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Open access

Collateral circulation status–guided mechanical thrombectomy in pediatric stroke with an extended ghost infarct core: illustrative case

Tian-Min Lai, Kun-Xin Lin, Ying Fu, Ling Fang, and Wen-Long Zhao

BACKGROUND

Mechanical thrombectomy (MT) has been proved to be a highly effective therapy to treat acute ischemic stroke due to large vessel occlusion. Often, the ischemic core extent on baseline imaging is an important determinant for endovascular treatment eligibility. However, computed tomography (CT) perfusion (CTP) or diffusion-weighted imaging may overestimate the infarct core on admission and, consequently, smaller infarct lesions called “ghost infarct cores.”

OBSERVATIONS

A 4-year-old, previously healthy boy presented with acute-onset, right-sided weakness and aphasia. Fourteen hours after the onset of symptoms, the patient presented with a National Institutes of Health Stroke Scale (NIHSS) score of 22, and magnetic resonance angiography demonstrated a left middle cerebral artery occlusion. MT was not considered because of a large infarct core (infarct core volume: 52 mL; mismatch ratio 1.6 on CTP). However, multiphase CT angiography indicated good collateral circulation, which encouraged MT. Complete recanalization was achieved via MT at 16 hours after the onset of symptoms. The child’s hemiparesis improved. Follow-up magnetic resonance imaging was nearly normal and showed that the baseline infarct lesion was reversible, in agreement with neurological improvement (NIHSS score 1).

LESSONS

The selection of pediatric stroke with a delayed time window guided by good collateral circulation at baseline seems safe and efficacious, which suggests a promising value of vascular window.

In Journal of Neurosurgery: Case Lessons Volume 5 (2023): Issue 20 (May 2023)

Open access

Pneumorrhachis and pneumocephalus resulting from pneumothorax: illustrative case

Davaine Joel Ndongo Sonfack, Bilal Tarabay, Jesse Shen, Zhi Wang, Ghassan Boubez, Daniel Shédid, and Sung-Joo Yuh

BACKGROUND

Pneumorrhachis and pneumocephalus are rare conditions in which air is found within the spinal canal and brain, respectively. It is mostly asymptomatic and can be located in the intradural or extradural space. Intradural pneumorrhachis should prompt clinicians to search and treat any underlying injury of the skull, chest, or spinal column.

OBSERVATIONS

A 68-year-old man presented with a history of cardiopulmonary arrest together with pneumorrhachis and pneumocephalus following a recurrent pneumothorax. The patient reported acute headaches with no other neurological symptoms. He was managed conservatively with bed rest for 48 hours following thoracoscopic talcage of his pneumothorax. Follow-up imaging showed regression of the pneumorrhachis, and the patient reported no other neurological symptoms.

LESSONS

Pneumorrhachis is an incidental radiological finding that self-resolves with conservative management. However, it can be a complication resulting from a serious injury. Therefore, close monitoring of neurological symptoms and complete investigations should be performed in patients with pneumorrhachis.

In Journal of Neurosurgery: Case Lessons Volume 5 (2023): Issue 20 (May 2023)

Open access

A silent corticotroph adenoma: making the case for a pars intermedia origin. Illustrative case

Mohammad Bilal Alsavaf, Kyle C. Wu, Guilherme Finger, Eman H. Salem, Maria Jose Castello Ruiz, Saniya S. Godil, Luma Ghalib, Ricardo L. Carrau, and Daniel M. Prevedello

BACKGROUND

Silent corticotroph adenomas (SCAs) are the only pituitary adenomas thought to originate from the pars intermedia. This case report presents the rare finding of a multimicrocystic corticotroph macroadenoma displacing the anterior and posterior lobes of the pituitary gland on magnetic resonance imaging (MRI). This finding supports the hypothesis that silent corticotroph adenomas may originate from the pars intermedia and should be considered in the differential for tumors arising from this location.

OBSERVATIONS

A 55-year-old man presented with an episode of confusion and blurred vision. MRI demonstrated separation of the anterior and posterior glands by a solid-cystic lesion located within the pars intermedia that superiorly displaced the optic chiasm. Endocrinologic evaluation was unremarkable. The differential diagnosis included pituitary adenoma, Rathke cleft cyst, and craniopharyngioma. The tumor was confirmed to be an SCA on pathology and was completely removed through the endoscopic endonasal transsphenoidal approach.

LESSONS

The case highlights the importance of preoperative screening for subclinical hypercortisolism for tumors arising from this location. Knowledge of a patient’s preoperative functional status is critical and dictates their postoperative biochemical assessment to determine remission. The case also illustrates surgical strategies for resecting pars intermedia lesions without injuring the gland.

In Journal of Neurosurgery: Case Lessons Volume 5 (2023): Issue 20 (May 2023)

Open access

Technical advantages of a novel flow diverter in complex flow diversion: patient series

Catherine Lei, Cody Heskett, Lane Fry, Aaron Brake, Frank A. De Stefano, Jeremy Peterson, and Koji Ebersole

BACKGROUND

The Surpass Streamline flow diverter (SSFD) possesses 4 attributes that may offer an important advantage in the treatment of complex pathologies: (1) utilization of an over-the-wire (OTW) delivery system, (2) greater device length, (3) larger potential diameter, and (4) propensity to open in tortuosity.

OBSERVATIONS

Case 1 leveraged device diameter to embolize a large, recurrent vertebral artery aneurysm. Angiography at 1 year posttreatment showed complete occlusion with a patent SSFD. Case 2 leveraged device length and opening in tortuosity to manage a symptomatic 20-mm cavernous carotid aneurysm. Magnetic resonance imaging at 2 years demonstrated aneurysm thrombosis and patent stents. Case 3 utilized diameter, length, and the OTW delivery system to treat a giant intracranial aneurysm previously treated with surgical ligation and a high-flow bypass procedure. Angiography at 5 months postprocedure demonstrated the return of laminar flow, as the vein graft had healed around the stent construct. Case 4 used diameter, length, and the OTW system to treat a giant, symptomatic, dolichoectatic vertebrobasilar aneurysm. Twelve-month follow-up imaging revealed a patent stent construct with no change to the aneurysm size.

LESSONS

Increased awareness of the unique attributes of the SSFD may allow a larger number of cases to be treated with the proven mechanism of flow diversion.

In Journal of Neurosurgery: Case Lessons Volume 5 (2023): Issue 20 (May 2023)

Restricted access

Developing interdisciplinary research teams in neurosurgery: key elements to success in brachial plexus and peripheral nerve surgery

Whitney E. Muhlestein, Kate W. C. Chang, Denise Justice, Sarah Johnson, Shawn Brown, and Miriana Popadich

The highest-impact medical literature is increasingly produced by interdisciplinary teams. The field of neurosurgery, which involves complex pathologies and recoveries, is particularly amenable to interdisciplinary research approaches. However, research in the medical context regarding the characteristics of effective teams, as well as how to develop and maintain interdisciplinary teams, remains lacking. Here, the authors used the business literature to identify the characteristics of effective teams. They then used the University of Michigan Brachial Plexus and Peripheral Nerve Program, founded under the leadership of the late Dr. Lynda Yang, as a case study for how these principles can be applied to build and operationalize a successful interdisciplinary team. They suggest that these same techniques can be used to create interdisciplinary research groups in other areas of neurosurgery.

In Journal of Neurosurgery Publish Before Print

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Does tumoral cavernous carotid stenosis predict an increased risk of future stroke in skull base meningiomas?

Joshua I. Macarthur, Frazer O’Brien, Cathal John Hannan, Charlotte Hammerbeck-Ward, Omar N. Pathmanaban, Scott A. Rutherford, Rekha Siripurapu, Andrew T. King, and Wayne Ng

OBJECTIVE

Skull base meningiomas (SBMs) involving the cavernous sinus encase the internal carotid artery (ICA) and may lead to stenosis of the vessel. Although ischemic stroke has been reported in the literature, there are to the authors’ knowledge no reported studies quantifying the risk of stroke in these patients. The authors aimed to determine the frequency of arterial stenosis in patients with SBMs that encase the cavernous ICA and to estimate the risk of ischemic stroke in these patients.

METHODS

Records of all patients with SBM encasing the ICA whose cases were managed by the skull base multidisciplinary team at Salford Royal Hospital between 2011 and 2017 were reviewed using a two-stage approach: 1) clinical and radiological strokes were identified from electronic patient records, and 2) cases were reviewed to examine the correlation between ICA stenosis associated with SBM encasement and anatomically related stroke. Strokes that were caused by another pathology or did not occur in the perfusion territory were excluded.

RESULTS

In the review of patient records the authors identified 118 patients with SBMs encasing the ICA. Of these, 62 SBMs caused stenosis. The median age at diagnosis was 70 (IQR 24) years, and 70% of the patients were female. The median follow-up was 97 (IQR 101) months. A total of 13 strokes were identified in these patients; however, only 1 case of stroke was associated with SBM encasement, which occurred in the perfusion territory of a patient without stenosis. Risk of acute stroke during the follow-up period for the entire cohort was 0.85%.

CONCLUSIONS

Acute stroke in patients with ICA encasement by SBMs is rare despite the propensity of these tumors to stenose the ICA. Patients with ICA stenosis secondary to their SBM did not have a higher incidence of stroke than those with ICA encasement without stenosis. The results of this study demonstrate that prophylactic intervention to prevent stroke is not necessary in ICA stenosis secondary to SBM.

In Journal of Neurosurgery Publish Before Print

Open access

Endoscopic third ventriculostomy with choroid plexus cauterization: predictors of long-term success and comparison with shunt placement for primary treatment of infant hydrocephalus

Benjamin C. Warf, Daniel S. Weber, Emily L. Day, Coleman P. Riordan, Steven J. Staffa, Lissa C. Baird, Katie P. Fehnel, and Scellig S. D. Stone

OBJECTIVE

Endoscopic third ventriculostomy (ETV) with choroid plexus cauterization (CPC) can avoid ventriculoperitoneal shunt (VPS) dependence in very young hydrocephalic children, although long-term success as a primary treatment in North America has not been previously reported. Moreover, optimal age at surgery, impact of preoperative ventriculomegaly, and relationship to prior cerebrospinal fluid (CSF) diversion remain poorly defined. The authors compared ETV/CPC and VPS placement for averting reoperation, and they evaluated preoperative predictors for reoperation and shunt placement after ETV/CPC.

METHODS

All patients under 12 months of age who underwent initial hydrocephalus treatment via ETV/CPC or VPS placement at Boston Children’s Hospital between December 2008 and August 2021 were reviewed. Analyses included Cox regression for independent outcome predictors, and both Kaplan-Meier and log-rank rank tests for time-to-event outcomes. Cutoff values for age and preoperative frontal and occipital horn ratio (FOHR) were determined with receiver operating characteristic curve analysis and Youden’s J index.

RESULTS

In total, 348 children (150 females) were included with principal etiologies of posthemorrhagic hydrocephalus (26.7%), myelomeningocele (20.1%), and aqueduct stenosis (17.0%). Of these, 266 (76.4%) underwent ETV/CPC and 82 (23.6%) underwent VPS placement. Treatment choice largely reflected surgeon preferences before practice shifted toward endoscopy, with endoscopy not considered for > 70% of initial VPS cases. ETV/CPC patients trended toward fewer reoperations, and Kaplan-Meier analysis estimated that 59% of patients would achieve long-term shunt freedom through 11 years (median 42 months of actual follow-up). Among all patients, corrected age < 2.5 months (p < 0.001), prior temporizing CSF diversion (p = 0.003), and excess intraoperative bleeding (p < 0.001) independently predicted reoperation. Among ETV/CPC patients, corrected age < 2.5 months (p = 0.031), prior CSF diversion (p = 0.001), preoperative FOHR > 0.613 (p = 0.011), and excessive intraoperative bleeding (p = 0.001) independently predicted ultimate conversion to VPS. The actual VPS insertion rates remained low in patients who were ≥ 2.5 months old at ETV/CPC either with prior CSF diversion (2/10 [20.0%]) or without prior CSF diversion (24/123 [19.5%]); however, the actual VPS insertion rates increased in patients who were < 2.5 months old at ETV/CPC with prior CSF diversion (19/26 [73.1%]) or without prior CSF diversion (44/107 [41.1%]).

CONCLUSIONS

ETV/CPC successfully treated hydrocephalus in most patients younger than 1 year irrespective of etiology, averting observed shunt dependence in 80% of patients ≥ 2.5 months of age regardless of prior CSF diversion and in 59% of those < 2.5 months of age without prior CSF diversion. For infants aged < 2.5 months with prior CSF diversion, particularly those with severe ventriculomegaly, ETV/CPC was unlikely to succeed unless safely delayed.

In Journal of Neurosurgery: Pediatrics Publish Before Print

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Graft subsidence and reoperation after lateral lumbar interbody fusion: a propensity score–matched and cost analysis of polyetheretherketone versus 3D-printed porous titanium interbodies

Nima Alan, Hansen Deng, Nallammai Muthiah, Lena Vodovotz, Robert Dembinski, Daipayan Guha, Nitin Agarwal, Alp Ozpinar, D. Kojo Hamilton, Adam S. Kanter, and David O. Okonkwo

OBJECTIVE

Lumbar interbody cage subsidence has a multifactorial etiology. Cage material, although well studied after transforaminal lumbar interbody fusion, has not been investigated as a contributing factor to subsidence after lateral lumbar interbody fusion (LLIF). In this study the authors compared rates of subsidence and reoperation after LLIF between polyetheretherketone (PEEK) and 3D-printed porous titanium (pTi) in an institutional propensity score–matched and cost analysis.

METHODS

This is a retrospective observational cohort analysis of adult patients who underwent LLIF with pTi versus PEEK between 2016 and 2020. Demographic, clinical, and radiographic characteristics were collected. Propensity scores were calculated and 1:1 matching without replacement of surgically treated levels was performed. The primary outcome of interest was subsidence. The Marchi subsidence grade was determined at the time of last follow-up. Chi-square or Fisher’s exact tests were used to compare subsidence and reoperation rates between lumbar levels treated with PEEK versus pTi. Modeling and cost analysis were performed using TreeAge Pro Healthcare.

RESULTS

The authors identified a total of 192 patients; 137 underwent LLIF with PEEK (212 levels) and 55 had LLIF with pTi (97 levels). After propensity score matching, a total of 97 lumbar levels remained in each treatment group. After matching, there were no statistically significant differences between groups in baseline characteristics. Levels treated with pTi were significantly less likely to exhibit subsidence (any grade) compared to those treated with PEEK (8% vs 27%, p = 0.001). Five (5.2%) levels treated with PEEK required reoperation for subsidence, but only 1 (1.0%) level treated with pTi required reoperation for subsidence (p = 0.12). Given subsidence and revision rates experienced in the cohorts in this study, the pTi interbody device is economically superior to PEEK in a single-level LLIF as long as its cost is at least $1185.94 lower than that of PEEK.

CONCLUSIONS

The pTi interbody device was associated with less subsidence, but statistically similar revision rates after LLIF. pTi is potentially a superior economic choice at this study’s reported revision rate.

In Journal of Neurosurgery: Spine Publish Before Print

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Healthcare disparities in pediatric neurosurgery: a scoping review

Krisna Maddy, Karen Eliahu, Jean-Paul Bryant, Roxanna Garcia, Rebecca Du, Sandi Lam, and Toba N. Niazi

OBJECTIVE

The aim of this scoping review was to identify relevant articles that have contributed to the body of knowledge describing pediatric neurosurgical healthcare disparities. Identifying healthcare disparities in pediatric neurosurgery is essential to understanding how to best provide care for this unique patient population. Although it is undoubtedly important to increase the knowledge of pediatric neurosurgical healthcare disparities, it is also important to understand the current state of the literature.

METHODS

This scoping review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews (PRISMA-ScR) guidelines. The search terms "pediatric neurosurgical disparities" and "pediatric neurosurgical inequities" were entered into the following databases: PubMed, Scopus, and Embase.

RESULTS

The initial database search returned a total of 366 results from the PubMed, Embase, and Scopus databases. One hundred thirty-seven duplicates were removed, and the remaining articles were screened by title and abstract. Articles were excluded on the basis of the inclusion and exclusion criteria. Of the remaining 229 articles, 168 were excluded. Sixty-one full-text articles were then examined for eligibility, and 28 did not reach the specified inclusion and exclusion criteria. The remaining 33 articles were included for final review. The results of the reviewed studies were stratified on the basis of disparity type.

CONCLUSIONS

Although there has been an increase in the number of publications discussing pediatric neurosurgical healthcare disparities within the last decade, there still remains a scarcity of information regarding healthcare disparities in neurosurgery. Furthermore, less information exists that specifically addresses healthcare disparities in the pediatric population.

In Journal of Neurosurgery: Pediatrics Publish Before Print

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Letter to the Editor. Spinal cerebrospinal fluid leaks

Oliver Ayling, Richard B. Rodgers, and Allan D. Levi

In Journal of Neurosurgery: Spine Publish Before Print