Clinical Outcomes After Nonoperative Management of Large Acute Traumatic Subdural Hematomas in Older Patients: A Propensity-Scored Retrospective Analysis.

BACKGROUND: Large (≥1 cm) acute traumatic subdural hematomas (aSDHs) are neurosurgical emergencies. Elderly patients with asymptomatic large aSDHs may benefit from conservative management. OBJECTIVE: To investigate inpatient mortality after conservative management of large aSDHs. METHODS: Single-center retrospective review of adult patients with traumatic brain injury from 2018 to 2021 revealed 45 large aSDHs that met inclusion criteria. Inpatient outcomes included mortality, length of stay, and discharge disposition. Follow-up data included rate of surgery for chronic SDH progression. Patients with large aSDHs were 2:1 propensity score-matched to patients with small (<1 cm) aSDHs based on age, Injury Severity Scale, Glasgow Coma Scale, and Rotterdam computed tomography scale. RESULTS: Median age (78 years), sex (male 52%), and race (Caucasian 91%) were similar between both groups. Inpatient outcomes including length of stay ( P = .32), mortality ( P = .37), and discharge home ( P = .28) were similar between those with small and large aSDHs. On multivariate logistic regression (odds ratio [95% CI]), increased in-hospital mortality was predicted by Injury Severity Scale (1.3 [1.0-1.6]), Rotterdam computed tomography scale 3 to 4 (99.5 [2.1-4754.0), parafalcine (28.3 [1.7-461.7]), tentorial location (196.7 [2.9-13 325.6]), or presence of an intracranial contusion (52.8 [4.0-690.1]). Patients with large aSDHs trended toward higher progression on follow-up computed tomography of the head (36% vs 16%; P = .225) and higher rates of chronic SDH surgery (25% vs 7%; P = .110). CONCLUSION: In conservatively managed patients with minimal symptoms and mass effect on computed tomography of the head, increasing SDH size did not contribute to worsened in-hospital mortality or length of stay. Patients with large aSDHs may undergo an initial course of nonoperative management if symptoms and the degree of mass effect are mild.

Revision Thoracic Syringo-Subarachnoid Shunt for Recurrent Syrinx With Syringobulbia: Technique and Surgical Video.

Syringomyelia and syringobulbia continue to remain a diagnosis without widely accepted treatment paradigms. Furthermore, the currently available treatment options can be complicated by delayed symptom recurrence and the need for revision surgery. Revision intradural surgery is challenging, and currently, there is a paucity of literature describing safe techniques for revision syringotomy and shunt placement. In this technical report, we present a surgical video describing the technique of revision syringo-subarachnoid shunt placement in a 61-year-old female with a history of multiple intradural surgeries who presented with progressively symptomatic ascending syringobulbia.

Difficult-to-Localize Epilepsy After Stereoelectroencephalography: Technique, Safety, and Efficacy of Placing Additional Electrodes During the Same Admission.

BACKGROUND: Stereoelectroencephalography (SEEG) is used to identify the epileptogenic zone (EZ) in patients with epilepsy for potential surgical intervention. Occasionally, the EZ is difficult to localize even after an SEEG implantation. OBJECTIVE: To demonstrate a safe technique for placing additional electrodes in ongoing SEEG evaluations. Describe efficacy, complications, and surgical outcomes. METHODS: An operative technique which involves maintaining previously placed electrodes and sterilely placing new electrodes was developed and implemented. All patients who underwent placement of additional SEEG electrodes during the same admission were retrospectively reviewed. RESULTS: A total of 14 patients met criteria and had undergone SEEG evaluation with 198 electrodes implanted. A total 93% of patients (13/14) had nonlesional epilepsy. After unsuccessful localization of the EZ after a mean of 9.6 d of monitoring, each patient underwent additional placement of electrodes (5.5 average electrodes per patient) to augment the original implantation. At no point did any patients develop new hemorrhage, infection, wound breakdown, or require any kind of additional antimicrobial treatment. A total 64% (9/14) of patients were able to undergo surgery aimed at removing the EZ guided by the additional SEEG electrodes. A total 44% (4/9) of surgical patients had Engel class I outcomes at an average follow-up time of 11 mo. CONCLUSION: Placing additional SEEG electrodes, while maintaining the previously placed electrodes, appears to be safe, effective, and had no infectious complications. When confronted with difficult-to-localize epilepsy even after invasive monitoring, it appears to be safe and potentially clinically effective to place additional electrodes during the same admission.

Laser Interstitial Thermal Therapy for Epileptogenic Periventricular Nodular Heterotopia.

OBJECTIVE: Epilepsy with periventricular nodular heterotopia (PVNH) lacks a conclusive surgical treatment strategy as eloquent cortex and important white matter tracts frequently overlay the deep periventricular nodules. Our goal was to evaluate the safety and efficacy of laser interstitial thermal therapy (LITT) for the treatment of epilepsy in PVNH. METHODS: Data on demographic characteristics, complications, visual outcomes, Engel classification at last follow-up, antiepileptic drug use, morbidity, and mortality among patients who underwent this procedure were retrospectively reviewed. RESULTS: Between May 2015 and January 2019, 5 patients underwent 6 LITT procedures for epilepsy with PVNH. One patient had residual nodules after their first procedure and underwent a second ablation. The average follow-up time was 12 months. Three patients were Engel class Ia, 1 patient was Engel class II, and 1 patient was Engel class III at last follow-up. Two patients were able to reduce their antiepileptic drugs postoperatively. Three patients had no changes in vision, 1 patient experienced a quadrantanopsia, and 1 patient had subjective blurry vision after their procedures. No patients experienced motor deficits, dysphasia, infection, or mortality. CONCLUSIONS: LITT appears to be a safe and promising option to provide seizure relief for patients with refractory epilepsy and PVNH that otherwise may not be surgical candidates. Some appropriately determined patients with refractory epilepsy may benefit from LITT before proceeding with an invasive intracranial evaluation. A larger sample size and long-term follow-up is necessary to further elucidate safety and efficacy.

Gorham-Stout disease of the spine presenting with intracranial hypotension and cerebrospinal fluid leak: A case report and review of the literature.

BACKGROUND: Gorham-Stout (GS) disease or "vanishing bone disease" is rare and characterized by progressive, spontaneous osteolysis resulting in loss of bone on imaging studies. Treatment modalities include combinations of medical and/or surgical treatment and radiation therapy. CASE DESCRIPTION: A 14-year-old female with GS disease presented with a 1-year history of thoracic back pain and atypical headaches consistent with intracranial hypotension. Magnetic resonance imaging and operative findings demonstrated a spontaneous thoracic cerebrospinal fluid leak (CSF) (e.g., that extended into the pleural cavity) and complete osteolysis of the T9-10 posterior bony elements (e.g., including the rib head, lamina, and transverse processes). The patient underwent repair of CSF fistula followed by a T6-11 instrumented fusion. CONCLUSION: This case of GS disease, involving a thoracic CSF fistula and absence/osteolysis of the T9-T10 bony elements, could be successfully managed with direct dural repair and an instrumented T6-T11 fusion.

Combined use of minimal access craniotomy, intraoperative magnetic resonance imaging, and awake functional mapping for the resection of gliomas in 61 patients.

OBJECTIVECurrent management of gliomas involves a multidisciplinary approach, including a combination of maximal safe resection, radiotherapy, and chemotherapy. The use of intraoperative MRI (iMRI) helps to maximize extent of resection (EOR), and use of awake functional mapping supports preservation of eloquent areas of the brain. This study reports on the combined use of these surgical adjuncts.METHODSThe authors performed a retrospective review of patients with gliomas who underwent minimal access craniotomy in their iMRI suite (IMRIS) with awake functional mapping between 2010 and 2017. Patient demographics, tumor characteristics, intraoperative and postoperative adverse events, and treatment details were obtained. Volumetric analysis of preoperative tumor volume as well as intraoperative and postoperative residual volumes was performed.RESULTSA total of 61 patients requiring 62 tumor resections met the inclusion criteria. Of the tumors resected, 45.9% were WHO grade I or II and 54.1% were WHO grade III or IV. Intraoperative neurophysiological monitoring modalities included speech alone in 23 cases (37.1%), motor alone in 24 (38.7%), and both speech and motor in 15 (24.2%). Intraoperative MRI demonstrated residual tumor in 48 cases (77.4%), 41 (85.4%) of whom underwent further resection. Median EOR on iMRI and postoperative MRI was 86.0% and 98.5%, respectively, with a mean difference of 10% and a median difference of 10.5% (p < 0.001). Seventeen of 62 cases achieved an increased EOR > 15% related to use of iMRI. Seventeen (60.7%) of 28 low-grade gliomas and 10 (30.3%) of 33 high-grade gliomas achieved complete resection. Significant intraoperative events included at least temporary new or worsened speech alteration in 7 of 38 cases who underwent speech mapping (18.4%), new or worsened weakness in 7 of 39 cases who underwent motor mapping (18.0%), numbness in 2 cases (3.2%), agitation in 2 (3.2%), and seizures in 2 (3.2%). Among the patients with new intraoperative deficits, 2 had residual speech difficulty, and 2 had weakness postoperatively, which improved to baseline strength by 6 months.CONCLUSIONSIn this retrospective case series, the combined use of iMRI and awake functional mapping was demonstrated to be safe and feasible. This combined approach allows one to achieve the dual goals of maximal tumor removal and minimal functional consequences in patients undergoing glioma resection.

Utility of repeat magnetic resonance imaging in surgical patients with lumbar stenosis without disc herniation.

BACKGROUND CONTEXT: Routine use of magnetic resonance imaging (MRI) as a diagnostic tool in lumbar stenosis is becoming more prevalent due to the aging population. Currently, there is no clinical guideline to clarify the utility of repeat MRI in patients with lumbar stenosis, without instability, neurological deficits, or disc herniation. PURPOSE: To evaluate the utility of routine use of MRI as a diagnostic tool in lumbar stenosis, and to help formulate clinical guidelines on the appropriate use of preoperative imaging for lumbar stenosis. STUDY DESIGN/SETTING: Retrospective radiographic analysis. PATIENT SAMPLE: Retrospective chart review was performed to review patients with lumbar stenosis, who underwent lumbar decompression without fusion from 2011 to 2015 at a single institution. OUTCOME MEASURES: Previously established stenosis grading systems were used to measure and compare the initial and the subsequent repeat lumbar MRIs performed preoperatively. If patients were found to have a moderate or severe grade change, and if the surgical plan was altered due to such exacerbated radiographic findings, then their grade changes were considered clinically meaningful. METHODS: We identified patients with lumbar stenosis without radiographic instability or neurological deficits, who had at least two preoperative lumbar MRIs performed and underwent decompressive surgeries. At each pathologic disc level, the absolute value of the change in grade for central and lateral recess stenosis, right foraminal stenosis, and left foraminal stenosis from the first preoperative MRI to the repeated MRI was calculated. These changed data were then used to calculate the mean and median changes in each of the three types of stenosis for each pathologic disc level. Identical calculations were carried out for the subsample of patients who only underwent discectomy or had a discectomy included as part of their surgery. RESULTS: Among the 103 patients who met the inclusion criteria, 37 of those patients had more than one level surgically addressed, and a total of 161 lumbar levels were reviewed. Among the subset of patients that had any grade change, the majority of the grades only had a mild change of 1 (36 out of 42 patients, 85.7%, 95% confidence interval [CI]: 73.1%-94.1%); there was a moderate grade change of 2 in two patients (4.8%, CI: 0.8%-14.0%), and a severe change of 3 in one patient (2.4%, CI: 0.2%-10.1%). There were three patients with decreased grade change (7.1%, CI: 1.8%-17.5%). All clinically meaningful grade changes were from the subset of patients who had only discectomy or discectomy as part of the procedure. Lastly, both patients that had a clinically meaningful grade change had their MRIs performed at an interval of greater than 360 days. CONCLUSIONS: The radiographic evaluation of the utility of routinely repeated MRIs in lumbar stenosis without instability, neurological deficits, or disc herniations demonstrated that there were no significant changes found in the repeated MRI in the preoperative setting, especially if the MRIs were performed less than one year apart. The results of this present study can help to standardize the diagnostic evaluation of lumbar stenosis and to formulate clinical guidelines on the appropriate use of preoperative imaging for lumbar stenosis patients.

Thalamic Deep Brain Stimulation.

The use of deep brain stimulation (DBS) of the thalamus has been proven to be a safe and efficacious treatment for the management of many diseases. The most common indication for thalamic DBS remains essential tremor (ET), one of the most common movement disorders in the world. ET patients should be considered for surgical intervention when their tremor has demonstrated to be refractory to medication, a characteristic estimated to be present in roughly 50% of ET cases. Advantages of DBS over thalamotomy include its reversibility, the ability to adjust stimulation settings to optimize efficacy and minimize side effects, the ability to perform bilateral procedures safely, and an association with a lower risk of postoperative cognitive problems. The most common target of DBS for ET is the ventralis intermedius (VIM) of the thalamus, and the optimal electrode location corresponds to the anterior margin of the VIM. Other indications for thalamic DBS include non-ET tremor, obsessive-compulsive disorder, neuropathic pain, traumatic brain injury, Tourette's syndrome, and drug-resistant epilepsy among others.

Misplacement of Stent Into Epidural Venous Plexus With Resultant Cauda Equina Syndrome and Open Surgical Treatment: A Case Report.

BACKGROUND AND IMPORTANCE: Endovascular therapy has proven to be a safe, minimally invasive treatment for multiple etiologies, but proper precautions must be taken to avoid complications. When complications occur, they should be promptly identified and corrected when possible. This case report describes endovascular stents misplaced into the epidural spinous venous plexus rather than the iliofemoral arteries, causing cauda equina syndrome, as well as the spinal procedure performed to treat the resulting spinal canal compression. CLINICAL PRESENTATION: A 67-yr-old man had undergone what he thought was iliofemoral arterial stenting at an outside hospital for peripheral vascular disease. He presented 8 d later to our hospital with cauda equina syndrome comprising back pain, right L5 radiculopathy, perianal numbness, urinary retention, and constipation. Scans demonstrated stents deployed into the venous system, traversing the spinal canal and the right L5-S1 neural foramen, resulting in severe spinal canal stenosis, right L5-S1 foraminal stenosis, and moderate left S1-S2 foraminal stenosis. The patient underwent an L5-S1 laminectomy with full right L5-S1 facetectomy and left S1-S2 medial facetectomy, with associated L5-S1 posterolateral fusion with fixation to remove the stent and decompress the neural elements. CONCLUSION: Although stent misplacement is an uncommon complication of endovascular therapy, this case demonstrates the importance of ensuring access to the proper vessel before stent placement. Once this complication was recognized, safe removal of the stents was possible and the patient demonstrated meaningful postoperative improvement in symptoms and strength.

Pleomorphic Hyalinizing Angiectatic Tumor Arising in the Hand: A Case Report.

Background: Background: Pleomorphic hyalinizing angiectatic tumors (PHATs) are extremely rare, non-metastasizing tumors of uncertain origin that are typically seen in the lower extremities. To date, it is estimated that less than 100 cases have been reported worldwide since first described in 1996. Methods: The case of a 35-year-old male with a several-year history of a dorsal hand mass is presented. Although the patient was initially asymptomatic, in the months prior to presentation, the patient complained of pain with power grasp and direct pressure over the mass. The patient underwent uncomplicated surgical excision, during which the mass was noted to be adherent to the underlying extensor tendons. Results: Immunopathology confirmed the mass to be PHAT. We believe this is the first documented case of this rare tumor occurring in the hand. Conclusions: History and epidemiology of PHAT are reviewed. Then, in the context of the presented case, pre-operative evaluation, surgical management, pathologic findings and post-operative follow-up are all discussed.

Comparison of Intervertebral ROM in Multi-Level Cadaveric Lumbar Spines Using Distinct Pure Moment Loading Approaches.

BACKGROUND: Pure-moment loading is the test method of choice for spinal implant evaluation. However, the apparatuses and boundary conditions employed by laboratories in performing spine flexibility testing vary. The purpose of this study was to quantify the differences, if they exist, in intervertebral range of motion (ROM) resulting from different pure-moment loading apparatuses used in two laboratories. METHODS: Twenty-four (laboratory A) and forty-two (laboratory B) intact L1-S1 specimens were loaded using pure moments (±7.5 Nm) in flexion-extension (FE), lateral bending (LB) and axial torsion (AT). At laboratory A, pure moments were applied using a system of cables, pulleys and suspended weights in 1.5 Nm increments. At laboratory B, specimens were loaded in a pneumatic biaxial test frame mounted with counteracting stepper-motor-driven biaxial gimbals. ROM was obtained in both labs using identical optoelectronic systems and compared. RESULTS: In FE, total L1-L5 ROM was similar, on average, between the two laboratories (lab A: 37.4° ± 9.1°; lab B: 35.0° ± 8.9°, p=0.289). Larger apparent differences, on average, were noted between labs in AT (lab A: 19.4° ± 7.3°; lab B: 15.7° ± 7.1°, p=0.074), and this finding was significant for combined right and left LB (lab A: 45.5° ± 11.4°; lab B: 35.3° ± 8.5°, p < 0.001). CONCLUSIONS: To our knowledge, this is the first study comparing ROM of multi-segment lumbar spines between laboratories utilizing different apparatuses. The results of this study show that intervertebral ROM in multi-segment lumbar spine constructs are markedly similar in FE loading. Differences in boundary conditions are likely the source of small and sometimes statistically significant differences between the two techniques in LB and AT ROM. The relative merits of each testing strategy with regard to the physiologic conditions that are to be simulated should be considered in the design of a study including LB and AT modes of loading. An understanding of these differences also serves as important information when comparing study results across different laboratories.

Lateral hypothalamic area deep brain stimulation for refractory obesity: a pilot study with preliminary data on safety, body weight, and energy metabolism.

OBJECT: Deep brain stimulation (DBS) of the lateral hypothalamic area (LHA) has been suggested as a potential treatment for intractable obesity. The authors present the 2-year safety results as well as early efficacy and metabolic effects in 3 patients undergoing bilateral LHA DBS in the first study of this approach in humans. METHODS: Three patients meeting strict criteria for intractable obesity, including failed bariatric surgery, underwent bilateral implantation of LHA DBS electrodes as part of an institutional review board- and FDA-approved pilot study. The primary focus of the study was safety; however, the authors also received approval to collect data on early efficacy including weight change and energy metabolism. RESULTS: No serious adverse effects, including detrimental psychological consequences, were observed with continuous LHA DBS after a mean follow-up of 35 months (range 30-39 months). Three-dimensional nonlinear transformation of postoperative imaging superimposed onto brain atlas anatomy was used to confirm and study DBS contact proximity to the LHA. No significant weight loss trends were seen when DBS was programmed using standard settings derived from movement disorder DBS surgery. However, promising weight loss trends have been observed when monopolar DBS stimulation has been applied via specific contacts found to increase the resting metabolic rate measured in a respiratory chamber. CONCLUSIONS: Deep brain stimulation of the LHA may be applied safely to humans with intractable obesity. Early evidence for some weight loss under metabolically optimized settings provides the first "proof of principle" for this novel antiobesity strategy. A larger follow-up study focused on efficacy along with a more rigorous metabolic analysis is planned to further explore the benefits and therapeutic mechanism behind this investigational therapy.

Accuracy of the freehand pass technique for ventriculostomy catheter placement: retrospective assessment using computed tomography scans.

OBJECTIVES: The standard method of ventriculostomy catheter placement is a freehand pass technique using surface anatomical landmarks. This study was undertaken to determine the accuracy of successful ventriculostomy procedures performed at a single institution's intensive care unit (ICU). The authors hypothesized that use of surface anatomical landmarks alone with successful results frequently do not correlate with desirable catheter tip placement. METHODS: Retrospective evaluation was performed on the head computed tomography (CT) scans of 97 patients who underwent 98 freehand pass ventriculostomy catheter placements in an ICU setting. Using the postprocedure CT scans of the patients, 3D measurements were made to calculate the accuracy of ventriculostomy catheter placement. RESULTS: The mean distance (+/- standard deviation [SD]) from the catheter tip to the Monro foramen was 16 +/- 9.6 mm. The mean distance (+/- SD) from the catheter tip to the center of the bur hole was 87.4 +/- 14.0 mm. Regarding accurate catheter tip placement, 56.1% of the catheter tips were in the ipsilateral lateral ventricle, 7.1% were in the contralateral lateral ventricle, 8.2% were in the third ventricle, 6.1% were within the interhemispheric fissure, and 22.4% were within extraventricular spaces. CONCLUSIONS: The accuracy of freehand ventriculostomy catheterization at the authors' institution typically required 2 passes per successful placement, and, when successful, was 1.6 cm from the Monro foramen. More importantly, 22.4% of these catheter tips were in nonventricular spaces. Although many neurosurgeons believe that the current practice of ventriculostomy is good enough, the results of this study show that there is certainly much room for improvement.