated with postoperative C5P. RESULTS: Sixteen studies were included after initial screening of 122 studies. Eighty-four risk factors were analyzed; 27 in ≥2 studies and 57 in single studies. The pooled prevalence of C5P was 6.0% (range: 4.2%-24.1%) with no consistent evidence that C5P was associated with demographic, clinical, or specific surgical factors. Of the radiographic factors assessed, specifically decreased foraminal diameter and preoperative cord rotation were identified as risk factors for C5P. CONCLUSION: Although risk factors for C5P have been reported, ambiguity remains due to potentially multifactorial pathophysiology and study heterogeneity. We found foraminal diameter and cord rotation to be associated with postoperative C5P occurrence in our meta-analysis. These findings support the notion that factors contributing to, and acting synergistically with foraminal stenosis increase the risk of postoperative C5P.

Management of Acute Traumatic Central Cord Syndrome: A Narrative Review.

STUDY DESIGN: Narrative review. OBJECTIVES: To provide an updated overview of the management of acute traumatic central cord syndrome (ATCCS). METHODS: A comprehensive narrative review of the literature was done to identify evidence-based treatment strategies for patients diagnosed with ATCCS. RESULTS: ATCCS is the most commonly encountered subtype of incomplete spinal cord injury and is characterized by worse sensory and motor function in the upper extremities compared with the lower extremities. It is most commonly seen in the setting of trauma such as motor vehicles or falls in elderly patients. The operative management of this injury has been historically variable as it can be seen in the setting of mechanical instability or preexisting cervical stenosis alone. While each patient should be evaluated on an individual basis, based on the current literature, the authors' preferred treatment is to perform early decompression and stabilization in patients that have any instability or significant neurologic deficit. Surgical intervention, in the appropriate patient, is associated with an earlier improvement in neurologic status, shorter hospital stay, and shorter intensive care unit stay. CONCLUSIONS: While there is limited evidence regarding management of ATCCS, in the presence of mechanical instability or ongoing cord compression, surgical management is the treatment of choice. Further research needs to be conducted regarding treatment strategies and patient outcomes.

The ABC's of Spinal Decompression: Pearls and Technical Notes.

OBJECTIVE: The foundation of spine surgery centers on the proper identification, decompression, and stabilization of bony and neural elements. We describe easily reproducible and reliable methods for optimal decompression and release of neural structures to alleviate symptoms and improve patients' quality of life. METHODS: Multiple spinal decompression techniques were described in procedures for which the goal of surgery was decompression alone or decompression and fusion. Eight fundamental techniques were described: inverted U-cut, J-cut, T-cut, L-cut, Z-cut, I-track cuts, C-cut, and O-cut. RESULTS: These foundational cuts may be combined, as needed, to develop an individually tailored approach to the patient's pathology. CONCLUSIONS: After properly identifying the anatomic structures, each of these techniques provides a consistent, reproducible, and efficient means to decompress the spine under various circumstances. These techniques provide surgical trainees with a framework for approaching surgical decompression.

Early Complications and Cement Leakage in Elderly Patients Who Have Undergone Intraoperative Computed Tomography (CT)-Guided Cement Augmented Pedicle Screw Placement: Eight-Year Single-Center Experience.

OBJECTIVE: To assess early complications, mortality rate, and cement leakage in elderly patients who had undergone navigation-based pedicle screw placement of the thoracic and lumbar spine. METHODS: Eighty-six patients older than 65 years of age who had received cement-augmented pedicle screws for various conditions were retrospectively included between May 2008 and December 2016. Complications, mortality, and cement leakage were determined. All patients had a radiograph as a control. In patients with cement leakage seen on radiographs, a computed tomography scan of the surgical area was also obtained. RESULTS: Average age was 73.4 years (range 65-86 years). A total of 319 vertebral bodies with 637 screws were inserted, of which 458 screws were cement-augmented; 348 (76%) of the augmented screws were placed in the lumbar spine and 110 (24%) in the thoracic spine. Cement leakage occurred in 55 of 86 patients, of whom 52 (60%) were asymptomatic. In all cases with cement leakage (asymptomatic or symptomatic), cement could be found in the perivertebral veins: in the inferior vena cava in 25%, in the epidural space in 7%, in the azygos vein in 5%, and in pulmonary arteries in 7%. CONCLUSIONS: Our study confirms that the use of cement correlates with a high risk of cement leakage in elderly patients. Using computed tomography navigation for screw placement did not reduce the risk of venous cement leakage, but leakage into the epidural space or through a cortical defect seems to be low.

Neurotrauma From Border Wall Jumping: 6 Years at the Mexican-American Border Wall.

BACKGROUND: The border between the United States (US) and Mexico is an international boundary spanning 3000 km, where unauthorized crossings occur regularly. We examine patterns of neurotrauma, health care utilization, and financial costs at our level 1 trauma center incurred by patients from wall-jumping into the US. OBJECTIVE: To determine the clinical and socioeconomic consequences from neurotrauma as a result of jumping over the US-Mexico border wall. METHODS: Medical records of patients at (Banner University of Arizona Medical Center - Tucson) were retrospectively reviewed from January 2012 through December 2017. Demographics, clinical status, radiographic findings, treatment, length of stay, and financial data were analyzed for all patients suffering neurotrauma during that time. RESULTS: Over 6 yr, 64 patients sustained cranial or spinal injuries directly from jumping or falling onto US soil from the border wall. Fifty (78%) suffered spinal injuries, 15 (23%) experienced cranial injury, and 1 patient had both. Total medical charges were available in 36 patients and summed $3.6 M, of which 22% was reimbursed, an amount significantly lower than expected from more conventional trauma. Neurotrauma steadily declined over the 6-yr observation period, dropping in 2017 to 6% of rates observed in 2012. CONCLUSION: In the Southern US, neurotrauma from unauthorized border crossings occurs commonly as a result of wall-jumping. These injuries represent a clinical and costly extreme of border-related trauma, and future efforts from both sides of the border wall are needed to decrease the detrimental impacts felt both by immigrants and surrounding health care systems.

Intracranial Hemorrhage in Patients with Durable Mechanical Circulatory Support Devices: Institutional Review and Proposed Treatment Algorithm.

BACKGROUND: Spontaneous intracranial hemorrhage (ICH) is frequently managed in neurosurgery. Patients with durable mechanical circulatory support devices, including total artificial heart (TAH) and left ventricular assist device (LVAD), are often encountered in the setting of ICH. Although durable mechanical circulatory support devices have improved survival and quality of life for patients with advanced heart failure, ICH is one of the most feared complications following LVAD and TAH implantation. Owing to anticoagulation and clinically relevant acquired coagulopathies, ICH should be treated promptly by neurosurgeons and cardiac critical care providers. We provide an analysis of ICH in patients with mechanical circulatory support and propose a treatment algorithm. METHODS: We retrospectively reviewed medical records from 2013-2016 for patients with a durable mechanical circulatory device at Banner-University of Arizona Medical Center Tucson. All patients with suspected ICH underwent computed tomography scan of the brain. Anticoagulation was managed by the cardiothoracic surgeon. RESULTS: In 58 patients, an LVAD (n = 49), TAH (n = 10), or both (n = 1) were implanted. Both acquired von Willebrand disease and spontaneous ICH were diagnosed in 5 patients (8.6%) who underwent LVAD implantation. Seven neurosurgical procedures were performed in 2 patients. The overall mortality rate was 60%. Two patients had little or no deficits after treatment with modified Rankin Scale score of 1 and 2, respectively. CONCLUSIONS: We propose a novel treatment algorithm to manage patients with a LVAD or TAH and ICH, implemented in a multidisciplinary manner to best avoid neurologic and cardiovascular complications.

Completion of the Circle of Willis Varies by Gender, Age, and Indication for Computed Tomography Angiography.

OBJECTIVE: The circle of Willis (CoW) is the foremost anastomosis and blood distribution center of the brain. Its effectiveness depends on its completion and the size and patency of its vessels. Gender-related and age-related anatomic variations in the CoW may play an important role in the pathogenesis of cerebrovascular diseases. In this study, we analyzed computed tomography angiograms (CTAs) to assess for differences in CoW completion related to gender, age, and indication for CTA. METHODS: A total of 834 CTAs were retrospectively analyzed for all CoW vessels to compare the incidence of complete CoW and variation frequency based on gender, age, and indication. RESULTS: The incidence of complete CoW was 37.1% overall. CoW completion showed a statistically significant decrease with increasing age for all age groups in both men (47.0%, 29.4%, 18.8%) and women (59.1%, 44.2%, 30.9%). Completion was greater in women (43.8%) than in men (31.2%) overall and for all age groups. These gender differences were all statistically significant except for the 18-39 years age group. The most frequent of the 28 CoW variations were absent posterior communicating artery (PCOM) bilaterally (17.1%), right PCOM (15.3%), and left PCOM (10.9%). Ischemic stroke and the 18-39 years age group of hemorrhagic stroke showed a statistically significant reduction in completion relative to trauma. CONCLUSIONS: The incidence of complete CoW is likely greater in women for all age groups and likely decreases with age in both genders. The most frequently absent vessel is likely the PCOM, either unilaterally or bilaterally. Completion may play a role in ischemic stroke and a subset of patients with hemorrhagic stroke.

A Rare Case of Optic Nerve Schwannoma: Case Report and Review of the Literature.

BACKGROUND AND IMPORTANCE: Schwannomas are typically benign tumors of the peripheral nervous system that originate from Schwann cells. It is well known that the optic nerves are myelinated by oligodendrocytes since their cell bodies arise centrally within the lateral geniculate nuclei. Because of this basic cellular anatomy, optic schwannomas should theoretically not exist. It is possible, however, these rare lesions stem from small sympathetic fibers that innervate the vasculature surrounding the optic nerve and its sheath. CLINICAL PRESENTATION: The patient is a 46-year-old male with a one-year history of progressive right eye blurry vision. To our knowledge, there are only five known reported case of an optic nerve schwannoma. Additionally, because of its medial position relative to the optic nerve and within the orbital apex, it is the first such case to be resected via an endoscopic endonasal approach. The lesion was subtotally resected because of its adherence and continuity with the optic nerve and the patient's wish to preserve his vision. He was subsequently referred to radiation oncology for external beam radiation therapy. CONCLUSION: Herein, we discuss the pertinent clinical findings of this rare lesion and review the literature relative to optic nerve and solitary orbital schwannomas.