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Open access

Fahad J. Laghari, Sarah Eakin, and Salem El-Zuway

BACKGROUND

Previously, solitary and unilateral aggregates of intracranial subdural osteomas have been described. These tumors are thought to be slow growing and at times inconsequential on the basis of characteristics of subjacent brain. Unilateral location and history of traumas have led to the thought that the head trauma may play a role in pathogenesis.

OBSERVATIONS

The authors describe a unique case of a patient who was found to have bilateral intracranial subdural osteomas of unequal size on the basis of computed tomography and magnetic resonance imaging. The presenting symptom was headache. Initially small and thought to be irrelevant, these tumors grew over the course of 7 years to cause mass effect and effacement of the sulci and gyri. The larger 15-cm-long tumor was excised and was sent for pathology, which showed classic histology for subdural osteoma.

LESSONS

The described case uniquely demonstrates evidence of the slow growth of intracranial subdural osteomas over the course of years. It is crucial not to disregard the tumor because it can grow over time to cause mass effect. Patient follow-up is strongly recommended. Bilateral tumor occurrence at a similar location in this case supports an etiology other than trauma. Further research is necessary.

Open access

Yuto Shingai, Hiroyuki Sakata, Toshiki Endo, Shinsuke Suzuki, Masayuki Ezura, and Teiji Tominaga

BACKGROUND

Bow hunter’s syndrome (BHS) is an uncommon cause of vertebrobasilar ischemic stroke, which results from occlusion or injury to the vertebral artery (VA) during neck rotation. Although hemodynamic insufficiency is the predominant underlying mechanism of this entity, BHS due to embolic mechanisms is rare. The authors report a case of BHS characterized by repeated posterior circulation embolism and present some considerations of BHS with an embolic mechanism.

OBSERVATIONS

A 57-year-old man suffered from repeated embolic stroke in the posterior circulation. Digital subtraction angiography revealed caliber irregularity of the V3 segment of the left nondominant-side VA, which occluded when the neck rotated to the right side. The patient was diagnosed with BHS with an embolic mechanism due to endothelial damage caused by osteophytes at the C1 foramen transversarium. After C1–C2 fusion surgery, the patient never experienced the recurrence of stroke. According to a literature review, BHS due to embolic mechanisms tends to occur in young male adults, manifesting as recurrent stroke in the posterior circulation. Involvement of the nondominant-side VA can cause BHS with an underlying embolic mechanism.

LESSONS

BHS due to an embolic mechanism should be considered as a differential diagnosis if patients have repeated embolic strokes in the posterior circulation.

Open access

Thomas K. Mattingly, Pablo Lopez-Ojeda, Miguel Arango, Chris Harle, Nirmal Kakani, Peter Allen, Barbara Lehrbass, and Stephen P. Lownie

BACKGROUND

The authors present a case of selective hypothermia used for neuroprotection during clipping of a giant partially thrombosed middle cerebral artery (MCA) aneurysm. Although these cases have traditionally required deep hypothermic cardiac arrest, this case illustrates a novel and entirely endovascular solution that avoids cardiac standstill and whole-body cooling.

OBSERVATIONS

This is, to the authors’ knowledge, the first case in human surgery of a catheter-based selective hypothermic circuit used to facilitate MCA trapping for almost 30 minutes. Core temperatures never dropped below 34°C, and the patient recovered uneventfully and has been well for over 5 years.

LESSONS

The technical nuances and physiological changes unique to selective hypothermia are discussed.

Open access

Ariana Barkley, Lynn B. McGrath Jr., and Christoph P. Hofstetter

BACKGROUND

Primary intramedullary spinal tumors cause significant morbidity and death. Intraoperative ultrasound as an adjunct for localization and monitoring the extent of resection has not been systematically evaluated in these patients; the effectiveness of intraoperative contrast-enhanced ultrasound (CEUS) remains almost completely unexplored.

OBSERVATIONS

A retrospective case series of patients at a single institution who had consented to the off-label use of intraoperative CEUS was identified. Seven patients with a mean age of 52.8 ± 15.8 years underwent resection of intramedullary tumors assisted by CEUS performed by a single attending neurosurgeon. Histopathological evaluation revealed 3 cases of hemangioblastoma, 1 case of pilocytic astrocytoma, 2 cases of ependymoma, and 1 case of subependymoma. Contrast enhancement correlated with gadolinium enhancement on preoperative magnetic resonance imaging. Intraoperative CEUS facilitated precise lesion localization and myelotomy planning. Dynamic CEUS studies were useful in demonstrating the blood supply to lesions with a dominant vascular pedicle. Regardless of contrast uptake, the differential enhancement between spinal cord tissue and neoplasm assisted in determining interface boundaries.

LESSONS

Intraoperative CEUS constitutes a useful adjunct for the intraoperative delineation of contrast-enhancing intramedullary tumors and in vivo confirmation of gross-total resection. Systematic investigation is needed to establish the role of CEUS for resection of intramedullary spinal tumors of various pathologies.

Open access

Gregory W. Basil, Annelise C. Sprau, Robert M. Starke, Allan D. Levi, and Michael Y. Wang

BACKGROUND

The percutaneous, endoscope-assisted anterior cervical discectomy is a relatively new procedure, and because of its novelty, complications are minimal and pertinent literature is scarce. This approach relies on a sufficient anatomical understanding of the vital neurovascular structures in the operating workspace. Although complications are rare, they can be significant.

OBSERVATIONS

The patient presented with difficulty breathing following an anterior percutaneous cervical discectomy performed at an outpatient surgical center. Imaging revealed a prevertebral hematoma and multiple carotid pseudoaneurysms. Given the large prevertebral hematoma and concern for imminent airway collapse, the authors proceeded with emergent intubation and surgical evacuation of the clot.

LESSONS

The authors propose managing complications in a fashion similar to those for comparable injuries after classic anterior approaches. Definitive management of our patient’s carotid injury would require stenting and, therefore, dual antiplatelet agents. Thus, the authors proceeded with the hematoma evacuation first. Additionally, careful dissection was needed to decrease further carotid damage. Thus, the authors made a more rostral incision to maintain the given stability of the carotid insult before the angiographic intervention to follow. It is the authors’ hope that the technical pearls from this two-staged open hematoma evacuation and endovascular stenting may guide future presurgical and intraoperative planning and management of complications, should they arise.

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Thomas J. Wilson, Forrest Hamrick, Saud Alzahrani, Christopher F. Dibble, Sravanthi Koduri, Courtney Pendleton, Sara Saleh, Zarina S. Ali, Mark A. Mahan, Rajiv Midha, Wilson Z. Ray, Lynda J. S. Yang, Eric L. Zager, and Robert J. Spinner

OBJECTIVE

The aim of this study was to examine the role of intraoperative neuromonitoring (IONM) during resection of benign peripheral nerve sheath tumors in achieving gross-total resection (GTR) and in reducing postoperative neurological complications.

METHODS

Data from consecutive adult patients who underwent resection of a benign peripheral nerve sheath tumor at 7 participating institutions were combined. Propensity score matching was used to balance covariates. The primary outcomes of interest were the association between IONM and GTR and the association of IONM and the development of a permanent postoperative neurological complication. The secondary outcomes of interest were the association between IONM and GTR and the association between IONM and the development of a permanent postoperative neurological complication in the subgroup of patients with tumors involving a motor or mixed nerve. Univariate and multivariate logistic regression were then performed on the propensity score–matched samples to assess the ability of the independent variables to predict the outcomes of interest.

RESULTS

A total of 337 patients who underwent resection of benign nerve sheath tumors were included. In multivariate analysis, the use of IONM (OR 0.460, 95% CI 0.199–0.978; p = 0.047) was a significant negative predictor of GTR, whereas none of the variables, including IONM, were associated with the occurrence of a permanent postoperative neurological complication. Within the subgroup of motor/mixed nerve tumors, in the multivariate analysis, IONM (OR 0.263, 95% CI 0.096–0.723; p = 0.010) was a significant negative predictor of a GTR, whereas IONM (OR 3.800, 95% CI 1.925–7.502; p < 0.001) was a significant positive predictor of a permanent postoperative motor deficit.

CONCLUSIONS

Overall, 12% of the cohort had a permanent neurological complication, with new or worsened paresthesias most common, followed by pain and then weakness. The authors found that formal IONM was associated with a reduced likelihood of GTR and had no association with neurological complications. The authors believe that these data argue against IONM being considered standard of care but do not believe that these data should be used to universally argue against IONM during resection of benign nerve sheath tumors.

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Joel Beck, Olof Westin, Helena Brisby, and Adad Baranto

OBJECTIVE

Sciatica is the hallmark symptom of a lumbar disc herniation (LDH). Up to 90% of LDH patients recover within 12 weeks regardless of treatment. With continued deteriorating symptoms and low patient quality of life, most surgeons recommend surgical discectomy. However, there is not yet a clear consensus regarding the proper timing of surgery. The aim of this study was to evaluate how the duration of preoperative leg pain (sciatic neuralgia) is associated with patient-reported levels of postoperative leg pain reduction and other patient-reported outcome measures (PROMs) in a prospectively collected data set from a large national cohort.

METHODS

All patients aged 18–65 years undergoing a lumbar discectomy during 2013–2016 and registered in Swespine (the Swedish national spine registry) with 1 year of postoperative follow-up data were included in the study (n = 6216). The patients were stratified into 4 groups according to preoperative pain duration: < 3, 3–12, 12–24, or > 24 months. Patient results assessed with the numeric rating scale (NRS) for leg pain (rated from 0 to 10), global assessment of leg pain, EQ-5D, Oswestry Disability Index (ODI), and patient satisfaction with the final surgical outcome were analyzed and compared with preoperative values and between groups.

RESULTS

A significant improvement was seen 1 year postoperatively regardless of preoperative pain duration (change in NRS score: mean −4.83, 95% CI −4.73 to −4.93 in the entire cohort). The largest decrease in leg pain NRS score (mean −5.59, 95% CI −5.85 to −5.33) was seen in the operated group with the shortest sciatica duration (< 3 months). The patients with a leg pain duration in excess of 12 months had a significantly higher risk of having unchanged radiating leg pain 1 year postoperatively compared with those with < 12-month leg pain duration at the time of surgery (OR 2.41, 95% CI 1.81–3.21, p < 0.0001).

CONCLUSIONS

Patients with the shortest leg pain duration (< 3 months) reported superior outcomes in all measured parameters. More significantly, using a 12-month pain duration as a cutoff, patients who had a lumbar discectomy with a preoperative symptom duration < 12 months experienced a larger reduction in leg pain and were more satisfied with their surgical outcome and perception of postoperative leg pain than those with > 12 months of sciatic leg pain.

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Keita Shibahashi, Hidenori Hoda, Takuto Ishida, Takayuki Motoshima, Kazuhiro Sugiyama, and Yuichi Hamabe

OBJECTIVE

The objective of this study was to derive and validate a new screening model using a nomogram that allows clinicians to quantify the risk of blunt cerebrovascular injury (BCVI).

METHODS

In this study, the authors examined 258,935 patients from a prospectively collected nationwide Japanese database (January 2009–December 2018) who experienced blunt injury. Patients were randomly divided into training (n = 129,468) and validation (n = 129,467) cohorts. First, the authors investigated the prevalence of BCVI, which was defined as blunt injury to any intracranial vessel, the extracranial vertebral artery, the extracranial carotid (common, internal) artery, or the internal jugular vein. Then, a new arterial BCVI screening model using a nomogram was derived, based on multivariate logistic regression analysis through quantifying the association of potential predictive factors with BCVI in the training cohort. The model’s discriminatory ability was validated using the area under the receiver operating characteristic curve (AUC) in the validation cohort.

RESULTS

Multivariate analysis in the training cohort showed that 13 factors were significantly associated with arterial BCVI and were included in our model. These factors were 1) male sex; 2) high-energy impact; 3) hypotension on hospital arrival; 4) Glasgow Coma Scale score < 9; 5) injury to the face; 6) injury to the neck; 7) injury to the spine; 8) skull base fracture; 9) cervical spine fracture or subluxation; and those with negative associations, i.e., 10) injury to the lower-extremity region; 11) supratentorial subdural hemorrhage; 12) lumbar spine fracture or subluxation; and 13) soft tissue injury of the face. In the validation cohort, the model had an AUC of 0.83 (95% CI 0.81–0.86). When the definition of BCVI was narrowed to include only carotid (common, internal) and vertebral artery injuries, the AUC of the model in predicting these injuries was 0.89 (95% CI 0.87–0.91).

CONCLUSIONS

A new screening model that incorporates an easy-to-use nomogram to quantify the risk of BCVI and assist clinicians in identifying patients who warrant additional evaluation was established.

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Alexander T. Yahanda, P. David Adelson, S. Hassan A. Akbari, Gregory W. Albert, Philipp R. Aldana, Tord D. Alden, Richard C. E. Anderson, David F. Bauer, Tammy Bethel-Anderson, Douglas L. Brockmeyer, Joshua J. Chern, Daniel E. Couture, David J. Daniels, Brian J. Dlouhy, Susan R. Durham, Richard G. Ellenbogen, Ramin Eskandari, Timothy M. George, Gerald A. Grant, Patrick C. Graupman, Stephanie Greene, Jeffrey P. Greenfield, Naina L. Gross, Daniel J. Guillaume, Todd C. Hankinson, Gregory G. Heuer, Mark Iantosca, Bermans J. Iskandar, Eric M. Jackson, James M. Johnston, Robert F. Keating, Mark D. Krieger, Jeffrey R. Leonard, Cormac O. Maher, Francesco T. Mangano, J. Gordon McComb, Sean D. McEvoy, Thanda Meehan, Arnold H. Menezes, Brent R. O’Neill, Greg Olavarria, John Ragheb, Nathan R. Selden, Manish N. Shah, Chevis N. Shannon, Joshua S. Shimony, Matthew D. Smyth, Scellig S. D. Stone, Jennifer M. Strahle, James C. Torner, Gerald F. Tuite, Scott D. Wait, John C. Wellons III, William E. Whitehead, Tae Sung Park, and David D. Limbrick Jr.

OBJECTIVE

Posterior fossa decompression with duraplasty (PFDD) is commonly performed for Chiari I malformation (CM-I) with syringomyelia (SM). However, complication rates associated with various dural graft types are not well established. The objective of this study was to elucidate complication rates within 6 months of surgery among autograft and commonly used nonautologous grafts for pediatric patients who underwent PFDD for CM-I/SM.

METHODS

The Park-Reeves Syringomyelia Research Consortium database was queried for pediatric patients who had undergone PFDD for CM-I with SM. All patients had tonsillar ectopia ≥ 5 mm, syrinx diameter ≥ 3 mm, and ≥ 6 months of postoperative follow-up after PFDD. Complications (e.g., pseudomeningocele, CSF leak, meningitis, and hydrocephalus) and postoperative changes in syrinx size, headaches, and neck pain were compared for autograft versus nonautologous graft.

RESULTS

A total of 781 PFDD cases were analyzed (359 autograft, 422 nonautologous graft). Nonautologous grafts included bovine pericardium (n = 63), bovine collagen (n = 225), synthetic (n = 99), and human cadaveric allograft (n = 35). Autograft (103/359, 28.7%) had a similar overall complication rate compared to nonautologous graft (143/422, 33.9%) (p = 0.12). However, nonautologous graft was associated with significantly higher rates of pseudomeningocele (p = 0.04) and meningitis (p < 0.001). The higher rate of meningitis was influenced particularly by the higher rate of chemical meningitis (p = 0.002) versus infectious meningitis (p = 0.132). Among 4 types of nonautologous grafts, there were differences in complication rates (p = 0.02), including chemical meningitis (p = 0.01) and postoperative nausea/vomiting (p = 0.03). Allograft demonstrated the lowest complication rates overall (14.3%) and yielded significantly fewer complications compared to bovine collagen (p = 0.02) and synthetic (p = 0.003) grafts. Synthetic graft yielded higher complication rates than autograft (p = 0.01). Autograft and nonautologous graft resulted in equal improvements in syrinx size (p < 0.0001). No differences were found for postoperative changes in headaches or neck pain.

CONCLUSIONS

In the largest multicenter cohort to date, complication rates for dural autograft and nonautologous graft are similar after PFDD for CM-I/SM, although nonautologous graft results in higher rates of pseudomeningocele and meningitis. Rates of meningitis differ among nonautologous graft types. Autograft and nonautologous graft are equivalent for reducing syrinx size, headaches, and neck pain.

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Marianne I. Tissot, Naja N. Hill, Austin J. Borja, Nicholas Edouard, Vamsi Reddy, and Donald K. Detchou