Endovascular Applications for the Management of High-Grade Gliomas in the Modern Era.

High-grade gliomas (HGGs) have a poor prognosis and are difficult to treat. This review examines the evolving landscape of endovascular therapies for HGGs. Recent advances in endovascular catheter technology and delivery methods allow for super-selective intra-arterial cerebral infusion (SSIACI) with increasing precision. This treatment modality may offer the ability to deliver anti-tumoral therapies directly to tumor regions while minimizing systemic toxicity. However, challenges persist, including blood-brain barrier (BBB) penetration, hemodynamic complexities, and drug-tumor residence time. Innovative adjunct techniques, such as focused ultrasound (FUS) and hyperosmotic disruption, may facilitate BBB disruption and enhance drug penetration. However, hemodynamic factors that limit drug residence time remain a limitation. Expanding therapeutic options beyond chemotherapy, including radiotherapy and immunobiologics, may motivate future investigations. While preclinical and clinical studies demonstrate moderate efficacy, larger randomized trials are needed to validate the clinical benefits. Additionally, future directions may involve endovascular sampling for peri-tumoral surveillance; changes in drug formulations to prolong residence time; and the exploration of non-pharmaceutical therapies, like radioembolization and photodynamic therapy. Endovascular strategies hold immense potential in reshaping HGG treatment paradigms, offering targeted and minimally invasive approaches. However, overcoming technical challenges and validating clinical efficacy remain paramount for translating these advancements into clinical care.

Global, Regional, and National Economic Consequences of Stroke.

BACKGROUND: An understanding of global, regional, and national macroeconomic losses caused by stroke is important for allocation of clinical and research resources. The authors investigated the macroeconomic consequences of stroke disease burden in the year 2019 in 173 countries. METHODS: Disability-adjusted life year data for overall stroke and its subtypes (ischemic stroke, intracerebral hemorrhage, and subarachnoid hemorrhage) were collected from the GBD study (Global Burden of Disease) 2019 database. Gross domestic product (GDP, adjusted for purchasing power parity [PPP]) data were collected from the World Bank; GDP and disability-adjusted life year data were combined to estimate macroeconomic losses using a value of lost welfare (VLW) approach. All results are presented in 2017 international US dollars adjusted for PPP. RESULTS: Globally, in 2019, VLW due to stroke was $2059.67 billion or 1.66% of the global GDP. Global VLW/GDP for stroke subtypes was 0.78% (VLW=$964.51 billion) for ischemic stroke, 0.71% (VLW=$882.81 billion) for intracerebral hemorrhage, and 0.17% (VLW=$212.36 billion) for subarachnoid hemorrhage. The Central European, Eastern European, and Central Asian GBD super-region reported the highest VLW/GDP for stroke overall (3.01%), ischemic stroke (1.86%), and for subarachnoid hemorrhage (0.26%). The Southeast Asian, East Asian, and Oceanian GBD super-region reported the highest VLW/GDP for intracerebral hemorrhage (1.48%). CONCLUSIONS: The global macroeconomic consequences related to stroke are vast even when considering stroke subtypes. The present quantification may be leveraged to help justify increased spending of finite resources on stroke in an effort to improve outcomes for patients with stroke globally.

Cerebrovascular injuries in traumatic brain injury.

Traumatic brain injury is a complex and highly heterogeneous disease due to the host of concomitant injuries that may accompany the initial insult. Due to the dynamic interplay between the injuries that may arise, the management of these injuries is challenging. In a small subset of patients with traumatic brain injury, cerebral vascular injury may occur, which presents its own diagnostic and therapeutic challenges. These vascular injuries often present in a delayed fashion, thereby going unnoticed by clinicians. Early recognition and treatment of these injuries is crucial, given their high morbidity and mortality. Through a critical review of the literature, we present the spectrum of cerebrovascular injuries that may occur with traumatic brain injury and discuss classification systems that are used to stratify cerebrovascular injury. We then focus on the diagnosis of cerebral vascular injury using different neuroimaging modalities. Lastly, we explore the treatment of these injuries ranging from antiplatelet therapies to endovascular and open vascular procedures. By highlighting the pitfalls and challenges of this complex disease, we hope to provide clinicians with the framework to recognize and treat vascular injuries that are seen in patients with traumatic brain injury.

Development of a Neurosurgical Cadaver Laboratory despite Limited Resources.

OBJECTIVE: Our neurosurgical program did not have a cadaver laboratory. The need to create one arose following a decrease in elective cranial cases at our institution after Hurricane Maria. Many neurosurgical programs are in countries where financial support for projects such as developing a cadaver research laboratory cannot be expected from their parent institutions. This article describes how, despite limited resources, a neurosurgical cadaver dissection laboratory can be created and maintained to promote resident education and stimulate future research. MATERIALS AND METHODS: The University of Puerto Rico Institutional Review Board evaluated and approved the proposal for creating a neurosurgical cadaver laboratory. The process to establish the laboratory was broken into steps. After obtaining the basic materials, the laboratory was created. RESULTS: The creation of our neurosurgical cadaver laboratory was divided into discrete steps that can be undertaken by any institution with a similar goal. First, a suitable workspace was identified. Second, the surgical instruments and equipment required to perform dissections were obtained. Third, cadaveric specimens for dissection and for practicing surgical approaches were acquired. Last, documentation regarding the laboratory's development was maintained, and an expansion plan was created. We created a dissection laboratory by gathering decommissioned or donated operating room equipment, seeking out contributions from other institutions, and, sometimes, by monetary contribution from the faculty or residents. CONCLUSION: Clear goals, interdepartmental collaboration, and a high degree of motivation were essential in creating, despite limited resources, a working neurosurgical cadaver laboratory to improve resident education.

Retreatment of Residual and Recurrent Aneurysms After Embolization With the Woven EndoBridge Device: Multicenter Case Series.

BACKGROUND: The Woven EndoBridge (WEB) device (Terumno Corp. [parent company of Microvention]) was approved by the U.S. Food and Drug Administration as the first intrasaccular device for intracranial aneurysm treatment in December 2018. Its use has become more common since then, but both trial results and postmarket experiences have raised questions about the efficacy in achieving complete aneurysm obliteration. Retreatment after WEB embolization has not been extensively discussed. OBJECTIVE: To discuss the incidence and retreatment of aneurysms after initial WEB embolization. METHODS: Retrospective review across 13 institutions identified all occurrences of WEB retreatment within neurovascular databases. Details regarding demographics, aneurysm characteristics, treatment considerations, clinical outcomes, and aneurysm occlusion were obtained and analyzed. RESULTS: Thirty aneurysms were retreated in 30 patients in a cohort of 342 WEB-treated aneurysms. The retreatment rate was 8.8%. Endovascular methods were used for 23 cases, and 7 were treated surgically. Two aneurysms presented with rehemorrhage after initial WEB embolization. Endovascular treatments included stent-assisted coiling (12), flow diversion (7), coiling (2), PulseRider (Johnson & Johnson)-assisted coiling (1), and additional WEB placement (1). Surgical treatments included primary clipping (6) and Hunterian ligation (1). There were no major complications within the study group. CONCLUSION: WEB retreatments were successfully performed by a variety of techniques, including stent-assisted coiling, clipping, and flow diversion as the most common. These procedures were performed safely with subsequent obliteration of most aneurysms. The potential need for retreatment of aneurysms should be considered during primary WEB treatments.

Mechanical thrombectomy beyond the circle of Willis: efficacy and safety of different techniques for M2 occlusions.

BACKGROUND: M2 segment occlusions represent approximately one-third of non-lacunar ischemic stroke and can lead to permanent neurological deficits. Various techniques are available for mechanical thrombectomy beyond the circle of Willis, but data evaluating their effectiveness and safety are lacking. METHODS: A retrospective review of patients with ischemic stroke undergoing mechanical thrombectomy for M2 occlusions from 13 centers in North American and Europe was performed. Tandem or multiple-territory occlusions were excluded. The primary outcome was 90-day modified Rankin Scale and reperfusion rates across stent-retriever, direct aspiration and combined techniques. RESULTS: There were 465 patients (mean age 71.48±14.03 years, 53.1% female) with M2 occlusions who underwent mechanical thrombectomy. Stent-retriever alone was used in 133 (28.6%), direct aspiration alone in 93 (20.0%) and the combined technique in 239 (51.4%) patients. Successful reperfusion was achieved with the combined technique in 198 (82.2%; OR 2.6 (1.1-6.9)), with stent-retriever alone in 112 (84.2%; OR 9.2 (1.9-44.6)) and with direct aspiration alone in 62 (66.7%; referencecategory). Intraprocedural subarachnoid hemorrhages (iSAH) were 36 (7.7%) and were more likely to occur in patients treated with the stent-retrievers (OR 5.0 (1.1-24.3)) and combined technique (OR 4.6 (1.1-20.9)). Good clinical outcome was achieved in 260 (61.8%) patients, while 59 (14.0%) patients died. Older age, higher baseline NIHSS (National Institutes of Health Stroke Scale), parenchymal hemorrhage and iSAH were associated with poor outcome while successful recanalization and higher baseline ASPECTS (Alberta Stroke Program Early CT Score) were associated with good outcome. No differences were found among the three techniques in terms of clinical outcome. CONCLUSION: Stent-retrievers and a combined approach for M2 occlusions seem more effective than direct aspiration, but with higher rates of iSAH. This leads to no detectable difference in clinical outcome at 3 months.

Posterior Cerebral Artery Aneurysm Re-Rupture Following Revascularization for Moyamoya Disease.

OBJECTIVES: Aneurysms associated with hemorrhagic moyamoya disease (MMD) are reported to stabilize or recede following revascularization. CASE REPORT/RESULTS: A 29 year-old male with no past medical history presented obtunded with diffuse intraventricular hemorrhage and vascular imaging demonstrating bilateral MMD without any associated aneurysms. He underwent a delayed right-sided STA-MCA bypass and pial synangiosis, and was subsequently discharged on hospital day 24 with a modified Rankin Scale score (mRS) of 2. He returned eleven days later from a rehabilitation facility with recurrent IVH. A saccular 5 mm right P4 segment posterior cerebral artery aneurysm was seen on a diagnostic angiogram and embolized with Onyx glue. CONCLUSIONS: Distal posterior circulation artery aneurysmal rupture is a rare cause of hemorrhagic MMD. This case demonstrates the capacity of these aneurysms to re-rupture following revascularization and underscores the importance of treating the aneurysms directly.

Endovascular treatment of a ruptured posterior fossa pure arterial malformation: illustrative case.

BACKGROUND: Pure arterial malformations (PAMs) are rare vascular anomalies that are commonly mistaken for other vascular malformations. Because of their purported benign natural history, PAMs are often conservatively managed. The authors report the case of a ruptured PAM leading to subarachnoid hemorrhage (SAH) with intraventricular extension that was treated endovascularly. OBSERVATIONS: A 38-year-old man presented with a 1-day history of headaches and nausea. A computed tomography scan demonstrated diffuse SAH with intraventricular extension, and angiography revealed a right posterior inferior cerebellar artery-associated PAM. The PAM was treated with endovascular Onyx embolization. LESSONS: To the authors' knowledge, only 2 other cases of SAH associated with PAM have been reported. In those 2 cases, surgical clipping was pursued for definitive treatment. Here, the authors report the first case of a ruptured PAM treated using an endovascular approach, showing its feasibility as a treatment option particularly in patients in whom open surgery is too high a risk.

Temporal Evolution of Hypertrophic Olivary Degeneration in a Pediatric Patient: A Case Report and Review of Literature.

Hypertrophic olivary degeneration (HOD) is a rare type of neuronal degeneration seen after interruption of the dentato-rubro-olivary tract also known as the Guillain-Mollaret triangle (GMT). It is associated with hypertrophic changes of the inferior olive. Commonly reported in adults, this lesion presents with ataxia and oculopalatal myoclonus. Up to date, few cases have been published in the literature that refer to pediatric cases. This diagnosis is particularly important in the setting of brainstem tumor surgery as it should not be confused for tumor recurrence or metastasis, in turn avoiding unwarranted surgical intervention. We present the case of a 15-year-old male who underwent resection of a left superior cerebellar peduncle (SCP) pilocytic astrocytoma. On follow-up, magnetic resonance imaging (MRI) demonstrated evidence of mild residual tumor as well as progressive engorgement of the inferior olivary nucleus (ION). The patient was clinically asymptomatic and has since been observed expectantly without any issues. We were able to pinpoint the most probable location of injury in our patient's GMT. HOD remains a somewhat obscure entity. Its presentation may be early and not accompanied by significant neurologic findings, in contrast to what has been previously reported. Particularly in neoplastic cases, it may represent a diagnostic challenge and could be easily confused for tumor recurrence. A multidisciplinary approach for this entity, as with other pathologies, is of particular importance. Its proper recognition will result in the best outcomes for the patient.

Obstructive Hydrocephalus and Chemical Meningitis Secondary to a Ruptured Spinal Epidermoid Cyst.

BACKGROUND: Epidermoid cysts of the spinal cord may rupture, resulting in keratin dissemination in the subarachnoid space, in the ventricles, and along the central canal of the spinal cord causing meningitis, myelopathic changes, or hydrocephalus. CASE DESCRIPTION: A 53-year-old woman with no past medical history presented with a 2-week history of headache located in the occipital region associated with neck pain. Brain magnetic resonance imaging demonstrated multiple fat droplets scattered throughout the subarachnoid and intraventricular spaces with significant edema of the right posterior temporoparietal lobes with trapping of the right temporal horn of the lateral ventricle and atrium. An intracranial lesion could not be observed in the study. The spinal region was suspected as the possible culprit, and spinal imaging showed a large cystic lesion at the level of the conus medullaris. The patient underwent neuronavigation endoscopic exploration of the right lateral ventricle with flushing of the keratin particles followed by a posterior lumbar decompression with resection of the epidermoid cyst. Pathology was consistent with an epidermoid cyst. Successful recovery with improvement in symptoms was quickly observed. CONCLUSIONS: When an epidermoid cyst is suspected but no intracranial lesion is found, the intraspinal area should be studied. Rupture of a spinal epidermoid cyst may cause meningitis and inflammation producing obstructive hydrocephalus. We present this rare entity and describe the diagnostic and surgical techniques used.

Radiologic Features with Pathologic Correlation of an Unusual Large Intraosseous Skull Cavernous Hemangioma.

BACKGROUND Intraosseous cavernous skull hemangiomas are rare benign vascular tumors that are usually found incidentally on imaging, with an asymptomatic and slow-growing course. We present a case in which the patient had a mass on her forehead for many years, which began to grow rapidly after head trauma. Imaging characteristics play a crucial role in the diagnosis and description of this disease, and in differentiating it from other more common calvarial lesions that may present with a similar clinical picture. Here, we report an unusual presentation of a large skull hemangioma and discuss the different radiologic imaging findings and pathologic correlations. CASE REPORT A 58-year-old female with history of a lump on her forehead since childhood, which began to grow rapidly after experiencing a closed-head injury. Due to its large size, she went on to seek further management. Radiologic images revealed a frontal skull lesion suggestive of an intraosseous hemangioma. She underwent embolization of the tumor, and 2 days later underwent bilateral frontal craniectomy and cranioplasty. Histopathologic findings confirmed this diagnosis. CONCLUSIONS Intraosseous skull hemangioma may be confidently diagnosed and differentiated from other skull lesions by its imaging characteristics. An accurate diagnosis is essential to selecting correct management and avoiding complications.

aPKC-Mediated Persistent Increase in AMPA/NMDA Ratio in the VTA Participates in the Neuroadaptive Signal Necessary to Induce NAc Synaptic Plasticity After Cocaine Administration.

Chronic cocaine exposure produces enduring neuroadaptations in the brain's reward system. Persistence of early cocaine-evoked neuroadaptations in the ventral tegmental area (VTA) is necessary for later synaptic alterations in the nucleus accumbens (NAc), suggesting a temporal sequence of neuroplastic changes between these two areas. However, the molecular nature of the signal that mediates this sequential event is unknown. Here we used the behavioral sensitization model and the aPKC inhibitor of late-phase LTP maintenance, ZIP, to investigate if a persistent increase in AMPA/NMDA ratio plays a role in the molecular mechanism that allows VTA neuroadaptations to induce changes in the NAc. Results showed that intra-VTA ZIP microinfusion successfully blocked cocaine-evoked synaptic enhancement in the VTA and the expected AMPA/NMDA ratio decrease in the NAc following cocaine sensitization. ZIP microinfusions also blocked the expected AMPA/NMDA ratio increase in the NAc following cocaine withdrawal. These results suggest that a persistent increase in AMPA/NMDA ratio, mediated by aPKCs, could be the molecular signal that enables the VTA to elicit synaptic alterations in the NAc following cocaine administration.

Interval Recovery of Syringomyelia in Chiari I Malformation Patient with Acute Cervical Trauma After Anterior Decompression: Case Report and Review of Literature.

BACKGROUND: Syringomyelia in the cervical spinal cord is a complex pathology that is commonly associated with Chiari I malformation or spinal cord trauma. In both cases the development of syringomyelia has been linked to multiple anatomic and molecular elements including epidural compression. Literature has mainly reported posterior cervical decompressive procedures or shunting of the cyst as options to address this pathology. Anterior decompression is rarely recommended. CASE DESCRIPTION: We present the case of a 19-year-old female who suffered a motor vehicle accident causing a cervical subluxation with mild new-onset neurologic deficits. Preoperative workup showed a large incidental cervical syringomyelia associated with a Chiari I malformation. Anterior cervical decompression at the subluxated cervical segment with a concomitant anterior and posterior fusion was performed. Postoperative workup revealed a significant interval reduction in the size of the syrinx cavity with concomitant neurologic improvement. CONCLUSIONS: Anterior decompression may be considered as an option in select cases of syringomyelia. The findings of this case support the theory of epidural compression as one of the inciting events for the development of syringomyelia.

A rare case of a vertebrojugular arteriovenous fistula: A case report and review of literature.

Vertebrojugular fistulas have been described in the literature associated with blunt or penetrating injury and iatrogenic or spontaneous development. Its presentation may be broad and may include symptoms of radiculopathy, vertebrobasilar insufficiency, tinnitus, and bruit. However, so far, no direct cardiac complications had been reported. Here, we describe a case of an 86-year-old female who suffered a C5 vertebral fracture secondary to a ground-level fall that was initially treated conservatively due to the onset of new severe atrial fibrillation. However, the patient was later on taken to surgery due to progressive neurologic deterioration. Intraoperative complications led to the diagnosis of a vertebral-jugular fistula that was successfully embolized. The effective obliteration of the fistulae led to the recovery of both neurologic and cardiac symptoms.