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Open access

Evan Joyce, Ramesh Grandhi, and William T. Couldwell

Arteriovenous malformations (AVMs) of the posterior fossa represent just 5%–15% of all intracranial AVMs. Rupture often leads to devastating brainstem compression, with mortality reported as high as 67%. A life-saving decompressive craniectomy with or without hematoma evacuation may be necessary in the acute setting to alleviate mass effect before proceeding with definitive treatment of the vascular pathology. Here, the authors demonstrate the utility of using a generously sized temporizing decompressive suboccipital craniectomy to subsequently allow for a more judicious resection of a Spetzler-Martin grade III AVM fed by the right superior cerebellar artery using a sitting supracerebellar infratentorial approach.

The video can be found here: https://youtu.be/L195wmw3p_4

Free access

Hussam Abou-Al-Shaar, Michael Karsy, Vijay Ravindra, Evan Joyce, and Mark A. Mahan

Particularly challenging after complete brachial plexus avulsion is reestablishing effective hand function, due to limited neurological donors to reanimate the arm. Acute repair of avulsion injuries may enable reinnervation strategies for achieving hand function. This patient presented with pan–brachial plexus injury. Given its irreparable nature, the authors recommended multistage reconstruction, including contralateral C-7 transfer for hand function, multiple intercostal nerves for shoulder/triceps function, shoulder fusion, and spinal accessory nerve–to–musculocutaneous nerve transfer for elbow flexion. The video demonstrates distal contraction from electrical stimulation of the avulsed roots. Single neurorrhaphy of the contralateral C-7 transfer was performed along with a retrosternocleidomastoid approach.

The video can be found here: https://youtu.be/GMPfno8sK0U.

Open access

Evan Joyce, Michael Karsy, Serge Makarenko, Gretchen M. Oakley, and William T. Couldwell

Anterior skull base approaches have included endoscopic or open microsurgical approaches for intracranial pathologies. However, discussion of a combined hybrid, cranioendoscopic approach, leveraging the benefits of both techniques, has been limited. Here we describe a case of a combined endoscopic, endonasal, and open microsurgical frontotemporal approach for resection of a complex anterior skull base lesion. A 62-year-old man with a large meningioma extending intradurally through the cribiform plate and sphenoethmoidal sinuses underwent a cranioendoscopic resection. Surgical techniques, including repair of the anterior skull base defect as well as complication avoidance and the coordination of multiple surgeons, are discussed.

The video can be found here: https://youtu.be/Ti9tUUdWgJc.

Full access

Hussam Abou-Al-Shaar, Yair M. Gozal, Jason P. Hunt, Clough Shelton, Lyska L. Emerson, Evan Joyce, and William T. Couldwell

Jugular foramen cavernous hemangiomas are extremely rare vascular malformations, and, to the best of the authors’ knowledge, their occurrence as multifocal lesions involving both intra- and extracranial compartments has never been reported before. Here, the authors describe the case of a 60-year-old woman with a complex multifocal jugular foramen cavernous hemangioma. The patient presented with signs and symptoms concerning for jugular foramen syndrome, as well as a right neck mass. Surgical extirpation of the lesion was achieved by a multidisciplinary team via a right infratemporal fossa approach (Fisch type A) with concurrent high neck dissection and a closure buttressed with an autologous fat graft and a temporoparietal fascial flap. Although rare, cavernous hemangiomas should be included in the differential diagnosis of jugular foramen masses.

Open access

Evan Joyce, Michael Karsy, Serge Makarenko, Jeramiah Alt, Richard Orlandi, and William T. Couldwell

Endoscopic and open microsurgical approaches for pediatric patients are useful for a wide variety of skull base pathologies. A hybrid, cranioendoscopic approach may be beneficial in improving surgical resection for complex lesions. A case of a 13-year-old boy with a large juvenile nasopharyngeal angiofibroma extending through the nasopharynx and pterygopalatine fossa into the maxillary, sphenoid, and cavernous sinuses is demonstrated via an endoscopic, transnasal and frontotemporal, extended middle cranial fossa microsurgical approach. Management of a large pediatric tumor via narrow nasal passages, safe surgical resection around critical neurovascular structures, and complication avoidance is demonstrated.

The video can be found here: https://youtu.be/1WqvsOnQCxs.

Restricted access

Vijay M. Ravindra, Rajiv R. Iyer, Alexander T. Yahanda, Robert J. Bollo, Huirong Zhu, Evan Joyce, Tammy Bethel-Anderson, Thanda Meehan, Matthew D. Smyth, Jennifer M. Strahle, Tae Sung Park, David D. Limbrick Jr., Douglas L. Brockmeyer, and on behalf of the Park-Reeves Syringomyelia Research Consortium

OBJECTIVE

The condylar–C2 sagittal vertical alignment (C-C2SVA) describes the relationship between the occipitoatlantal joint and C2 in patients with Chiari malformation type I (CM-I). It has been suggested that a C-C2SVA ≥ 5 mm is predictive of the need for occipitocervical fusion (OCF) or ventral brainstem decompression (VBD). The authors’ objective was to validate the predictive utility of the C-C2SVA by using a large, multicenter cohort of patients.

METHODS

This validation study used a cohort of patients derived from the Park-Reeves Syringomyelia Research Consortium; patients < 21 years old with CM-I and syringomyelia treated from June 2011 to May 2016 were identified. The primary outcome was the need for OCF and/or VBD. After patients who required OCF and/or VBD were identified, 10 age- and sex-matched controls served as comparisons for each OCF/VBD patient. The C-C2SVA (defined as the position of a plumb line from the midpoint of the O–C1 joint relative to the posterior aspect of the C2–3 disc space), pBC2 (a line perpendicular to a line from the basion to the posteroinferior aspect of the C2 body), and clival-axial angle (CXA) were measured on sagittal MRI. The secondary outcome was the need for ≥ 2 CM-related operations.

RESULTS

Of the 206 patients identified, 20 underwent OCF/VBD and 14 underwent repeat posterior fossa decompression. A C-C2SVA ≥ 5 mm was 100% sensitive and 86% specific for requiring OCF/VBD, with a 12.6% misclassification rate, whereas CXA < 125° was 55% sensitive and 99% specific, and pBC2 ≥ 9 was 20% sensitive and 88% specific. Kaplan-Meier analysis demonstrated that there was a significantly shorter time to second decompression in children with C-C2SVA ≥ 5 mm (p = 0.0039). The mean C-C2SVA was greater (6.13 ± 1.28 vs 3.13 ± 1.95 mm, p < 0.0001), CXA was lower (126° ± 15.4° vs 145° ± 10.7°, p < 0.05), and pBC2 was similar (7.65 ± 1.79 vs 7.02 ± 1.26 mm, p = 0.31) among those who underwent OCF/VBD versus decompression only. The intraclass correlation coefficient for the continuous measurement of C-C2SVA was 0.52; the kappa value was 0.47 for the binary categorization of C-C2SVA ≥ 5 mm.

CONCLUSIONS

These results validated the C-C2SVA using a large, multicenter, external cohort with 100% sensitivity, 86% specificity, and a 12.6% misclassification rate. A C-C2SVA ≥ 5 mm is highly predictive of the need for OCF/VBD in patients with CM-I. The authors recommend that this measurement be considered among the tools to identify the “high-risk” CM-I phenotype.

Free access

Evan Joyce, Michael T. Bounajem, Jonathan Scoville, Ajith J. Thomas, Christopher S. Ogilvy, Howard A. Riina, Omar Tanweer, Elad I. Levy, Alejandro M. Spiotta, Bradley A. Gross, Brian T. Jankowitz, C. Michael Cawley, Alexander A. Khalessi, Aditya S. Pandey, Andrew J. Ringer, Ricardo Hanel, Rafael A. Ortiz, David Langer, Michael R. Levitt, Mandy Binning, Philipp Taussky, Peter Kan, and Ramesh Grandhi

OBJECTIVE

The incidence of already common chronic subdural hematomas (CSDHs) and other nonacute subdural hematomas (NASHs) in the elderly is expected to rise as the population ages over the coming decades. Surgical management is associated with recurrence and exposes elderly patients to perioperative and operative risks. Middle meningeal artery (MMA) embolization offers the potential for a minimally invasive, less morbid treatment in this age group. The clinical and radiographic outcomes after MMA embolization treatment for NASHs have not been adequately described in elderly patients. In this paper, the authors describe the clinical and radiographic outcomes after 151 cases of MMA embolization for NASHs among 121 elderly patients.

METHODS

In a retrospective review of a prospectively maintained database across 15 US academic centers, the authors identified patients aged ≥ 65 years who underwent MMA embolization for the treatment of NASHs between November 2017 and February 2020. Patient demographics, comorbidities, clinical and radiographic factors, treatment factors, and clinical outcomes were abstracted. Subgroup analysis was performed comparing elderly (age 65–79 years) and advanced elderly (age > 80 years) patients.

RESULTS

MMA embolization was successfully performed in 98% of NASHs (in 148 of 151 cases) in 121 patients. Seventy elderly patients underwent 87 embolization procedures, and 51 advanced elderly patients underwent 64 embolization procedures. Elderly and advanced elderly patients had similar rates of embolization for upfront (46% vs 61%), recurrent (39% vs 33%), and prophylactic (i.e., with concomitant surgical intervention; 15% vs 6%) NASH treatment. Transfemoral access was used in most patients, and the procedure time was approximately 1 hour in both groups. Particle embolization with supplemental coils was most common, used in 51% (44/87) and 44% (28/64) of attempts for the elderly and advanced elderly groups, respectively. NASH thickness decreased significantly from initial thickness to 6 weeks, with additional decrease in thickness observed in both groups at 90 days. At longest follow-up, the treated NASHs had stabilized or improved in 91% and 98% of the elderly and advanced elderly groups, respectively, with > 50% improvement seen in > 60% of patients for each group. Surgical rescue was necessary in 4.6% and 7.8% of cases, and the overall mortality was 8.6% and 3.9% for elderly and advanced elderly patients, respectively.

CONCLUSIONS

MMA embolization can be used safely and effectively as an alternative or adjunctive minimally invasive treatment for NASHs in elderly and advanced elderly patients.