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Hannah E. Goldstein, Andrew Poliakov, Dennis W. Shaw, Dwight Barry, Kieu Tran, Edward J. Novotny, Russell P. Saneto, Ahmad Marashly, Molly H. Warner, Jason N. Wright, Jason S. Hauptman, Jeffrey G. Ojemann, and Hillary A. Shurtleff

OBJECTIVE

The goal of epilepsy surgery is both seizure cessation and maximal preservation of function. In temporal lobe (TL) cases, the lack of functional MRI (fMRI) tasks that effectively activate mesial temporal structures hampers preoperative memory risk assessment, especially in children. This study evaluated pediatric TL surgery outcome optimization associated with tailored resection informed by an fMRI memory task.

METHODS

The authors identified focal onset TL epilepsy patients with 1) TL resections; 2) viable fMRI memory scans; and 3) pre- and postoperative neuropsychological (NP) evaluations. They retrospectively evaluated preoperative fMRI memory scans, available Wada tests, pre- and postoperative NP scores, postoperative MRI scans, and postoperative Engel class outcomes. To assess fMRI memory task outcome prediction, the authors 1) overlaid preoperative fMRI activation onto postoperative structural images; 2) classified patients as having "overlap" or "no overlap" of activation and resection cavities; and 3) compared these findings with memory improvement, stability, or decline, based on Reliable Change Index calculations.

RESULTS

Twenty patients met the inclusion criteria. At a median of 2.1 postoperative years, 16 patients had Engel class IA outcomes and 1 each had Engel class IB, ID, IIA, and IID outcomes. Functional MRI activation was linked to NP memory outcome in 19 of 20 cases (95%). Otherwise, heterogeneity characterized the cohort.

CONCLUSIONS

Functional MRI memory task activation effectively predicted individual NP outcomes in the context of tailored TL resections. Patients had excellent seizure and overall good NP outcomes. This small study adds to extant literature indicating that pediatric TL epilepsy does not represent a single clinical syndrome. Findings support individualized surgical intervention using fMRI memory activation to help guide this precision medicine approach.

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Chang Hwan Pang, Si Un Lee, Yongjae Lee, Woong-Beom Kim, Min-Yong Kwon, Leonard Sunwoo, Tackeun Kim, Jae Seung Bang, O-ki Kwon, and Chang Wan Oh

OBJECTIVE

The aim of this study was to identify predictive factors for hemorrhagic cerebral hyperperfusion syndrome (hCHS) after direct bypass surgery in adult nonhemorrhagic moyamoya disease (non-hMMD) using quantitative parameters on rapid processing of perfusion and diffusion (RAPID) perfusion CT software.

METHODS

A total of 277 hemispheres in 223 patients with non-hMMD who underwent combined bypass were retrospectively reviewed. Preoperative volumes of time to maximum (Tmax) > 4 seconds and > 6 seconds were obtained from RAPID analysis of perfusion CT. These quantitative parameters, along with other clinical and angiographic factors, were statistically analyzed to determine the significant predictors for hCHS after bypass surgery.

RESULTS

Intra- or postoperative hCHS occurred in 13 hemispheres (4.7%). In 7 hemispheres, subarachnoid hemorrhage occurred intraoperatively, and in 6 hemispheres, intracerebral hemorrhage was detected postoperatively. All hCHS occurred within the 4 days after bypass. Advanced age (OR 1.096, 95% CI 1.039–1.163, p = 0.001) and a large volume of Tmax > 6 seconds (OR 1.011, 95% CI 1.004–1.018, p = 0.002) were statistically significant factors in predicting the risk of hCHS after surgery. The cutoff values of patient age and volume of Tmax > 6 seconds were 43.5 years old (area under the curve [AUC] 0.761) and 80.5 ml (AUC 0.762), respectively.

CONCLUSIONS

In adult patients with non-hMMD older than 43.5 years or with a large volume of Tmax > 6 seconds over 80.5 ml, more prudence is required in the decision to undergo bypass surgery and in postoperative management.

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Edoardo Agosti, Stephen Graepel, and Giuseppe Lanzino

Arteriovenous malformations (AVMs) are some of the most challenging surgical entities. Like any challenging surgical procedure, AVM surgery is a series of basic but fundamental steps, each with its own nuances. Despite a myriad of published material regarding AVMs, there are few succinct illustrated summaries of these steps with an accompanying elucidation of the most common pitfalls. This paper provides a step-by-step description and illustration of the basic surgical principles of AVM microsurgical resection, focusing on the main key points and addressing the critical issues that surround this surgery. Deep anatomical knowledge and presurgical planning of these basic steps, combined with good contingency management skills, are paramount for an effective and safe AVM surgery.

Open access

Lauren E. Stone, Luis Daniel Diaz-Aguilar, David Rafael Santiago-Dieppa, William R. Taylor, and Andrew D. Nguyen

The lateral lumbar interbody fusion has evolved as newly envisioned access corridors become feasible with technological advances. Prone lateral access has evolved as a single-access approach to combine the benefits of minimally invasive surgery with direct and indirect decompression of the neural elements with synergistic anterior and posterior column correction. In this video, the authors discuss the pearls, pitfalls, and adjuvant technologies they use in a high-volume prone lateral center via case demonstration of a prone lateral corpectomy.

The video can be found here: https://stream.cadmore.media/r10.3171/2022.3.FOCVID2216

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Rebecca A. Reynolds, Katherine A. Kelly, Ranbir Ahluwalia, Shilin Zhao, E. Haley Vance, Harold N. Lovvorn III, Holly Hanson, Chevis N. Shannon, and Christopher M. Bonfield

OBJECTIVE

Isolated linear skull fractures without intracranial findings rarely require urgent neurosurgical intervention. A multidisciplinary fracture management protocol based on antiemetic usage was implemented at our American College of Surgeons–verified level 1 pediatric trauma center on July 1, 2019. This study evaluated protocol safety and efficacy.

METHODS

Children younger than 18 years with an ICD-10 code for linear skull fracture without acute intracranial abnormality on head CT were compared before and after protocol implementation. The preprotocol cohort was defined as children who presented between July 1, 2015, and December 31, 2017; the postprotocol cohort was defined as those who presented between July 1, 2019, and July 1, 2020.

RESULTS

The preprotocol and postprotocol cohorts included 162 and 82 children, respectively. Overall, 57% were male, and the median (interquartile range) age was 9.1 (4.8–25.0) months. The cohorts did not differ significantly in terms of sex (p = 0.1) or age (p = 0.8). Falls were the most common mechanism of injury (193 patients [79%]). After protocol implementation, there was a relative increase in patients who fell from a height > 3 feet (10% to 29%, p < 0.001) and those with no reported injury mechanism (12% to 16%, p < 0.001). The neurosurgery department was consulted for 86% and 44% of preprotocol and postprotocol cases, respectively (p < 0.001). Trauma consultations and consultations for abusive head trauma did not significantly change (p = 0.2 and p = 0.1, respectively). Admission rate significantly decreased (52% to 38%, p = 0.04), and the 72-hour emergency department revisit rate trended down but was not statistically significant (2.8/year to 1/year, p = 0.2). No deaths occurred, and no inpatient neurosurgical procedures were performed.

CONCLUSIONS

Protocolization of isolated linear skull fracture management is safe and feasible at a high-volume level 1 pediatric trauma center. Neurosurgical consultation can be prioritized for select patients. Further investigation into criteria for admission, need for interfacility transfers, and healthcare costs is warranted.

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Rong Xie, Jinping Liu, Minghao Wang, Yinhui Dong, Praveen V. Mummaneni, and Dean Chou

OBJECTIVE

Postoperative dysphagia after anterior cervical discectomy and fusion (ACDF) has many contributing factors, and long-term data are sparse. The authors evaluated dysphagia after ACDF based on levels fused and cervical sagittal parameters.

METHODS

Patients who underwent ACDF between 2009 and 2018 at the University of California, San Francisco (UCSF), were retrospectively studied. Dysphagia was evaluated preoperatively, immediately postoperatively, and at last follow-up using the UCSF dysphagia score. Dysphagia was categorized as normal (level 7), mild (levels 5 and 6), moderate (levels 3 and 4), and severe (levels 1 and 2). The UCSF mild dysphagia score was further classified as "minimal dysphagia," while moderate and severe dysphagia were classified as "significant dysphagia." "Any dysphagia" included any dysphagia, regardless of grade. Cervical sagittal parameters were measured preoperatively, immediately postoperatively, and at last follow-up.

RESULTS

A total of 131 patients met inclusion criteria. The mean follow-up was 43.89 (24–142) months. Seventy-eight patients (59.5%) reported dysphagia immediately postoperatively, and 44 patients (33.6%) reported some dysphagia at last follow-up (p < 0.001). The rates of moderate dysphagia were 13.0% immediately postoperatively and 1.5% at the last follow-up (p < 0.001). Twenty-two patients (16.8%) had significant dysphagia immediately postoperatively, and 2 patients (1.5%) had significant dysphagia at last follow-up (p < 0.001). Patients with immediate postoperative dysphagia had less C2–7 preoperative lordosis (−9.35°) compared with patients without (−14.15°, p = 0.029), but there was no association between C2–7 lordosis and dysphagia at last follow-up (p = 0.232). The prevalence rates of immediate postoperative dysphagia and long-term dysphagia were 87.5% and 58.3% in ≥ 3-level ACDF; 64.0% and 40.0% in 2-level ACDF; and 43.9% and 17.5% in 1-level ACDF, respectively (p < 0.001).

CONCLUSIONS

The realistic incidence of any dysphagia after ACDF was 59.5% immediately postoperatively and 33.6% at the minimum 2-year follow-up, higher than previously published rates. However, most dysphagia was not severe. The number of fused levels was the most important risk factor for long-term dysphagia, but not for immediate postoperative dysphagia. Loss of preoperative C2–7 lordosis was associated with immediate postoperative dysphagia, but not long-term dysphagia. ACDF segmental lordosis and cervical sagittal vertical axis were not associated with long-term dysphagia in ACDF.

Free access

Stylianos Pikis, Georgios Mantziaris, Purushotham Ramanathan, Zhiyuan Xu, and Jason P. Sheehan

OBJECTIVE

The purpose of this retrospective, single-institution study was to evaluate radiological and clinical outcomes of patients managed with repeat stereotactic radiosurgery (SRS) for residual cerebral arteriovenous malformation (AVM) after prior SRS.

METHODS

The authors evaluated the clinical and radiological outcomes of consecutive patients treated with repeat single-session SRS for a residual brain AVM from 1989 to 2021.

RESULTS

In total, 170 patients underwent repeat SRS for AVM (90 [52.9%] females; median [interquartile range] age at the first SRS procedure 28 [21.5] years; median [interquartile range] age at the second SRS procedure 32 [22.5] years). After repeat SRS, the actuarial 3-, 5-, and 10-year AVM obliteration rates were 37.6%, 57.3%, and 80.9%, respectively. Higher obliteration rates were associated with margin dose ≥ 19 Gy (p = 0.001). After the second SRS procedure, hemorrhage occurred in 8.2% of patients and was lethal in 1 patient. The risk factors of intracranial hemorrhage were age < 18 years (p = 0.03) and residual AVM diameter > 20 mm (p = 0.004). Lower obliteration rates were noted in patients with residual AVM diameter > 20 mm (p = 0.04) and those < 18 years of age (p = 0.04). Asymptomatic, symptomatic, and permanent radiation-induced changes (RICs) after the second SRS procedure occurred in 25.9%, 8.8%, and 5.3% of patients, respectively, and were associated with RIC after the first SRS procedure (p = 0.006). There was 1 case of a radiation-induced meningioma 12 years after SRS.

CONCLUSIONS

Repeat SRS is a reasonable therapeutic option, in particular for patients with residual AVM. Repeat SRS was associated with more favorable outcomes in adult patients and those with residual AVM smaller than 20 mm in maximum diameter. To increase the rate of residual AVM obliteration, a prescription dose ≥ 19 Gy should ideally be used for repeat SRS.

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Takayoshi Shimizu, Shunsuke Fujibayashi, Bungo Otsuki, Koichi Murata, Soichiro Masuda, and Shuichi Matsuda

OBJECTIVE

Residual anterior spinal cord compression (RASCC) after cervical laminoplasty, which has been confirmed on postoperative MRI, is reportedly associated with poor clinical outcomes. To date, only a few studies have described the risk factors associated with RASCC. The aim of this study was to identify the factors that can predict the occurrence of RASCC after laminoplasty for cervical spondylotic myelopathy (CSM), focusing on the location of the most stenotic segment.

METHODS

In this retrospective, single-center study, 120 patients who underwent C3–7 laminoplasty for multilevel CSM were included. Different techniques were used for C3 decompression, i.e., partial (dome-laminotomy) or complete (laminoplasty/laminectomy) decompression. RASCC was diagnosed using MRI conducted 3 weeks postoperatively. The patients were divided into two groups according to the segment with the most severe stenosis (Seg-MSS; C3–4 vs C4–7). Demographics, radiological data, and C3 decompression technique were compared between the two groups. Furthermore, intergroup comparisons were performed based on Seg-MSS. A logistic regression model was constructed to identify the factors predicting RASCC after patient stratification according to Seg-MSS.

RESULTS

Forty patients (33.3%) had RASCC. The patients with Seg-MSS at C3–4 (51.3%) had a significantly higher incidence of RASCC (p = 0.003) than those with Seg-MSS at C4–7 (24.7%). Logistic regression analysis showed that in patients with Seg-MSS at C3–4, C3 partial decompression demonstrated a greater association with RASCC as opposed to complete decompression. Conversely, in patients with Seg-MSS at C4–7, kyphotic segmental lordotic angle was associated with an increased risk of RASCC.

CONCLUSIONS

The risk factors for RASCC differed depending on the location of the most stenotic segment (C3–4 vs C4–7). If there is segmental kyphosis at the most stenotic segment at C4–7, anterior decompression and fusion should be considered. If C3–4 is the most stenotic segment, anterior surgery is also recommended, but alternatively, one can choose laminoplasty with complete C3 laminectomy and resection of the C2–3 ligamentum flavum.

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Shahab Aldin Sattari, Ataollah Shahbandi, Risheng Xu, Alice Hung, James Feghali, Wuyang Yang, Ryan P. Lee, Chetan Bettegowda, and Judy Huang

OBJECTIVE

In microvascular decompression (MVD) surgery through the retrosigmoid approach, the surgeon may have to sacrifice the superior petrosal vein (SPV). However, this is a controversial maneuver. To date, high-level evidence comparing the operative outcomes of patients who underwent MVD with and without SPV sacrifice is lacking. Therefore, this study sought to bridge this gap.

METHODS

The authors searched the Medline and PubMed databases with appropriate Medical Subject Heading (MeSH) terms and keywords. The primary outcome was vascular-related complications; secondary outcomes were new neurological deficit, cerebrospinal fluid (CSF) leak, and neuralgia relief. The pooled proportions of outcomes and OR (95% CI) for categorical data were calculated by using the logit transformation and Mantel-Haenszel methods, respectively.

RESULTS

Six studies yielding 1143 patients were included, of which 618 patients had their SPV sacrificed. The pooled proportion (95% CI) values were 3.82 (0.87–15.17) for vascular-related complications, 3.64 (1.0–12.42) for new neurological deficits, 2.85 (1.21–6.58) for CSF leaks, and 88.90 (84.90–91.94) for neuralgia relief. The meta-analysis concluded that, whether the surgeon sacrificed or preserved the SPV, the odds were similar for vascular-related complications (2.5% vs 1.5%, OR [95% CI] 1.01 [0.33–3.09], p = 0.99), new neurological deficits (1.2% vs 2.8%, OR [95% CI] 0.55 [0.18–1.66], p = 0.29), CSF leak (3.1% vs 2.1%, OR [95% CI] 1.16 [0.46–2.94], p = 0.75), and neuralgia relief (86.6% vs 87%, OR [95% CI] 0.96 [0.62–1.49], p = 0.84).

CONCLUSIONS

SPV sacrifice is as safe as SPV preservation. The authors recommend intentional SPV sacrifice when gentle retraction fails to enhance surgical field visualization and if the surgeon encounters SPV-related neurovascular conflict and/or anticipates impeding SPV-related bleeding.

Open access

David S. Xu, Gabriella M. Paisan, Joelle N. Hartke, Gennadiy A. Katsevman, Juan S. Uribe, and Laura A. Snyder

The lateral access approach for L1–2 interbody placement or other levels at or near the thoracolumbar junction may be difficult without proper knowledge and visualization of anatomy. Specifically, understanding where the fibers of the diaphragm travel and avoiding injury to the diaphragm are paramount.

The video can be found here: https://stream.cadmore.media/r10.3171/2022.3.FOCVID2221