The Scope and Impact of the COVID-19 Pandemic on Neuroemergent Patient Transfers, Clinical Care and Patient Outcomes.

Introduction: The SARS-CoV-2 (COVID-19) pandemic continues to substantially alter previously established clinical practice patterns and has transformed patient care in American healthcare. However, studies to evaluate the impact of COVID-19 on neuroemergent patient care and associated clinical outcomes are limited. Herein, we describe the impact of COVID-19 on the Neuroemergency Transfer Program (NTP) - a novel, urban, high volume interhospital patient transfer program. Objective: To evaluate and describe the clinical impact of the COVID-19 pandemic on the NTP. Study Design: A single-center retrospective study of prospectively collected consecutive neuroemergent patient transfer data between 2018-2021 was analyzed. Adult patients were divided based upon transfer date into a Pre-COVID (PCOV) or COVID cohort. Patient demographics, transfer characteristics and clinical data and outcomes were analyzed. Results: 3,096 patients were included for analysis. Mean age at transfer in the PCOV and COVID cohorts were 62.4 ± 0.36 and 61.1 ± 0.6 years. A significant decrease in mean transfers per month was observed between cohorts (PCOV = 97.8 vs. COV = 68.2 transfers/month, p < 0.01). Total transfer time in the PCOV cohort was 155.1 ± 3.4 min which increased to 169.3 ± 12.8 min in the COVID cohort (p = 0.13). Overall mean transfer distance was significantly longer in the PCOV cohort at 22.0 ± 0.4 miles vs. 20.3 ± 0.67 miles in the COV cohort (p = 0.03). The relative frequency of transfer diagnoses was unchanged between cohorts. A significant increase in mean inpatient length of stay was noted, 7.9 ± 0.15 days to 9.6 ± 0.33 days in the PCOV vs. COVID cohorts (p < 0.01). Ultimately, no difference in the frequency of good vs. poor clinical outcome were noted between the PCOV (79.8% and 19.4%) vs. COV (78.8% and 20.4%) cohorts. Conclusion: The impact of COVID-19 on current healthcare dynamics are far reaching. Here, we show a significant decrease in interhospital patient transfers and increased length of stay between a Pre-COVID and COVID cohort. Further work to better elucidate the specific interplay of clinical contributors to account for these changes is indicated.

Petrous Apex Cephaloceles: Radiology Features and Surgical Management of a Rare Entity.

OBJECTIVE: To characterize the radiologic findings of petrous apex cephalocele (PAC) in a patient cohort, and report the surgical management for three symptomatic PAC patients and cerebrospinal fluid (CSF) leak via the middle cranial fossa approach. STUDY DESIGN: Retrospective case series. SETTING: Academic center. PATIENTS: Thirty-five patients with PAC were identified by review of the imaging archive between 2008 and 2019 (29 females; mean, 55 yrs; range, 4-86 yrs). All patients underwent magnetic resonance imaging of the skull base and/or computed tomography examination. INTERVENTIONS: Surgical repair of PAC. MAIN OUTCOME MEASURES: Radiologic features of PAC. RESULTS: Radiological features of PAC: 25.7% bilateral; partial or expanded empty sella in 82.9%; arachnoid pits in 14.2%; and enlarged CSF space of optic nerve sheath in 20.0%. Coexisting pathology included temporal, sphenoid, and bilateral jugular foramen meningocele; as well as cribriform, middle crania fossa, and right temporal defect. Three case studies describing the surgical course of spontaneous CSF leak secondary to PAC were managed with the middle cranial fossa approach. CONCLUSIONS: PAC is an exceedingly unusual cause for CSF leak in the adult and pediatric population. A middle fossa approach may be used to treat CSF leak as a result of PAC. Typically, CSF otorrhea originates from an encephalocele that extends via a bony defect in the tegmen tympani or tegmen mastoideum. However, on occasion the source of the CSF otorrhea is not via the tegmen, instead defects in the middle fossa floor, medial to the ridge for the gasserian ganglion (tubercle of Princeteau), need to be considered.

Atypical Teratoid/Rhabdoid Tumor of the Conus Medullaris.

INTRODUCTION: Atypical teratoid/rhabdoid tumor (AT/RT) is a rare tumor of the central nervous system, especially when involving the spinal column or spinal cord. CASE PRESENTATION: We present a case of a 5-year-old girl with progressive bilateral lower extremity pain found to have a discrete nodular lesion of the conus with mild heterogeneous enhancement. Surgical decompression and resection demonstrated a pathologic tumor consistent with AT/RT with loss of INI1 protein on immunohistochemistry. DISCUSSION AND CONCLUSION: AT/RT lesions of the conus medullaris are exceedingly rare and associated with extensive disease. We report a rare case of AT/RT with selective involvement of the conus medullaris, as well as describe the surgical, radiographic, and pathologic findings of this tumor.

A Pivotal Randomized Clinical Trial Evaluating the Safety and Effectiveness of a Novel Hydrogel Dural Sealant as an Adjunct to Dural Repair.

BACKGROUND: A watertight dural repair is critical to minimizing the risk of postoperative complications secondary to cerebrospinal fluid (CSF) leaks. OBJECTIVE: To evaluate the safety and efficacy of a novel hydrogel, Adherus Dural Sealant, when compared with control, DuraSeal Dural Sealant System, as an adjunct to standard methods of dural repair. METHODS: In this 17-center, prospective, randomized clinical trial designed as a noninferiority, single-blinded study, 124 patients received Adherus Dural Sealant (test sealant) and 126 received DuraSeal (control). The primary composite endpoint was the proportion of patients who were free of any intraoperative CSF leakage during Valsalva maneuver after dural repair, CSF leak/pseudomeningocele, and unplanned retreatment of the surgical site. Each component was then analyzed individually as a secondary endpoint. Patients were followed for 4 mo after surgery. RESULTS: The primary composite endpoint at the 120-d follow-up was achieved in 91.2% of the test sealant group compared with 90.6% of the control, thus showing that the test sealant was statistically significantly noninferior to DuraSeal ( P = .0049). Post hoc analysis of the primary composite endpoint at 14 d demonstrated superiority of the test sealant over the control ( P = .030). Primary endpoint failures in the control group tended to occur early in follow-up period, while a majority of test dural sealant failures were identified through protocol-required radiographic imaging at the 120-d follow-up visit. CONCLUSION: The test sealant, Adherus Dural Sealant, is a practical, safe, and effective adjunct to achieving a watertight dural closure after primary dural closure in cranial procedures.

Post-operative intracranial hemorrhage related to using t-PA for declotting an occluded hemodialysis catheter: A cautionary tale.

Heparin and thrombolytic agents such as tissue plasminogen activator (t-PA) are frequently used to prevent and treat occluded hemodialysis (HD) catheters. Thrombolytic agents have not been well studied for systemic effects. We present a post-operative neurosurgical patient who experienced a symptomatic intracranial hemorrhage (ICH) after t-PA was used to treat an occluded HD catheter. This case highlights that using t-PA to treat dysfunctional catheters may be associated with ICH in neurosurgical patients. Management strategies are discussed with a review of pertinent literature.

Minimally invasive evacuation of intraventricular hemorrhage with the Apollo vibration/suction device.

Intraventricular hemorrhages (IVH) can occur as a consequence of spontaneous intracerebral hemorrhage, aneurysm rupture, arteriovenous malformation hemorrhage, trauma, or coagulopathy. IVH is a known risk factor for poor clinical outcome with up to 80% mortality. The current standard treatment strategy for IVH consists of the placement of an external ventricular drain. We report our early experience with using the Apollo suction/vibration aspiration system (Penumbra, Alameda, CA, USA) for minimally invasive evacuation of IVH with a review of the pertinent literature. Medical records of patients with IVH who were admitted to Rush University Medical Center, USA, from July to November 2014 were queried from the electronic database. Patients with Graeb Scores (GS) >6 were selected for minimally invasive IVH evacuation with the Apollo aspiration system. Patient demographics, pre- and post-operative GS, pre- and post-operative modified Graeb Score (mGS), as well procedure related complications were analyzed and recorded. A total of eight patients (five men) were identified during the study period. The average age was 55.5years. The mean GS was 9.6 pre-operatively and decreased to 4.9 post-operatively (p=0.0002). The mean mGS was 22.9 pre-operatively and decreased to 11.4 post-operatively (p=0.0001). Most of the IVH reduction occurred in the frontal horn and atrium of the lateral ventricle, as well the third ventricle. One (1/8) procedure-related complication occurred consisted of a tract hemorrhage. The Apollo system can be used for minimally invasive IVH evacuation to achieve significant blood clot volume reduction with minimal procedure-related complication.

Hyperdense suprasellar mass: An unusual radiological presentation of intracranial dermoid cyst.

We report an exceedingly rare patient with a hyperdense suprasellar dermoid cyst and a pertinent review of the literature. Intracranial dermoid tumors are rare congenital lesions of the brain that account for less than 1% of all intracranial tumors. Even though they are rare, typical CT scan and MRI features and location allow radiological diagnosis in the majority of patients. Radiologically, dermoid cysts typically present as low density masses on CT scan and are generally hyperintense on T1-weighted MRI sequences with variable signal on T2-weighted sequences. The recognition of atypical features can avoid diagnostic pitfalls and is clinically relevant for overall surgical management.

Outcome following intracranial hemorrhage associated with novel oral anticoagulants.

The emergence of dabigatran, rivaroxaban and apixaban has changed the approach to anticoagulation for patients worldwide. Continued approval of novel oral anticoagulants (NOAC) for non-valvular atrial fibrillation and venous thromboembolism will result in increasing use of these medications over warfarin. Morbidity and mortality of anticoagulant related intracranial hemorrhage (ICH) is relatively high and there is concern that outcomes may be worse with NOAC as there is a lack of specific antidotes for these agents with a greater risk for hematoma expansion. Unfortunately, the evidence supporting effective reversal strategies is lacking. Therefore, to gain further insight into the outcome after the management of NOAC related ICH, we present our experience with two patients with NOAC-induced ICH.

Ventriculoperitoneal shunt with a rare twist: small-bowel ischemia and necrosis secondary to knotting of peritoneal catheter.

Small-bowel ischemia and necrosis due to knotting of the peritoneal catheter is an extremely rare complication related to a ventriculoperitoneal shunt (VPS). A 3-month-old girl, with a history of Chiari II malformation and myelomeningocele (MM) after undergoing right occipital VPS insertion and MM repair at birth, presented to the emergency department with a high-grade fever. Examination of a CSF sample obtained via shunt tap raised suspicion for the presence of infection. Antibiotic therapy was initiated, and subsequently the VPS was removed and an external ventricular drain was placed. Intraoperatively, as attempts at pulling the distal catheter from the scalp incision were met with resistance, the distal catheter was cut and left in the abdomen while the remainder of the shunt system was successfully removed. While the patient was awaiting definitive shunt revision surgery to replace the VPS, she developed abdominal distension due to small-bowel obstruction. An emergency exploratory laparotomy revealed a knot in the distal catheter looping around and strangulating the distal ileum, causing small-bowel ischemia and necrosis in addition to the obstruction. A small-bowel resection with ileostomy was performed, with subsequent placement of ventriculoatrial shunt for treatment of hydrocephalus. The authors report this exceedingly rare clinical scenario to highlight the fact that any retained distal catheter must be carefully managed with immediate abdominal exploration to remove the distal catheter to avoid bowel necrosis as pulling of a knotted peritoneal catheter may strangulate the bowel and cause ischemia, with significant clinical morbidity and possible mortality.

Relevance of early head CT scans following neurosurgical procedures: an analysis of 892 intracranial procedures at Rush University Medical Center.

OBJECT: Early postoperative head CT scanning is routinely performed following intracranial procedures for detection of complications, but its real value remains uncertain: so-called abnormal results are frequently found, but active, emergency intervention based on these findings may be rare. The authors' objective was to analyze whether early postoperative CT scans led to emergency surgical interventions and if the results of neurological examination predicted this occurrence. METHODS: The authors retrospectively analyzed 892 intracranial procedures followed by an early postoperative CT scan performed over a 1-year period at Rush University Medical Center and classified these cases according to postoperative neurological status: baseline, predicted neurological change, unexpected neurological change, and sedated or comatose. The interpretation of CT results was reviewed and unexpected CT findings were classified based on immediate action taken: Type I, additional observation and CT; Type II, active nonsurgical intervention; and Type III, surgical intervention. Results were compared between neurological examination groups with the Fisher exact test. RESULTS: Patients with unexpected neurological changes or in the sedated or comatose group had significantly more unexpected findings on the postoperative CT (p < 0.001; OR 19.2 and 2.3, respectively) and Type II/III interventions (p < 0.001) than patients at baseline. Patients at baseline or with expected neurological changes still had a rate of Type II/III changes in the 2.2%-2.4% range; however, no patient required an immediate return to the operating room. CONCLUSIONS: Over a 1-year period in an academic neurosurgery service, no patient who was neurologically intact or who had a predicted neurological change required an immediate return to the operating room based on early postoperative CT findings. Obtaining early CT scans should not be a priority in these patients and may even be cancelled in favor of MRI studies, if the latter have already been planned and can be performed safely and in a timely manner. Early postoperative CT scanning does not assure an uneventful course, nor should it replace accurate and frequent neurological checks, because operative interventions were always decided in conjunction with the neurological examination.

Impact of therapeutic regimen and clinical presentation on overall survival in CNS lymphoma.

BACKGROUND: The authors present a retrospective analysis of 45 patients who underwent treatment of CNS lymphoma (both primary and secondary) at a single institution between 2005 and 2012. METHODS: This study involves 21 female and 24 male patients with a mean age of 59.2 years. All medical records and pathology reports were reviewed for each patient. Univariate and multivariate analyses of overall survival were performed. RESULTS: Presentation with altered mental status was a significant risk factor for worse overall survival. An HIV infection, deep lesion location, and age over 60 did not impact survival. A survival benefit was demonstrated with the use of systemic therapy, specifically rituximab, and radiation. The CNS Lymphoma Score was derived from this cohort, which proved a powerful predictive tool for overall survival. The surgical complication rate in this series was 17.8 %. CONCLUSIONS: This study highlights the prognostic importance of presenting mental status on outcomes in CNS lymphoma and demonstrates a summative benefit of rituximab and whole brain radiation therapy. Considering these factors together provides an easily applicable and meaningful stratification for this patient population. The surgical complication rate in this patient population is not negligible. The high percentage of wound-related surgical complications suggests the need for a waiting period between surgery and initiation of chemotherapy to allow for wound healing.

Stereotactic radiosurgery boost to the resection cavity for cerebral metastases: Report of overall survival, complications, and corticosteroid protocol.

BACKGROUND: This report focuses on the overall survival and complications associated with treatment of cerebral metastases with surgical resection followed by stereotactic radiosurgery (SRS). Management and complications of corticosteroid therapy are underreported in the literature but represent an important source of morbidity for patients. METHODS: Fifty-nine consecutive patients underwent surgical resection of a cerebral metastasis followed by SRS to the cavity. Patient charts were reviewed retrospectively to ascertain overall survival, local control, surgical complications, SRS complications, and corticosteroid complications. RESULTS: Our mean follow-up was 14.4 months (median 12.0 months, range 0.9-62.9 months). Median overall survival in this series was 15.25 months and local control was 98.3%. There was a statistically significant survival benefit conferred by Radiation Therapy Oncology Group recursive partitioning analysis Classes 1 and 2. The surgical complication rate was 6.8% while the SRS complication rate was 2.4%. Corticosteroid complications are reported and dependence at 1 month was 20.3%, at 3 months 6.8%, at 6 months 1.7%, and at 12 months no patients remained on corticosteroid therapy. CONCLUSIONS: Overall survival and local control with this treatment paradigm compare well to the other published literature. Complications associated with this patient population are low. A corticosteroid tapering protocol is proposed and demonstrated lower rates of steroid-related complications and dependence than previously reported.

Selective excision of cerebral metastases from the precentral gyrus.

BACKGROUND: The surgical management of cerebral metastases to the eloquent cortex is a controversial topic. Precentral gyrus lesions are often treated with whole brain radiation therapy (WBRT) or stereotactic radiosurgery (SRS) because of the concern for causing new or worsened postoperative neurological deficits. However, there is evidence in the literature that radiation therapy carries significant risk of complication. We present a series of patients who were symptomatic from a precentral gyrus metastasis and underwent surgical excision. METHODS: During a 2-year period from 2010 to 2012, 17 consecutive patients harboring a cerebral metastasis within the precentral gyrus underwent microsurgical resection. All patients were discussed at a multi-disciplinary tumor board. The prerequisite for neurosurgical treatment was stable systemic disease and life expectancy greater than 6 months as determined by the patient's oncologist. Patients also were required to harbor a symptomatic lesion within the motor cortex, defined as the precentral gyrus. RESULTS: We present the 3-month neurological outcome for this group of patients. Surgery was uneventful and without any severe perioperative complications in all 17 patients. At 3 month follow up, symptoms had improved or been stabilized in 94.1% of patients and were worsened in 5.9%. CONCLUSION: Our results have shown that surgery for cerebral metastases in the precentral gyrus can be done safely and improve or stabilize the neurological function of most patients. Microsurgical resection of precentral gyrus metastases should be a treatment option for patients with single or multiple lesions who present a focal neurologic deficit. This can be performed safely and without intraoperative cortical mapping.