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Diego San Millán Ruíz and Dheeraj Gandhi

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Michael L. Mumert, Michael T. Walsh, Steven S. Chin and William T. Couldwell

Symptomatic granular cell tumors of the neurohypophysis are a rarely reported entity. To the authors' knowledge, they report the first fully described case of a symptomatic granular cell tumor with a large cystic component. A 31-year-old woman presented with headaches and visual complaints with imaging findings confirming a cystic sellar and suprasellar mass. The lesion was resected, and histological examination confirmed the diagnosis. The literature has shown that granular cell tumors are rarely reported as being symptomatic but may actually be a fairly common finding in autopsy studies. The authors review the literature with a specific focus on radiographic findings in patients with symptomatic granular cell tumors.

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Michael Walsh, Hemant Parmar, Suresh K. Mukherji and Alexander Mamourian

Developmental venous anomalies (DVAs) are generally considered a benign and asymptomatic finding on CT and MR imaging. The authors report 2 cases of spontaneous thrombosis of the draining vein of a DVA depicted on CT and MR imaging. One patient presented with a nonhemorrhagic transient ischemia, which was successfully treated with anticoagulant therapy. The second patient presented with ischemia complicated by hemorrhagic conversion.

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Samuel J. Hassenbusch, Michael Stanton-Hicks, Derek Schoppa, James G. Walsh and Edward C. Covington

✓ This prospective, consecutive series describes peripheral nerve stimulation (PNS) for treatment of severe reflex sympathetic dystrophy (RSD) or complex regional pain syndrome, in patients with symptoms entirely or mainly in the distribution of one major peripheral nerve. Plate-type electrodes were placed surgically on affected nerves and tested for 2 to 4 days. Programmable generators were implanted if 50% or more pain reduction and objective improvement in physical changes were achieved. Patients were followed for 2 to 4 years and a disinterested third-party interviewer performed final patient evaluations. Of 32 patients tested, 30 (94%) underwent permanent PNS placement. Long-term good or fair relief was experienced in 19 (63%) of 30 patients. In successfully treated patients, allodynic and spontaneous pain was reduced on a scale of 10 from 8.3 ± 0.3 preimplantation to 3.5 ± 0.4 (mean ± standard error of the mean) at latest follow up (p < 0.001). Changes in vasomotor tone and patient activity levels were markedly improved but motor weakness and trophic changes showed less improvement. Six (20%) of the 30 patients undergoing PNS placement returned to part-time or full-time work after being unemployed prestimulator implantation. Initial involvement of more than one major peripheral nerve correlated with a poor or no relief rating (p < 0.01). Operative modifications that minimize technical complications are described. This study indicates that PNS can provide good relief for RSD that is limited to the distribution of one major nerve.

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Mandy J. Binning, Michael T. Walsh, Ronald I. Apfelbaum, Steven S. Chin and William T. Couldwell

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Yair M. Gozal, Gmaan Alzhrani, Hussam Abou-Al-Shaar, Mohammed A. Azab, Michael T. Walsh and William T. Couldwell

OBJECTIVE

Cavernous sinus meningiomas are complex tumors that offer a perpetual challenge to skull base surgeons. The senior author has employed a management strategy for these lesions aimed at maximizing tumor control while minimizing neurological morbidity. This approach emphasizes combining “safe” tumor resection and direct decompression of the roof and lateral wall of the cavernous sinus as well as the optic nerve. Here, the authors review their experience with the application of this technique for the management of cavernous sinus meningiomas over the past 15 years.

METHODS

A retrospective analysis was performed for patients with cavernous sinus meningiomas treated over a 15-year period (2002–2017) with this approach. Patient outcomes, including cranial nerve function, tumor control, and surgical complications were recorded.

RESULTS

The authors identified 50 patients who underwent subtotal resection via frontotemporal craniotomy concurrently with decompression of the cavernous sinus and ipsilateral optic nerve. Of these, 25 (50%) underwent adjuvant radiation to the remaining tumor within the cavernous sinus. Patients most commonly presented with a cranial nerve (CN) palsy involving CN III–VI (70%), a visual deficit (62%), headaches (52%), or proptosis (44%). Thirty-five patients had cranial nerve deficits preoperatively. In 52% of these cases, the neuropathy improved postoperatively; it remained stable in 46%; and it worsened in only 2%. Similarly, 97% of preoperative visual deficits either improved or were stable postoperatively. Notably, 12 new cranial nerve deficits occurred postoperatively in 10 patients. Of these, half were transient and ultimately resolved. Finally, radiographic recurrence was noted in 5 patients (10%), with a median time to recurrence of 4.6 years.

CONCLUSIONS

The treatment of cavernous sinus meningiomas using surgical decompression with or without adjuvant radiation is an effective oncological strategy, achieving excellent tumor control rates with low risk of neurological morbidity.

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The effect of C2–3 disc angle on postoperative adverse events in cervical spondylotic myelopathy

Presented at the 2018 AANS/CNS Joint Section on Disorders of the Spine and Peripheral Nerves

Bryan S. Lee, Kevin M. Walsh, Daniel Lubelski, Konrad D. Knusel, Michael P. Steinmetz, Thomas E. Mroz, Richard P. Schlenk, Iain H. Kalfas and Edward C. Benzel

OBJECTIVE

Complete radiographic and clinical evaluations are essential in the surgical treatment of cervical spondylotic myelopathy (CSM). Prior studies have correlated cervical sagittal imbalance and kyphosis with disability and worse health-related quality of life. However, little is known about C2–3 disc angle and its correlation with postoperative outcomes. The present study is the first to consider C2–3 disc angle as an additional radiographic predictor of postoperative adverse events.

METHODS

A retrospective chart review was performed to identify patients with CSM who underwent surgeries from 2010 to 2014. Data collected included demographics, baseline presenting factors, and postoperative outcomes. Cervical sagittal alignment variables were measured using the preoperative and postoperative radiographs. Univariable logistic regression analyses were used to explore the association between dependent and independent variables, and a multivariable logistic regression model was created using stepwise variable selection.

RESULTS

The authors identified 171 patients who had complete preoperative and postoperative radiographic and outcomes data. The overall rate of postoperative adverse events was 33% (57/171), and postoperative C2–3 disc angle, C2–7 sagittal vertical axis, and C2–7 Cobb angle were found to be significantly associated with adverse events. Inclusion of postoperative C2–3 disc angle in the analysis led to the best prediction of adverse events. The mean postoperative C2–3 disc angle for patients with any postoperative adverse event was 32.3° ± 17.2°, and the mean for those without any adverse event was 22.4° ± 11.1° (p < 0.0001).

CONCLUSIONS

In the present retrospective analysis of postoperative adverse events in patients with CSM, the authors found a significant association between C2–3 disc angle and postoperative adverse events. They propose that C2–3 disc angle be used as an additional parameter of cervical spinal sagittal alignment and predictor for operative outcomes.

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Paul S. Echlin, Andrew M. Johnson, Jeffrey D. Holmes, Annalise Tichenoff, Sarah Gray, Heather Gatavackas, Joanne Walsh, Tim Middlebro, Angelique Blignaut, Martin MacIntyre, Chris Anderson, Eli Fredman, Michael Mayinger, Elaine N. Skopelja, Takeshi Sasaki, Sylvain Bouix, Ofer Pasternak, Karl G. Helmer, Inga K. Koerte, Martha E. Shenton and Lorie A. Forwell

Current research on concussion is primarily focused on injury identification and treatment. Prevention initiatives are, however, important for reducing the incidence of brain injury. This report examines the development and implementation of an interactive electronic teaching program (an e-module) that is designed specifically for concussion education within an adolescent population. This learning tool and the accompanying consolidation rubric demonstrate that significant engagement occurs in addition to the knowledge gained among participants when it is used in a school curriculum setting.