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Ivo Peto, Hussam Abou-Al-Shaar and Amir R. Dehdashti

Posterior fossa dural arteriovenous fistulas (dAVFs) are rare vascular malformations. They carry a significant risk of hemorrhage if associated with cortical venous reflux. A 70-year-old man presented with right-sided medullary hemorrhage with pronounced Wallenberg syndrome. Angiography demonstrated right jugular foramen dAVF with direct brainstem venous reflux (Cognard IV). It was fed from multiple branches of the external carotid artery and the vertebral artery, and draining into the ascending pontomesencephalic vein. Primary two-stage transarterial embolization was performed with near-total occlusion of the fistula to prevent it from rebleeding in the acute phase. Because of the patient’s significant neurological deficit, the surgery was deferred to later and if the DAVF showed further progression. Follow-up angiography 8 months later demonstrated obvious recurrence and progression of the fistula from adjacent feeders. In the meantime, the patient had a remarkable recovery from the Wallenberg symptoms. To achieve complete occlusion of the fistula, a right far lateral approach was chosen with complete disconnection of the fistula. Postoperative angiography confirmed complete occlusion of the fistula, and the patient remained intact from the procedure.

The video can be found here: https://youtu.be/DJvpa8G4olc.

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Asem Salma, Hussam Abou Al-Shaar and Maher Hassounah

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Hussam Abou-Al-Shaar, Nam Yoon and Mark A. Mahan

Traumatic proximal sciatic nerve rupture poses surgical repair dilemmas. Disruption often causes a large nerve gap after proximal neuroma and distal scar removal. Also, autologous graft material to bridge the segmental defect may be insufficient, given the sciatic nerve diameter. The authors utilized knee flexion to allow single neurorrhaphy repair of a large sciatic nerve defect, bringing healthy proximal stump to healthy distal segment. To avoid aberrant regeneration, the authors split the sciatic nerve into common peroneal and tibial divisions. After 3 months, the patient can fully extend the knee and has evidence of distal regeneration and nerve continuity without substantial injury.

The video can be found here: https://youtu.be/lsezRT5I8MU.

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Hussam Abou-Al-Shaar and Mark A. Mahan

Endoscopic surgery has revolutionized the field of minimally invasive surgery. Nerve injury after laparoscopic surgery is presumably rare, with only scarce reports in the literature; however, the use of these techniques for new purposes presents the opportunity for novel complications. The authors report a case of subcostal nerve injury after an anterior laparoscopic approach to a posterior abdominal wall lipoma.

A 62-year-old woman presented with a left abdominal flank bulge (pseudohernia) that developed after laparoscopic posterior flank wall lipoma resection. Imaging demonstrated frank ballooning of the oblique muscles; denervation atrophy and thinning of the external oblique, internal oblique, and transverse abdominis muscles; and thinning of the rectus abdominis muscle. The patient underwent subcostal nerve repair and removal of a foreign plastic material from the laparoscopic procedure. At 8 months, she has regained substantial improvement in abdominal wall strength.

Although endoscopic procedures have resulted in significant reduction in morbidity, “minimally invasive” approaches should not be confused with “low risk” when approaching novel pathology. The subcostal nerve is at risk of injury in posterior abdominal wall surgery, whether laparoscopic or not. With the pseudohernia and abdominal bulge after this surgery, the cosmetic appeal of laparoscopic incisions was definitively undone. Selecting an approach based on the anatomy of adjacent structures may lead to a better functional result.

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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.

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Michael Karsy, Hussam Abou-Al-Shaar, Christian A. Bowers and Richard H. Schmidt

OBJECTIVE

Idiopathic intracranial hypertension (IIH), or pseudotumor cerebri, is a complex and difficult-to-manage condition that can lead to permanent vision loss and refractory headaches if untreated. Traditional treatment options, such as unilateral ventriculoperitoneal (VP) or lumboperitoneal (LP) shunt placement, have high complication and failure rates and often require multiple revisions. The use of bilateral proximal catheters has been hypothesized as a method to improve shunt survival. The use of stereotactic technology has improved the accuracy of catheter placement and may improve treatment of IIH, with fewer complications and greater shunt patency time.

METHODS

The authors performed a retrospective chart review for all patients with IIH who underwent stereotactic placement of biventriculoperitoneal (BVP) shunt catheters from 2008 to 2016 at their institution. Bilateral proximal catheters were Y-connected to a Strata valve with a single distal catheter. We evaluated clinical, surgical, and ophthalmological variables and outcomes.

RESULTS

Most patients in this series of 34 patients (mean age 34.4 ± 8.2 years, mean body mass index 38.7 ± 8.3 kg/m2; 91.2% were women) undergoing 41 shunt procedures presented with headache (94.1%) and visual deficits (85.3%). The mean opening pressure was 39.6 ± 9.0 cm H2O. In addition, 50.0% had undergone previous unilateral shunt placement, and 20.6% had undergone prior optic nerve sheath fenestration. After BVP shunt placement, there were no cases of proximal catheter obstruction and only a single case of valve obstruction at 41.9 months, with a mean follow-up of 24.8 ± 20.0 months. Most patients showed improvement in their headache (82.4%), subjective vision (70.6%), and papilledema (61.5% preoperatively vs 20.0% postoperatively, p = 0.02) at follow-up. Additional primary complications included 4 patients with migration of their distal catheters out of the peritoneum (twice in 1 patient), and an infection of the distal catheter after catheter dislodgment. The proximal obstructive shunt complication rate in this series (2.9%) was lower than that with LP (53.5%) or unilateral VP (37.8%) shunts seen in the literature.

CONCLUSIONS

This small series suggests that stereotactic placement of BVP shunt catheters appears to improve shunt survival rates and presenting symptoms in patients with IIH. Compared with unilateral VP or LP shunts, the use of BVP shunts may be a more effective and more functionally sustained method for the treatment of IIH.

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Troy Dawley, Zaker Rana, Hussam Abou-Al-Shaar, Anuj Goenka and Michael Schulder

OBJECTIVE

Complications from radiotherapy (RT), in a primary or adjuvant setting, have overall been described as uncommon, with few detailed descriptions of major complications. The authors present two cases involving significant complications and their management in their review of patients undergoing RT for treatment of atypical meningioma.

METHODS

The authors conducted a retrospective review of all patients with pathologically confirmed atypical meningioma (WHO grade II) treated with primary or adjuvant RT from February 2011 through February 2019. They identified two patients with long-term, grade 3 toxicity. The cases of these patients are described in detail.

RESULTS

Two patients had major complications associated with postoperative RT. Patients 1 and 2 both were treated with postoperative RT for pathologically confirmed atypical meningioma. Patient 1 experienced worsening behavioral changes, cognitive decline, and hydrocephalus following treatment. This required cerebrospinal fluid diversion. Patient 2 developed radiation necrosis with mass effect and cognitive decline. Neither patient returned to his/her initial post-RT status after steroid therapy, and each remained in need of supportive care. Both patients remained free of tumor progression at 52 and 38 months following treatment.

CONCLUSIONS

The postoperative management of patients with atypical meningioma continues to be defined, with questions remaining regarding timing of RT, dose, target delineation, and fractionation. Both of the patients in this study received fractionated RT, which included a greater volume of normal brain than more focal treatment options such as would be required by stereotactic radiosurgery (SRS). Further research is needed to compare SRS and fractionated RT for the management of patients with grade II meningiomas. The more focused nature of SRS may make this a preferred option in certain cases of focal recurrence.

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Timothy G. White, Hussam Abou-Al-Shaar, Jung Park, Jeffrey Katz, David J. Langer and Amir R. Dehdashti

OBJECTIVE

Cerebral revascularization for carotid occlusion was previously a mainstay procedure for the cerebrovascular neurosurgeon. However, the 1985 extracranial-intracranial bypass trial and subsequently the Carotid Occlusion Surgery Study (COSS) provided level 1 evidence via randomized controlled trials against bypass for symptomatic atherosclerotic carotid occlusion disease. However, in a small number of patients optimal medical therapy fails, and some patients with flow-limiting stenosis develop a perfusion-dependent neurological examination. Therefore it is necessary to further stratify patients by risk to determine who may most benefit from this intervention as well as to determine perioperative morbidity in this high-risk patient population.

METHODS

A retrospective review was performed of all revascularization procedures done for symptomatic atherosclerotic cerebrovascular steno-occlusive disease. All patients undergoing revascularization after the publication of the COSS in 2011 were included. Perioperative morbidity and mortality were assessed as the primary outcome to determine safety of revascularization in this high-risk population. All patients had documented hypoperfusion on hemodynamic imaging.

RESULTS

At total of 35 revascularization procedures were included in this review. The most common indication was for patients with recurrent strokes, who were receiving optimal medical therapy and who suffered from cerebrovascular steno-occlusion. At 30 days only 3 perioperative ischemic events were observed, 2 of which led to no long-term neurological deficit. Immediate graft patency was good, at 94%. Long term, no further strokes or ischemic events were observed, and graft patency remained high at 95%. There were no factors associated with perioperative ischemic events in the variables that were recorded.

CONCLUSIONS

Cerebral revascularization may be done safely at high-volume cerebrovascular centers in high-risk patients in whom optimal medical therapy has failed. Further research must be done to develop an improved methodology of risk stratification for patients with symptomatic atherosclerotic cerebrovascular steno-occlusive disease to determine which patients may benefit from intervention. Given the high risk of recurrent stroke in certain patients, and the fact that patients fail medical therapy, surgical revascularization may provide the best method to ensure good long-term outcomes with manageable up-front risks.

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Spencer Twitchell, Hussam Abou-Al-Shaar, Jared Reese, Michael Karsy, Ilyas M. Eli, Jian Guan, Philipp Taussky and William T. Couldwell

OBJECTIVE

With the continuous rise of health care costs, hospitals and health care providers must find ways to reduce costs while maintaining high-quality care. Comparing surgical and endovascular treatment of intracranial aneurysms may offer direction in reducing health care costs. The Value-Driven Outcomes (VDO) database at the University of Utah identifies cost drivers and tracks changes over time. In this study, the authors evaluate specific cost drivers for surgical clipping and endovascular management (i.e., coil embolization and flow diversion) of both ruptured and unruptured intracranial aneurysms using the VDO system.

METHODS

The authors retrospectively reviewed surgical and endovascular treatment of ruptured and unruptured intracranial aneurysms from July 2011 to January 2017. Total cost (as a percentage of each patient’s cost to the system), subcategory costs, and potential cost drivers were evaluated and analyzed.

RESULTS

A total of 514 aneurysms in 469 patients were treated; 273 aneurysms were surgically clipped, 102 were repaired with coiling, and 139 were addressed with flow diverter placements. Middle cerebral artery aneurysms accounted for the largest portion of cases in the clipping group (29.7%), whereas anterior communicating artery aneurysms were most frequently involved in the coiling group (30.4%) and internal carotid artery aneurysms were the majority in the flow diverter group (63.3%). Coiling (mean total cost 0.25% ± 0.20%) had a higher cost than flow diversion (mean 0.20% ± 0.16%) and clipping (mean 0.17 ± 0.14%; p = 0.0001, 1-way ANOVA). Coiling cases cost 1.5 times as much as clipping and flow diversion costs 1.2 times as much as clipping. Facility costs were the most significant contributor to intracranial clipping costs (60.2%), followed by supplies (18.3%). Supplies were the greatest cost contributor to coiling costs (43.2%), followed by facility (40.0%); similarly, supplies were the greatest portion of costs in flow diversion (57.5%), followed by facility (28.5%). Cost differences for aneurysm location, rupture status, American Society of Anesthesiologists (ASA) grade, and discharge disposition could be identified, with variability depending on surgical procedure. A multivariate analysis showed that rupture status, surgical procedure type, ASA status, discharge disposition, and year of surgery all significantly affected cost (p < 0.0001).

CONCLUSIONS

Facility utilization and supplies constitute the majority of total costs in aneurysm treatment strategies, but significant variation exists depending on surgical approach, rupture status, and patient discharge disposition. Developing and implementing approaches and protocols to improve resource utilization are important in reducing costs while maintaining high-quality patient care.

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Michael Karsy, Mohammed A. Azab, Hussam Abou-Al-Shaar, Jian Guan, Ilyas Eli, Randy L. Jensen and D. Ryan Ormond

Meningiomas are among the most common intracranial pathological conditions, accounting for 36% of intracranial lesions treated by neurosurgeons. Although the majority of these lesions are benign, the classical categorization of tumors by histological type or World Health Organization (WHO) grade has not fully captured the potential for meningioma progression and recurrence. Many targeted treatments have failed to generate a long-lasting effect on these tumors. Recently, several seminal studies evaluating the genomics of intracranial meningiomas have rapidly changed the understanding of the disease. The importance of NF2 (neurofibromin 2), TRAF7 (tumor necrosis factor [TNF] receptor–associated factor 7), KLF4 (Kruppel-like factor 4), AKT1, SMO (smoothened), PIK3CA (phosphatidylinositol-4,5-bisphosphate 3-kinase catalytic subunit alpha), and POLR2 (RNA polymerase II subunit A) demonstrates that there are at least 6 distinct mutational classes of meningiomas. In addition, 6 methylation classes of meningioma have been appreciated, enabling improved prediction of prognosis compared with traditional WHO grades. Genomic studies have shed light on the nature of recurrent meningioma, distinct intracranial locations and mutational patterns, and a potential embryonic cancer stem cell–like origin. However, despite these exciting findings, the clinical relevance of these findings remains elusive. The authors review the key findings from recent genomic studies in meningiomas, specifically focusing on how these findings relate to clinical insights for the practicing neurosurgeon.