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Kyle P. O’Connor and Bradley N. Bohnstedt

A 67-year-old male presented to the hospital with a left anterior cranial fossa arteriovenous fistula connecting the anterior ethmoidal artery to the cavernous sinus and superior sagittal sinus. After failed embolization, the patient was taken for a supra-orbital (eyebrow) craniotomy for surgical dissection and clipping of the fistula. An intraoperative angiogram confirmed successful fistula ligation. The patient was discharged without complications.

The video can be found here: https://youtu.be/79Pk11SEkJg.

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Kyle P. O’Connor, Adam D. Smitherman, Ali H. Palejwala, Greg A. Krempl and Michael D. Martin

Anterior cervical discectomy and fusion (ACDF) is the most common surgical procedure utilized for degenerative diseases of the cervical spine. The authors present the case of a 64-year-old man who underwent an ACDF for degenerative changes causing cervical stenosis with myelopathy. The patient’s symptoms consisted of pain and weakness of the bilateral upper extremities that slowly progressed over 1.5 years. During the procedure, the superior horn of the thyroid cartilage impeded proper retraction, preventing adequate visualization due to its prominent size. At this point, otorhinolaryngology was consulted, which allowed for safe resection of this portion of the thyroid cartilage while preserving nearby critical structures. With the frequent usage of this surgical approach for various etiologies, the importance of proper recognition and consultation is paramount. Encountering prominent thyroid cartilage resulting in surgical obstruction has not been described in the literature and this report represents a paradigm for the proper course of action.

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Joshua D. Burks, Andrew K. Conner, Robert G. Briggs, Phillip A. Bonney, Adam D. Smitherman, Cordell M. Baker, Chad A. Glenn, Cameron A. Ghafil, Dillon P. Pryor, Kyle P. O’Connor and Bradley N. Bohnstedt

OBJECTIVE

A shifting emphasis on efficient utilization of hospital resources has been seen in recent years. However, reduced screening for blunt vertebral artery injury (BVAI) may result in missed diagnoses if risk factors are not fully understood. The authors examined the records of blunt trauma patients with fractures near the craniocervical junction who underwent CTA at a single institution to better understand the risk of BVAI imposed by occipital condyle fractures (OCFs).

METHODS

The authors began with a query of their prospectively collected trauma registry to identify patients who had been screened for BVAI using ICD-9-CM diagnostic codes. Grade and segment were recorded in instances of BVAI. Locations of fractures were classified into 3 groups: 1) OCFs, 2) C1 (atlas) fractures, and 3) fractures of the C2–6 vertebrae. Univariate and multivariate analyses were performed to identify any fracture types associated with BVAI.

RESULTS

During a 6-year period, 719 patients underwent head and neck CTA following blunt trauma. Of these patients, 147 (20%) had OCF. BVAI occurred in 2 of 43 patients with type I OCF, 1 of 42 with type II OCF, and in 9 of 62 with type III OCF (p = 0.12). Type III OCF was an independent risk factor for BVAI in multivariate modeling (OR 2.29 [95% CI 1.04–5.04]), as were fractures of C1–6 (OR 5.51 [95% CI 2.57–11.83]). Injury to the V4 segment was associated with type III OCF (p < 0.01).

CONCLUSIONS

In this study, the authors found an association between type III OCF and BVAI. While further study may be necessary to elucidate the mechanism of injury in these cases, this association suggests that thorough cerebrovascular evaluation is warranted in patients with type III OCF.

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Victor M. Lu, Kyle P. O’Connor, Benjamin T. Himes, Desmond A. Brown, Cody L. Nesvick, Ruby G. Siada, Toba N. Niazi, Jonathan Schwartz and David J. Daniels

OBJECTIVE

Glioblastoma (GBM) during infancy is rare, and the clinical outcomes of congenital GBM are not well understood. Correspondingly, the aim of this study was to present a long-term survivor case from the authors’ institution, and establish an integrated cohort of cases across the published literature to better understand the clinical course of this disease in this setting.

METHODS

The authors report the outcomes of an institutional case of congenital GBM diagnosed within the first 3 months of life, and performed a comprehensive literature search for published cases from 2000 onward for an integrated survival analysis. All cases were integrated into 1 cohort, and Kaplan-Meier estimations, Fisher’s exact test, and logistic regression were used to interrogate the data.

RESULTS

The integrated cohort of 40 congenital GBM cases consisted of 23 (58%) females and 17 (42%) males born at a median gestational age of 38 weeks (range 22–40 weeks). Estimates of overall survival (OS) at 1 month was 67%, at 1 year it was 59%, and at 10 years it was 45%, with statistically superior outcomes for subgroups in which patients survived to be treated by resection and chemotherapy. In the overall cohort, multivariable analysis confirmed resection (p < 0.01) and chemotherapy (p < 0.01) as independent predictors of superior OS. Gestational age > 38 weeks (p < 0.01), Apgar scores ≥ 7 at 5 minutes (p < 0.01), absence of prenatal hydrocephalus (p < 0.01), and vaginal delivery (p < 0.01) were associated with greater odds of surgical diagnosis versus autopsy diagnosis.

CONCLUSIONS

Congenital GBM can deviate from the expected poor prognosis of adult GBM in terms of OS. Both resection and chemotherapy confer statistically superior prognostic advantages in those patients who survive within the immediate postnatal period, and should be first-line considerations in the initial management of this rare disease.

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Visish M. Srinivasan, Aditya Srivatsan, Alejandro M. Spiotta, Benjamin K. Hendricks, Andrew F. Ducruet, Felipe C. Albuquerque, Ajit Puri, Matthew R. Amans, Steven W. Hetts, Daniel L. Cooke, Christopher S. Ogilvy, Ajith J. Thomas, Alejandro Enriquez-Marulanda, Ansaar Rai, SoHyun Boo, Andrew P. Carlson, R. Webster Crowley, Leonardo Rangel-Castilla, Giuseppe Lanzino, Peng Roc Chen, Orlando Diaz, Bradley N. Bohnstedt, Kyle P. O’Connor, Jan-Karl Burkhardt, Jeremiah N. Johnson, Stephen R. Chen and Peter Kan

OBJECTIVE

Traditionally, stent-assisted coiling and balloon remodeling have been the primary endovascular treatments for wide-necked intracranial aneurysms with complex morphologies. PulseRider is an aneurysm neck reconstruction device that provides parent vessel protection for aneurysm coiling. The objective of this study was to report early postmarket results with the PulseRider device.

METHODS

This study was a prospective registry of patients treated with PulseRider at 13 American neurointerventional centers following FDA approval of this device. Data collected included clinical presentation, aneurysm characteristics, treatment details, and perioperative events. Follow-up data included degree of aneurysm occlusion and delayed (> 30 days after the procedure) complications.

RESULTS

A total of 54 aneurysms were treated, with the same number of PulseRider devices, across 13 centers. Fourteen cases were in off-label locations (7 anterior communicating artery, 6 middle cerebral artery, and 1 A1 segment anterior cerebral artery aneurysms). The average dome/neck ratio was 1.2. Technical success was achieved in 52 cases (96.2%). Major complications included the following: 3 procedure-related posterior cerebral artery strokes, a device-related intraoperative aneurysm rupture, and a delayed device thrombosis. Immediately postoperative Raymond-Roy occlusion classification (RROC) class 1 was achieved in 21 cases (40.3%), class 2 in 15 (28.8%), and class 3 in 16 cases (30.7%). Additional devices were used in 3 aneurysms. For those patients with 3- or 6-month angiographic follow-up (28 patients), 18 aneurysms (64.2%) were RROC class 1 and 8 (28.5%) were RROC class 2.

CONCLUSIONS

PulseRider is being used in both on- and off-label cases following FDA approval. The clinical and radiographic outcomes are comparable in real-world experience to the outcomes observed in earlier studies. Further experience is needed with the device to determine its role in the neurointerventionalist’s armamentarium, especially with regard to its off-label use.