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Mina G. Safain, Walter C. Dent and Carl B. Heilman

Epidermoid cysts are rare lesions accounting for 1% of intracranial tumors with approximately 50% located within the cerebello-pontine angle (CPA). Resection is complicated by their close anatomical relation to critical neurovascular structures and their tendency to be densely adherent making complete removal a significant neurosurgical challenge. We present a 35-year-old woman with left sided tongue numbness and lower lip paresthesias with a CPA epidermoid. An endoscopic assisted retrosigmoid approach was utilized for resection. A 30-degree endoscope was used to assist in removal of unseen tumor in Meckel's cave, medial to the lower cranial nerves, and along the ventral pons.

The video can be found here: http://youtu.be/bv0lMPbX7BY.

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Sameer H. Halani, Mina G. Safain and Carl B. Heilman

Arachnoid cysts are common, accounting for approximately 1% of intracranial mass lesions. Most are congenital, clinically silent, and remain static in size. Occasionally, they increase in size and produce symptoms due to mass effect or obstruction. The mechanism of enlargement of arachnoid cysts is controversial. One-way slit valves are often hypothesized as the mechanism for enlargement. The authors present 4 cases of suprasellar prepontine arachnoid cysts in which a slit valve was identified. The patients presented with hydrocephalus due to enlargement of the cyst. The valve was located in the arachnoid wall of the cyst directly over the basilar artery. The authors believe this slit valve was responsible for the net influx of CSF into the cyst and for its enlargement. They also present 1 case of an arachnoid cyst in the middle cranial fossa that had a small circular opening but lacked a slit valve. This cyst did not enlarge but surgery was required because of rupture and the development of a subdural hygroma. One-way slit valves exist and are a possible mechanism of enlargement of suprasellar prepontine arachnoid cysts. The valve was located directly over the basilar artery in each of these cases. Caudad-to-cephalad CSF flow during the cardiac cycle increased the opening of the valve, whereas cephalad-to-caudad CSF flow during the remainder of the cardiac cycle pushed the slit opening against the basilar artery and decreased the size of the opening. Arachnoid cysts that communicate CSF via circular, nonslit valves are probably more likely to remain stable.

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Shane M. Burke, Mina G. Safain, James Kryzanski and Ron I. Riesenburger

Lumbar nerve root anomalies are uncommon phenomena that must be recognized to avoid neural injury during surgery. The authors describe 2 cases of nerve root anomalies encountered during mini-open transforaminal lumbar interbody fusion (TLIF) surgery. One anomaly was a confluent variant not previously classified; the authors suggest that this variant be reflected in an amendment to the Neidre and Macnab classification system. They also propose strategies for identifying these anomalies and avoiding injury to anomalous nerve roots during TLIF surgery. Case 1 involved a 68-year-old woman with a 2-year history of neurogenic claudication. An MR image demonstrated L4–5 stenosis and spondylolisthesis and an L-4 nerve root that appeared unusually low in the neural foramen. During a mini-open TLIF procedure, a nerve root anomaly was seen. Six months after surgery this patient was free of neurogenic claudication. Case 2 involved a 60-year-old woman with a 1-year history of left L-4 radicular pain. Both MR and CT images demonstrated severe left L-4 foraminal stenosis and focal scoliosis. Before surgery, a nerve root anomaly was not detected, but during a unilateral mini-open TLIF procedure, a confluent nerve root was identified. Two years after surgery, this patient was free of radicular pain.

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Mina G. Safain, Jordan Talan, Adel M. Malek and Steven W. Hwang

Vertebral artery (VA) occlusion is a serious and potentially life-threatening occurrence. Bow hunter's syndrome, a mechanical occlusion of the VA due to physiological head rotation, has been well described in the medical literature. However, mechanical VA compression due to routine flexion or extension of the neck has not been previously reported. The authors present the unique case of a woman without any history of trauma who had multiple posterior fossa strokes and was found to have dynamic occlusion of her right VA visualized via cerebral angiogram upon extension of her neck. This occlusion was attributed to instability at the occipitocervical junction in a patient with a previously unknown congenital fusion of both the occiput to C-1 and C-2 to C-3. An occiput to C-3 fusion was performed to stabilize her cervical spine and minimize the dynamic vascular compression. A postoperative angiogram showed no evidence of restricted flow with flexion or extension of the neck. This case emphasizes the importance of considering symptoms of vertebrobasilar insufficiency as a result of physiological head movement. The authors also review the literature on VA compression resulting from physiological head movement as well as strategies for clinical diagnosis and treatment.

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Mina Safain, Matthew Shepard, Jason Rahal, James Kryzanski, Steven Hwang, Marie Roguski and Ron I. Riesenburger

Treprostinil is a synthetic analog of prostacyclin, which is used for treatment of pulmonary arterial hypertension (PAH). Continuous subcutaneous administration of treprostinil has been proven in randomized controlled trials to improve quality of life, hemodynamics, and 5-year survival in patients with PAH. The efficacy of treprostinil has been attributed to its vasodilatory and antiplatelet effects. Unfortunately, the efficacy of treprostinil in the treatment of PAH is rapidly reversed upon cessation of the continuous infusion. Furthermore, cases of patients rapidly declining or succumbing to disease progression upon cessation of treprostinil have raised significant concern regarding discontinuation of this medication. To date, there are no reports of emergency craniotomies performed in the setting of continuous subcutaneous infusion of treprostinil. The authors report a case of a patient with PAH, treated with continuous administration of subcutaneous treprostinil as well as warfarin, who developed an acute subdural hematoma (SDH). Despite adequate INR (international normalized ratio) correction, the patient eventually underwent an emergency craniotomy for evacuation of the SDH while on continuous treprostinil administration. This case highlights the neurosurgical dilemma regarding the appropriate management of acute SDHs in patients receiving continuous treprostinil infusion.

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Steven W. Hwang, Mina G. Safain, Joseph J. King, Jeff S. Kimball, Robert Ames, Randall R. Betz, Patrick J. Cahill and Amer F. Samdani

OBJECT

Almost all pediatric patients who incur a spinal cord injury (SCI) will develop scoliosis, and younger patients are at highest risk for curve progression requiring surgical intervention. Although the use of pedicle screws is increasing in popularity, their impact on SCI-related scoliosis has not been described. The authors retrospectively reviewed the radiographic outcomes of pedicle screw–only constructs in all patients who had undergone SCI-related scoliosis correction at a single institution.

Methods

Medical records and radiographs from Shriner's Hospital for Children–Philadelphia for the period between November 2004 and February 2011 were retrospectively reviewed.

Results

Thirty-seven patients, whose mean age at the index surgery was 14.91 ± 3.29 years, were identified. The cohort had a mean follow-up of 33.2 ± 22.8 months. The mean preoperative coronal Cobb angle was 65.5° ± 25.7°, which corrected to 20.3° ± 14.4°, translating into a 69% correction (p < 0.05). The preoperative coronal balance was 24.4 ± 22.6 mm, with a postoperative measurement of 21.6 ± 20.7 mm (p = 1.00). Preoperative pelvic obliquity was 12.7° ± 8.7°, which corrected to 4.1° ± 3.8°, translating into a 68% correction (p < 0.05). Preoperative shoulder balance, as measured by the clavicle angle, was 8.2° ± 8.4°, which corrected to 2.7° ± 3.1° (67% correction, p < 0.05). Preoperatively, thoracic kyphosis measured 44.2° ± 23.7° and was 33.8° ± 11.5° postoperatively. Thoracolumbar kyphosis was 18.7° ± 12.1° preoperatively, reduced to 8.1° ± 7.7° postoperatively, and measured 26.8° ± 20.2° at the last follow-up (p < 0.05). Preoperatively, lumbar lordosis was 35.3° ± 22.0°, which remained stable at 35.6° ± 15.0° postoperatively.

Conclusions

Pedicle screw constructs appear to provide better correction of coronal parameters than historically reported and provide significant improvement of sagittal kyphosis as well. Although pedicle screws appear to provide good radiographic results, correlation with clinical outcomes is necessary to determine the true impact of pedicle screw constructs on SCI-related scoliosis correction.

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Mina G. Safain, Jason P. Rahal, Samir Patel, Alexandra Lauric, Edward Feldmann and Adel M. Malek

Object

Intracranial atherosclerotic disease (ICAD) carries a high risk of stroke. Evaluation of ICAD has focused on assessing the absolute degree of stenosis, although plaque morphology has recently demonstrated increasing relevance. The authors provide the first report of the use of ultra-high-resolution C-arm cone-beam CT angiography (CBCT-A) in the evaluation of vessel stenosis as well as plaque morphology.

Methods

Between August 2009 and July 2012, CBCT-A was used in all patients with ICAD who underwent catheter-based angiography at the authors' institution (n = 18). Lesions were evaluated for maximum degree of stenosis as well as plaque morphological characteristics (ulcerated, calcified, dissected, or spiculated) via digital subtraction angiography (DSA), 3D-rotational angiography (3DRA), and CBCT-A. The different imaging modalities were compared in their assessment of absolute stenosis as well as their ability to resolve different plaque morphologies.

Results

Lesions were found to have similar degrees of stenosis when utilizing CBCT-A compared with 3DRA, but both 3DRA and CBCT-A differed from DSA in their assessment of the absolute degree of stenosis. CBCT-A provided the most detailed resolution of plaque morphology, identifying a new plaque characteristic in 61% of patients (n = 11) when compared with DSA and 50% (n = 9) when compared with 3DRA. CBCT-A identified all lesion characteristics visualized on DSA and 3DRA.

Conclusions

CBCT-A provides detailed spatial resolution of plaque morphology and may add to DSA and 3DRA in the evaluation of ICAD. Further prospective study is warranted to determine any benefit CBCTA-A may provide in clinical decision making and risk stratification over existing conventional imaging modalities.

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Mina G. Safain, Shane M. Burke, Ron I. Riesenburger, Vasilios Zerris and Steven W. Hwang

OBJECT

The standard surgical release of a tethered cord may result in recurrent scar formation and occasionally be associated with retethering. The application of spinal shortening procedures to this challenging problem potentially can reduce tension on the retethered spinal cord while minimizing the difficulties inherent in traditional lumbosacral detethering revision. Although spinal shortening procedures have proven clinical benefit in patients with a recurrent tethered cord, it is unclear how much shortening is required to achieve adequate reduction in spinal cord tension or what impact these osteotomies have on dural buckling.

METHODS

The authors calculated mean values from 4 human cadavers to evaluate the effect of 3 different spinal shortening procedures—Smith-Petersen osteotomy (SPO), pedicle subtraction osteotomy (PSO), and vertebral column resection (VCR)—on spinal cord tension and dural buckling. Three cadavers were dedicated to the measurement of spinal cord tension, and 3 other cadavers were devoted to myelography to measure dural buckling parameters.

RESULTS

The SPO was associated with a maximal decrease in spinal cord tension of 16.1% from baseline and no dural buckling with any degree of closure. The PSO led to a mean maximal decrease in spinal cord tension of 63.1% from baseline at 12 mm of closure and demonstrated a direct linear relationship between dural buckling and increasing osteotomy closure. Finally, VCR closure correlated with a mean maximal decrease in spinal cord tension of 87.2% from baseline at 10 mm of closure and also showed a direct linear relationship between dural buckling and increases in osteotomy closure.

CONCLUSIONS

In this cadaveric experiment, the SPO did not lead to appreciable tension reduction, while a substantial response was seen with both the PSO and VCR. The rate of tension reduction may be steeper for the VCR than the PSO. Adequate tension relief while minimizing dural buckling may be optimal with 12–16 mm of posterior osteotomy closure based on this cadaveric experiment.

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Mina Safain, Marie Roguski, Alexander Antoniou, Clemens M. Schirmer, Adel M. Malek and Ron Riesenburger

Object

The traditional methods for managing symptomatic chronic subdural hematoma (SDH) include evacuation via a bur hole or craniotomy, both with or without drain placement. Because chronic SDH frequently occurs in elderly patients with multiple comorbidities, the bedside approach afforded by the subdural evacuating port system (SEPS) is an attractive alternative method that is performed under local anesthesia and conscious sedation. The goal of this study was to evaluate the radiographic and clinical outcomes of SEPS as compared with traditional methods.

Methods

A prospectively maintained database of 23 chronic SDHs treated by bur hole or craniotomy and of 23 chronic SDHs treated by SEPS drainage at Tufts Medical Center was compiled, and a retrospective chart review was performed. Information regarding demographics, comorbidities, presenting symptoms, and outcome was collected. The volume of SDH before and after treatment was semiautomatically measured using imaging software.

Results

There was no significant difference in initial SDH volume (94.5 cm3 vs 112.6 cm3, respectively; p = 0.25) or final SDH volume (31.9 cm3 vs 28.2 cm3, respectively; p = 0.65) between SEPS drainage and traditional methods. In addition, there was no difference in mortality (4.3% vs 9.1%, respectively; p = 0.61), length of stay (11 days vs 9.1 days, respectively; p = 0.48), or stability of subdural evacuation (94.1% vs 83.3%, respectively; p = 0.60) for the SEPS and traditional groups at an average follow-up of 12 and 15 weeks, respectively. Only 2 of 23 SDHs treated by SEPS required further treatment by bur hole or craniotomy due to inadequate evacuation of subdural blood.

Conclusions

The SEPS is a safe and effective alternative to traditional methods of evacuation of chronic SDHs and should be considered in patients presenting with a symptomatic chronic SDH.

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Robert S. Heller, Claire M. Lawlor, Thomas R. Hedges III, Yanik J. Bababekov, Mina G. Safain and Adel M. Malek

Object

The benefits of treating intracranial aneurysms in the region of the anterior visual pathways are well understood. However, the adverse effects of endovascular stenting across the ophthalmic artery have received little attention. The authors reviewed their experience with patients who had stents deployed across the ophthalmic artery origin.

Methods

Patients' medical charts and imaging studies were reviewed to identify all patients with a non–flow diverting stent deployed over the ophthalmic artery origin for the treatment of intracranial aneurysms. All patients with neuro-ophthalmic complaints were referred for formal ophthalmological evaluation.

Results

A total of 104 consecutive patients with 106 aneurysms were identified to meet criteria for inclusion in the study cohort. Preoperatively, 30 patients (29%) described headache symptoms and 32 patients (31%) reported visual complaints. Of the patients with preoperative headaches, 15 (54%) of 28 patients for whom follow-up was available experienced improvement in their symptoms. Of the patients with preoperative visual complaints, improvement was noted in 11 (41%) of the 27 patients for whom follow-up was available, 9 (33%) of 27 patients reported no change in visual symptoms, and 7 (26%) of 27 patients reported progression of symptoms. Visual field defects developing posttreatment were noted to occur in 8 (7.7%) of 104 patients: 3 with immediate postoperative retinal infarcts, 1 with perioperative hemianopia that resolved by the time of discharge, 1 with a subjective visual field defect, 1 with subjective migratory visual field defects, and 2 with nonspecific visual symptoms. Compressive symptoms from aneurysm mass effect were noted in 6 patients preoperatively, with 4 of those patients experiencing persistent worsening, resolution in 1 case, and no change in 1 case. One patient developed a novel cranial nerve palsy from mass effect in the immediate postoperative period.

Conclusions

Deployment of stents across the ophthalmic artery origin for the treatment of intracranial aneurysms appears to be relatively safe with regard to visual outcomes. Neuro-ophthalmic complaint resolution rates were comparable to endovascular procedures that do not employ stents, with headache resolution rates comparable to coil-only aneurysm obliteration and low rates of retinal ischemic events. For patients presenting with mass effect, stent-assisted coiling appears to be less effective than microsurgery with decompression for relief of compressive symptoms.