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Brian A. O'Shaughnessy, Sean A. Salehi, Saad Ali and John C. Liu

✓ Chiari I malformation, a congenital disorder involving downward displacement of the cerebellar tonsils through the foramen magnum, is often treated surgically by performing suboccipital craniectomy and C-1 laminectomy. The authors report two cases in which fracture of the anterior atlantal arch occurred during the postoperative period following Chiari I decompression and C-1 laminectomy causing significant neck pain. The findings indicate that interruption of the integrity of the posterior arch of C-1, iatrogenically or otherwise, confers increased risk of anterior arch fracture. A C-1 fracture should therefore be considered in the differential diagnosis of posterior cervical pain in patients who have previously undergone decompression for Chiari I malformation.

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Brian A. O'Shaughnessy, Sean A. Salehi, Stefan A. Mindea and H. Hunt Batjer

Cerebral revascularization, an indispensable component of neurovascular surgery, has been performed in the treatment of cranial base tumors, complex cerebral aneurysms, and occlusive cerebrovascular disease. The goal of a revascularization procedure is to augment blood flow distally. It can therefore be used as an adjunctive measure in the treatment of complex neurosurgical disease processes that require parent artery sacrifice for definitive treatment. In the treatment of giant anterior circulation aneurysms, for instance, a cerebral revascularization procedure may be considered in patients in whom the collateral circulation is marginal and in whom lesions may be treated either using a Hunterian-based strategy or clip-assisted reconstruction requiring a prolonged period of temporary occlusion. To date, there is no entirely effective method known to produce long-term tolerance to carotid artery (CA) sacrifice and, largely for that reason, some neurovascular surgeons advocate universal revascularization. The authors of this report, however, prefer to perform revascularization only in the limited subset of patients in whom preoperative assessment has revealed risk factors for cerebral ischemia due to hypoperfusion. In this paper, the authors introduce their protocol for assessing cerebrovascular reserve capacity, indications for cerebral revascularization in the treatment of complex anterior circulation aneurysms, and discuss their rationale for choosing to practice selective, rather than universal, revascularization.

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Patrick A. Sugrue, Brian A. O'Shaughnessy, Fadi Nasr, Tyler R. Koski and Stephen L. Ondra

Spinal deformity surgery is associated with high rates of morbidity and a wide range of complications. The most significant abdominal complications following kyphosis correction, while uncommon, can certainly pose significant infectious and hemodynamic risks to the patient. Abdominal compartment syndrome is the most severe of the sequelae. It is the end result of elevated abdominal compartment pressure with physiological compromise and end organ system dysfunction. Although most commonly associated with trauma, abdominal compartment syndrome has also been witnessed following massive fluid shifts, which can occur during adult spinal deformity surgery. In this manuscript, we report on 2 patients with ankylosing spondylitis who developed significant abdominal pathology requiring exploratory laparotomy following kyphosis correction. In addition to describing the details of each case, we propose explanations of the relevant pathophysiology and review diagnostic and treatment strategies for such events. The key to effectively treating such a debilitating complication is to recognize it quickly and intervene rapidly and aggressively.

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Patrick C. Hsieh, Stephen L. Ondra, Robert J. Wienecke, Brian A. O'Shaughnessy and Tyler R. Koski

✓The authors describe the use of sacral pedicle subtraction osteotomy (PSO) with multiple sacral alar osteotomies for the correction of sacral kyphosis and pelvic incidence and for achieving sagittal balance correction in cases of fixed sagittal deformity after a sacral fracture.

In this paper, the authors report on a novel technique using a series of sacral osteotomies and a sacral PSO to correct a fixed sagittal deformity in a patient with a sacral fracture that had healed in a kyphotic position. The patient sustained this fracture after a previous surgery for multilevel instrumented fusion. Preoperative and postoperative radiographic studies are reviewed and the clinical course and outcome are presented.

Experts agree that the pelvic incidence is a fixed parameter that dictates the morphological characteristics of the pelvis and affects spinopelvic orientation and sagittal spinal alignment. An increased pelvic incidence is associated with a higher degree of spondylolisthesis in the lumbosacral junction, and increased shear forces across this junction. The authors demonstrate that the pelvic incidence can be altered and corrected with a series of sacral osteotomies to improve sacral kyphosis, compensatory lumbar hyperlordosis, and sagittal balance.

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Brian A. O'Shaughnessy, Christopher C. Getch, Bernard R. Bendok and H. Hunt Batjer

Intracranial aneurysms arising from the posterior wall of the supraclinoid carotid artery are extremely common lesions. The aneurysm dilation typically occurs in immediate proximity to the origin of the posterior communicating artery and, less commonly, the anterior choroidal artery (AChA). Because of the increasingly widespread use of non-invasive neuroimaging methods to evaluate patients believed to harbor cerebral lesions, many of these carotid artery aneurysms are now documented in their unruptured state, prior to occurrence of subarachnoid hemorrhage. Based on these factors, the management of unruptured posterior carotid artery (PCA) wall aneurysms is an important element of any neurosurgical practice.

Despite impressive recent advances in endovascular therapy, the placement of microsurgical clips to exclude aneurysms with preservation of all afferent and efferent vasculature remains the most efficacious and durable therapy. To date, an optimal outcome is only achieved when the neurosurgeon is able to combine systematic preoperative neurovascular assessment with meticulous operative technique. In this report, the authors review their surgical approach to PCA wall aneurysms, which is greatly based on the extensive neurovascular experience of the senior author. Focus is placed on their methods of preoperative evaluation and operative technique, with emphasis on neurovascular anatomy and the significance of oculomotor nerve compression. They conclude by discussing surgery-related complications, with a particular focus on intraoperative rupture of aneurysms and their management, and the postoperative ischemic AChA syndrome.

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Brian A. O'Shaughnessy, Arthur J. DiPatri Jr., Richard J. Parkinson and H. Hunt Batjer

✓The authors report the unique case of a 6-year-old African-American girl with sickle cell disease (SCD) and an associated moyamoya arteriopathy who developed a de novo arteriovenous malformation (AVM) of the cerebral circulation. Based on preoperative cerebral angiography, computerized tomography angiography, and magnetic resonance imaging, the incidentally discovered lesion was originally thought to be a direct arteriovenous fistula with an associated varix. At surgery, however, a 1.5-cm AVM was identified adjacent to the deep surface of the varix, and it was successfully resected. The diagnosis of cerebral AVM was then confirmed histopathologically. Based on a review of the literature, no published correlation between cerebral AVMs and SCD exists. In addition to reporting this case, the authors provide a description of AVM pathogenesis, with particular emphasis on acquired AVMs of the cerebral circulation.

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Brian A. O'Shaughnessy, Kristian T. Schafernak, Arthur J. DiPatri Jr., Stewart Goldman and Tadanori Tomita

✓ Microfibrillar collagen hemostat (MCH), also known by its trade name Avitene, is commonly used to control hemorrhage during neurosurgery. Among the documented complications associated with this agent, a granulomatous foreign body reaction is rare, having been described in the central nervous system in only one previous clinical report. In the present study, the authors report the case of a 3-year-old boy who presented with a lesion which appeared to be the recurrence of a tumor 2 months after he had undergone gross-total resection for a medulloblastoma. The patient underwent resection of the presumed recurrent tumor, but histopathological analysis of the specimen revealed a granulomatous foreign body reaction to MCH and no tumor recurrence. In addition to describing the case, the authors review the surgical literature on foreign body reactions to MCH.

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Brian A. O'Shaughnessy, Christopher C. Getch, Robin M. Bowman and H. Hunt Batjer

✓The authors present the case report of a pediatric patient with a ruptured traumatic pseudoaneurysm of the intracranial vertebral artery (VA) from which the posterior inferior cerebellar artery (PICA) emerged. After considering multiple therapeutic options, the patient was treated surgically by trapping of the aneurysm segment and direct reimplantation of the PICA distal to the rupture site. In addition to presenting this unique case, the authors discuss the treatment of VA pseudoaneurysms and the various techniques for PICA revascularization. A review of the literature on PICA reimplantation is provided as an adjunct in the treatment of complex VA aneurysms.

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Patrick C. Hsieh, Robert J. Wienecke, Brian A. O'Shaughnessy, Tyler R. Koski and Stephen L. Ondra

Pyogenic vertebral discitis and osteomyelitis (PVDO) has become an increasing problem for the spine surgeon. Despite recent advances in medical care and improved diagnostic neuroimaging, PVDO remains a major cause of illness and death in the elderly population. Infection of the spinal column often presents insidiously; however, if not treated appropriately and in a timely manner it can lead to severe neurological impairment, systemic septicemia, and progressive spinal deformity. In this paper the authors review the epidemiological and pathophysiological features and the clinical presentation of PVDO. Conventional medical therapy is described, with a particular focus on the methods of diagnosis. Surgical strategies for PVDO are then presented based on the literature and according to the practice of the senior author (S.L.O.), with an emphasis placed on structural considerations, implant selection, and techniques for augmenting vascular tissue to the site of infection.

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Brian A. O'Shaughnessy, Christopher C. Getch, Robin M. Bowman and H. Hunt Batjer

✓The authors present the case report of a pediatric patient with a ruptured traumatic pseudoaneurysm of the intracranial vertebral artery (VA) from which the posterior inferior cerebellar artery (PICA) emerged. After considering multiple therapeutic options, the patient was treated surgically by trapping of the aneurysm segment and direct reimplantation of the PICA distal to the rupture site. In addition to presenting this unique case, the authors discuss the treatment of VA pseudoaneurysms and the various techniques for PICA revascularization. A review of the literature on PICA reimplantation is provided as an adjunct in the treatment of complex VA aneurysms.