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G. Edward Vates, Kevin C. Wang, David Bonovich, Christopher F. Dowd and Michael T. Lawton

✓ Bow hunter stroke, which is characterized by transient vertebrobasilar ischemia brought on by head turning, is an unusual condition usually caused by structural abnormalities at the craniocervical junction. The authors present a case in which compression of the left vertebral artery (VA) at the C4–5 level was caused by a laterally herniated intervertebral disc. A 56-year-old man presented with a 6-month history of dizziness and syncope when he turned his head 45° or more to the left. Transcranial Doppler (TCD) ultrasonography demonstrated decreased blood flow through the left VA, and angiography revealed an occlusion of the left VA at the C4–5 level, both when the patient turned his head to the left. Via an anterior cervical approach, the VA canal was unroofed through the transverse foramina to decompress the left VA at C4–5; intraoperatively, the left VA was found to be compressed by a laterally herniated cervical disc fragment. To the best of the authors' knowledge this is the first report of a laterally herniated cervical disc causing bow hunter stroke. The use of TCD may be of value in the diagnosis and management of the disorder, and herniated cervical disc must be included in the roster of potential causes for this rare disease.

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Gabrielle Santangelo, Jonathan Stone, Tyler Schmidt, G. Edward Vates, Howard Silberstein and Pierre Girgis

Penetrating spinal injuries by wood are infrequently reported. They are particularly rare in children. Only 6 cases of wooden fragments causing penetrating intradural spinal injury have been reported. The authors report a case of a 3-year-old girl who suffered a penetrating wound on her lower back after sliding on a wood floor. A portion of the extraspinal part of the wooden splinter was removed prior to presentation; however, a high suspicion for retained foreign body was maintained. Findings on CT were equivocal, but the diagnosis was confirmed on MRI. An incomplete cauda equina syndrome was noted on examination. She was taken to the operating room for removal of the wooden foreign body, repair of a durotomy, and repair of a CSF leak. At 8 months after surgery, the patient had fully recovered without sequelae. The roles of imaging modalities, prophylactic antibiotics, and surgery are discussed.

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G. Edward Vates, Mitchel S. Berger and Charles B. Wilson

Object. Pituitary abscess is a rare but serious intrasellar infection. To better determine the salient signs and symptoms that help in making the diagnosis, and to determine the most appropriate treatment, the authors reviewed their experience in a series of 24 patients treated at the University of California at San Francisco.

Methods. Nine of the patients were female and 15 were male, and their mean age was 41.2 years (range 12–71 years). Surprisingly, most patients in our series presented with complaints and physical findings consistent with a pituitary mass, but rarely with evidence of a serious infection. Headache, endocrine abnormalities, and visual changes were the most common clinical indicators; fever, peripheral leukocytosis, and meningismus were present in 33% or fewer of the patients. Imaging tests demonstrated a pituitary mass in all patients, but the features evident on computerized tomography and magnetic resonance studies did not distinguish pituitary abscesses from other, more common intrasellar lesions. Because of the ambiguous clinical features and imaging findings, most abscesses were not diagnosed before treatment; rather, the diagnosis was made during surgical exploration of the sella turcica, when the surgeon encountered a cystic mass containing pus. There were only two deaths in this series (8.3%). Patients presenting with headache and visual changes noted improvement in almost all cases; patients with endocrine dysfunction generally did not recover normal pituitary function, but were easily treated with hormone replacement therapy.

Conclusions. Antibiotic therapy is suggested for patients who have symptoms of sepsis, or for patients in whom specific organisms are identified from cultures obtained during surgery. The transsphenoidal approach is recommended over open craniotomy for surgical drainage.

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G. Edward Vates, Tomoki Hashimoto, William L. Young and Michael T. Lawton

Object

The goal of this study was to examine the roles of vascular endothelial growth factor (VEGF) and angiopoietin- 2 (Ang-2) in the formation of blood vessels in the brain in a developmental animal model not routinely used for such a study.

Methods

Either VEGF, Ang-2, or a combination of the two factors were injected into the optic tectum of 4-day-old quail embryos. Immunohistochemical analysis and laser confocal microscopy were used to observe the effects on endothelial cells in the brain. Vascular endothelial growth factor and Ang-2 had very different effects on the development of blood vessels; the former caused expansion and the latter retraction of these vessels. Treatment with a combination of VEGF and Ang-2 caused retroorbital or intraventricular hemorrhage, and brain blood vessels appeared enlarged and dysmorphic, with dramatically extended filopodia.

Conclusions

Some of these observations may provide insight into how one may develop a better model of brain arteriovenous malformations.

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Tyler M. Schmidt, Ian A. DeAndrea-Lazarus, Kristopher T. Kimmell, G. Edward Vates, Stephen J. Haines and Webster H. Pilcher

The William P. Van Wagenen Fellowship, celebrating its 50th anniversary, is an annual award given by the AANS and administered by the Neurosurgery Research and Education Foundation (NREF). Named after its benefactor, Dr. William Van Wagenen, the fellowship continues his legacy of mentorship and innovation. As the premier research award for young neurosurgeons, it has provided a foundation for career development for many thought leaders in the field. The award was created in the spirit of Van Wagenen’s belief in collaboration with other institutions as a means of refining neurosurgical technique, creating new research initiatives, and improving patient outcomes. Van Wagenen’s commitment was informed by his early experiences in neurosurgery with his mentor Dr. Harvey Cushing, who helped to fund Van Wagenen’s scientific endeavors in Europe. This journey catalyzed Van Wagenen’s lifelong commitment to mentorship, which is exemplified by his instrumental role in the creation of the Harvey Cushing Society, now the AANS. Over the last 50 years, the recipients of this award have used the endowment to lay the groundwork for many scientific and technical innovations in neurosurgery. The fellowship remains an unmatched opportunity to explore new lines of investigation, foster academic and research goals, incorporate new technology and skills into American neurosurgical practice, and motivate young neurosurgeons to transform the field. The legacy of mentorship, scientific inquiry, and clinical excellence personified by Cushing and Van Wagenen is memorialized in the William P. Van Wagenen Fellowship.

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Jeffrey H. Zimering, Jonathan J. Stone, Audrey Paulzak, John D. Markman, Mahlon D. Johnson and G. Edward Vates

The authors report the case of a 52-year-old man who presented with rapid-onset lancinating facial pain consistent with trigeminal neuralgia. Magnetic resonance imaging revealed a nonenhancing small lesion on the right trigeminal nerve concerning for an atypical schwannoma or neuroma. The patient underwent resection of the mass via a right retrosigmoid approach. His facial pain completely resolved immediately postoperatively and had not recurred at 6 months after surgery. The mass was consistent with normal brain tissue (neurons and glial cells) without evidence of mitoses. A final histopathological diagnosis of ectopic brain tissue with neural tissue demonstrating focal, chronic T-cell inflammation was made. The partial rhizotomy during resection was curative for the facial pain. To the authors’ knowledge, this is the first report of neuroglial ectopia causing trigeminal neuralgia.

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Keaton Piper, Hanna Algattas, Ian A. DeAndrea-Lazarus, Kristopher T. Kimmell, Yan Michael Li, Kevin A. Walter, Howard J. Silberstein and G. Edward Vates

OBJECTIVE

Patients undergoing spinal surgery are at risk for developing venous thromboembolism (VTE). The authors sought to identify risk factors for VTE in these patients.

METHODS

The American College of Surgeons National Surgical Quality Improvement Project database for the years 2006–2010 was reviewed for patients who had undergone spinal surgery according to their primary Current Procedural Terminology code(s). Clinical factors were analyzed to identify associations with VTE.

RESULTS

Patients who underwent spinal surgery (n = 22,434) were identified. The rate of VTE in the cohort was 1.1% (pulmonary embolism 0.4%; deep vein thrombosis 0.8%). Multivariate binary logistic regression analysis revealed 13 factors associated with VTE. Preoperative factors included dependent functional status, paraplegia, quadriplegia, disseminated cancer, inpatient status, hypertension, history of transient ischemic attack, sepsis, and African American race. Operative factors included surgery duration > 4 hours, emergency presentation, and American Society of Anesthesiologists Class III–V, whereas postoperative sepsis was the only significant postoperative factor. A risk score was developed based on the number of factors present in each patient. Patients with a score of ≥ 7 had a 100-fold increased risk of developing VTE over patients with a score of 0. The receiver-operating-characteristic curve of the risk score generated an area under the curve of 0.756 (95% CI 0.726–0.787).

CONCLUSIONS

A risk score based on race, preoperative comorbidities, and operative characteristics of patients undergoing spinal surgery predicts the postoperative VTE rate. Many of these risks can be identified before surgery. Future protocols should focus on VTE prevention in patients who are predisposed to it.

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Tyler M. Schmidt, Ian A. DeAndrea-Lazarus, Kristopher T. Kimmell, G. Edward Vates, Stephen J. Haines and Webster H. Pilcher

The William P. Van Wagenen Fellowship, celebrating its 50th anniversary, is an annual award given by the AANS and administered by the Neurosurgery Research and Education Foundation (NREF). Named after its benefactor, Dr. William Van Wagenen, the fellowship continues his legacy of mentorship and innovation. As the premier research award for young neurosurgeons, it has provided a foundation for career development for many thought leaders in the field. The award was created in the spirit of Van Wagenen’s belief in collaboration with other institutions as a means of refining neurosurgical technique, creating new research initiatives, and improving patient outcomes. Van Wagenen’s commitment was informed by his early experiences in neurosurgery with his mentor Dr. Harvey Cushing, who helped to fund Van Wagenen’s scientific endeavors in Europe. This journey catalyzed Van Wagenen’s lifelong commitment to mentorship, which is exemplified by his instrumental role in the creation of the Harvey Cushing Society, now the AANS. Over the last 50 years, the recipients of this award have used the endowment to lay the groundwork for many scientific and technical innovations in neurosurgery. The fellowship remains an unmatched opportunity to explore new lines of investigation, foster academic and research goals, incorporate new technology and skills into American neurosurgical practice, and motivate young neurosurgeons to transform the field. The legacy of mentorship, scientific inquiry, and clinical excellence personified by Cushing and Van Wagenen is memorialized in the William P. Van Wagenen Fellowship.

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Ian F. Dunn, Graeme F. Woodworth, Adnan H. Siddiqui, Edward R. Smith, G. Edward Vates, Arthur L. Day and Liliana C. Goumnerova

✓ Traumatic intracranial aneurysms are rare in adults but account for up to 33% of all aneurysms encountered in a pediatric population. The most common location of such lesions in children is the pericallosal or adjacent branch of the anterior cerebral artery, where a head impact exerts sudden decelerating shearing forces on the arteries tethered on the brain surface against an immobile falx cerebri, weakening the arterial wall. This action can lead to dissection of the damaged vascular layers, with resultant expansion of the affected site into a fusiform aneurysm. Pericallosal aneurysms following a penetrating intracranial injury have also been described, and the resultant lesion in some cases can be a pseudoaneurysm. The incidence of iatrogenic pericallosal artery aneurysms, however, is extremely rare.

The authors describe the first reported case of a traumatic pericallosal artery aneurysm following transcallosal surgery. This 6-year-old boy underwent resection of a hypothalamic pilocytic astrocytoma, which was approached via the transcallosal corridor. A follow-up magnetic resonance image obtained within 1 year of surgery disclosed a small flow void off the right pericallosal artery, which was initially interpreted as residual tumor. Serial investigations showed the lesion enlarging over time, and subsequent angiography revealed a round 7-mm pericallosal artery aneurysm with an irregularly shaped 2- to 3-mm lumen. The aneurysm was difficult to treat with clip reconstruction or suturing of the affected segment, and an excellent outcome was ultimately achieved with resection of the lesion and autogenous arterial graft interposition. The authors also discuss the likely pathophysiology of the aneurysm and the surgical procedures undertaken to treat it.