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Nancy Mclaughlin and Michel W. Bojanowski

Object. Most reports of series on ruptured intracranial aneurysms contain information on select intraoperative complications. An understanding of all surgical complications, however, may guide us toward improved surgical procedures and enrich discussions concerning alternative management strategies, such as endovascular treatment, which are not exempt from complications and aneurysm recurrence.

Methods. The study consists of a retrospective review of the charts, images, and notes from follow-up visits of 143 consecutive patients with subarachnoid hemorrhage (SAH) who were surgically treated during a 3-year period by one neurosurgeon. A surgical complication was determined based on findings of a clinical and/or radiological study in the absence of confounding factors such as the initial SAH ictus, vasospasm, hydrocephalus, and septic status. Functional outcome was assessed between 2 and 3 months post-SAH by using the Glasgow Outcome Scale (GOS). A procedure-related surgical complication was diagnosed in 29 (20.3%) of 143 patients studied. A brain tissue injury, including cerebral edema and hemorrhagic contusions, was diagnosed in 6.3% of patients, an unpredicted residual aneurysm neck in 5.3% of patients, and a cranial nerve deficit in 2.8% of patients. Functional outcome was good in 22 (75.9%) of the 29 patients with surgical complications. Death due to a surgical complication occurred in one (0.7%) of 143 patients.

Conclusions. Surgical complications are more prevalent than previously thought. They may have been overlooked previously because of the high percentage of good functional outcomes and low mortality rates in this group. The identification of surgical complications may encourage the search for solutions to improve surgical treatment of aneurysmal SAH.

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Nancy McLaughlin, Aaron Cutler and Neil A. Martin

The supraorbital keyhole approach offers a limited access for aneurysms located at the middle cerebral artery (MCA) bifurcation with long M1 segments or proximal M2 aneurysms. Alternative minimally invasive routes centered on the pterion have been developed to address these aneurysms. Appropriate dissection and reconstruction of the temporal muscle are important for optimal exposure and best cosmetic results with the pterional keyhole craniotomy. The authors describe the technical nuances of temporal muscle dissection and reconstruction adapted to the pterional keyhole craniotomy.

After incising the scalp in a curvilinear fashion behind the hairline, an interfascial dissection is performed, allowing anterior reflection of the superficial temporal fat pat and superficial temporal fascia. The temporal muscle is incised 7–10 mm below its insertion at the superior temporal line. The deep temporal fascia and temporal muscle are incised vertically, completing a T-shaped incision. Subperiosteal dissection of both muscle flaps preserves the deep temporal arteries and nerves. A craniotomy measuring 2.5–3 cm in diameter, based anteriorly at the pterion, is made over the sylvian fissure. Dissection of the sylvian fissure and of MCA aneurysms can proceed without the use of retractors. The bone flap and associated hardware is entirely covered by the temporal muscle, which is reconstructed in 2 layers: the temporal muscle/deep temporal fascia and the superficial temporal fascia.

This dissection technique prevents damage to branches of the facial nerve and minimizes temporal muscle damage. Dividing the temporal muscle vertically and reflecting both parts anteriorly and posteriorly prevents suboptimal illumination and visualization under the microscope. Covering the bone flap and related hardware with a multilayer anatomical reconstruction optimizes cosmetic results.

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Nancy McLaughlin and Neil A. Martin

Numerous surgical techniques have been developed and refined for the treatment of moyamoya disease. Among the indirect techniques of revascularization, encephaloduroarteriosynangiosis has been recognized as effective in promoting revascularization and reversing symptomatology. Neovascularization occurs between the donor artery, either the superficial temporal artery or the occipital artery, and the underlying ischemic cortex. Additionally, the middle meningeal artery and its dural branches have also been shown to contribute to collateral blood supply. In this report the authors describe an integrated management of the meninges for optimal revascularization. They emphasize the importance of recognizing the 3 major layers of the dura and describe a technique of dural splitting at the locus minoris resistentiae between the dura mater's vascular (middle) layer and internal median layer. Applying the dura's vascular layer to the surface of the brain after opening of the arachnoid is designed to optimize dural-pial synangiosis related to middle meningeal artery branches.

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Nancy McLaughlin and Michel W. Bojanowski

✓ The authors report the case of a 34-year-old woman who presented with increasing headaches. Neuroimaging revealed bilateral anomalous vessels arising at the level of each ophthalmic artery, coursing rostromedially to join the anterior communicating artery (ACA), which harbored an aneurysm. Intraoperatively, the authors identified an abnormal gyral segmentation of the frontoorbital region, with a median gyrus separated from the olfactory tracts on each side by the gyrus rectus. No interhemispheric fissure was observed in the exposed area. This is the first report in the literature of an abnormal gyral segmentation in association with an infraoptic course of an ACA. Recognition of this possible gyral abnormality in association with this vascular anomaly is relevant for surgical exposure and treatment of aneurysms by clip placement.

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Nancy McLaughlin, Peng Jin and Neil A. Martin

OBJECT

Review of morbidities and mortality has been the primary method used to assess surgical quality by physicians, hospitals, and oversight agencies. The incidence of reoperation has been proposed as a candidate quality indicator for surgical care. The authors report a comprehensive assessment of reoperations within a neurosurgical department and discuss how such data can be integrated into quality improvement initiatives to optimize value of care delivery.

METHODS

All neurosurgical procedures performed in the main operating room or the outpatient surgery center at the Ronald Reagan UCLA Medical Center and UCLA Santa Monica Medical Center from July 2008 to December 2012 were considered for this study. Interventional radiology and stereotactic radiosurgery procedures were excluded. Early reoperations within 7 days of the index surgery were reviewed and their preventability status was evaluated.

RESULTS

The incidence of early unplanned reoperation was 2.6% (occurring after 183 of 6912 procedures). More than half of the patients who underwent early unplanned reoperation initially had surgery for shunt-related conditions (34.4%) or intracranial tumor (23.5%). Shunt failure was the most common indication for early unplanned reoperation (34.4%), followed by postoperative bleeding (20.8%) and postoperative elevated intracranial pressure (9.8%). The average time interval (± SD) between the index surgery and reoperation was 3.0 ± 1.9 days. The average length of stay following reoperation was 12.1 ± 14.4 days.

CONCLUSIONS

This study enabled an in-depth assessment of reoperations within an academic neurosurgical practice and identification of strategic opportunities for department-wide quality improvement initiatives. The authors provide a nuanced discussion regarding the use of absolute reoperations as a quality indicator for neurosurgical patient populations.

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Sergei Terterov, Nancy McLaughlin, Harry Vinters and Neil A. Martin

Angiographically occult cerebral vascular malformations (AOVMs) are usually found in the supratentorial brain parenchyma. Uncommonly, AOVMs can be found within the cavernous sinus or basal cisterns and can be associated with cranial nerves. AOVMs involving the intracranial segment of the spinal accessory nerve have not been described. A 46-year-old female patient presented with a history of episodic frontal headaches and episodes of nausea and dizziness, as well as gait instability progressing over 6 months prior to evaluation. Imaging revealed a well-circumscribed 3-cm extraaxial T1-weighted isointense and T2-weighted hyperintense contrast-enhancing mass centered in the region of the right lateral cerebellomedullary cistern. The patient underwent resection of the lesion. Although the intraoperative appearance was suggestive of a cavernous malformation, some histological findings were atypical, leading to the final diagnosis of vascular malformation, not otherwise specified. The patient’s postoperative course was uneventful with complete resolution of symptoms. To the authors’ knowledge, this is the first report of an AOVM involving the intracranial portion of the accessory nerve. For any AOVM located within the cerebellomedullary cistern or one suspected of involving a cranial nerve, the authors recommend including immunohistochemistry with primary antibody to neurofilament in the histopathology workup.

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Nancy McLaughlin, Radoslav Raychev, Gary Duckwiler and Neil A. Martin

The finding of dilated, elongated, and tortuous vessels on brain imaging should prompt clinicians to determine what vascular anomaly is present. Importantly, not all suspicious serpentine flow voids are manifestations of arteriovenous malformations or arteriovenous fistulas. Other types of intracranial vasculopathies should also be considered. The authors report a rare case of dilated, tortuous, and redundant left posterior communicating artery and left P2 segment of the posterior cerebral artery identified in a young healthy adult that remained stable over a 30-year period. Dynamic and 3D images were critical for determining the type of vascular anomaly and for guiding appropriate management. The authors propose that this case represents a pure arterial malformation and discuss its distinguishing features.

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John A. Jane Jr.

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Nancy McLaughlin, Pooja Upadhyaya, Farzad Buxey and Neil A. Martin

Object

Care providers have put significant effort into optimizing patient safety and quality of care. Value, defined as meaningful outcomes achieved per dollar spent, is emerging as a promising framework to redesign health care. Scarce data exist regarding cost measurement and containment for episodes of neurosurgical care. The authors assessed how cost measurement and strategic containment could be used to optimize the value of delivered care after the implementation and maturation of quality improvement initiatives.

Methods

A retrospective study of consecutive patients undergoing microvascular decompression was performed. Group 1 comprised patients treated prior to the implementation of quality improvement interventions, and Group 2 consisted of those treated after the implementation and maturation of quality improvement processes. A third group, Group 3, represented a contemporary group studied after the implementation of cost containment interventions targeting the three most expensive activities: pre-incision time in the operating room (OR) and total OR time, intraoperative neuromonitoring (IOM), and bed assignment (and overall length of stay [LOS]). The value of care was assessed for all three groups.

Results

Forty-four patients were included in the study. Average preparation time pre-incision decreased from 73 to 65 to 45 minutes in Groups 1, 2, and 3, respectively. The average total OR time and OR cost were 434 minutes and $8513 in Group 1; 348 minutes and $7592 in Group 2; and 407 minutes and $8333 in Group 3. The average cost for IOM, excluding electrode needles, was $1557, $1585, and $1263, respectively, in Groups 1, 2, and 3. Average total cost for bed assignment was $5747, $5198, and $4535, respectively, in Groups 1, 2, and 3. The average total LOS decreased from 3.16 days in Group 1 to 2.14 days in Group 3. Complete relief of or a significant decrease in preoperative symptomatology was achieved in 42 of the 44 patients, respectively. Overall, the average cost of a surgical care episode (index hospitalization + readmission/reoperation) decreased 25% from Group 1 to 3.

Conclusions

Linking cost-containment and cost-reduction strategies to ongoing outcome improvement measures is an important step toward the optimization of value-based delivery of care.

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Colin C. Buchanan, Nancy McLaughlin, Daniel C. Lu and Neil A. Martin

Rotational vertebral artery occlusion (RVAO), or bow hunter's syndrome, most often occurs at the C1–2 level on physiological head rotation. It presents with symptoms of vertebrobasilar insufficiency (VBI). Several previously published studies have reported on subaxial sites of vertebral artery (VA) compression by head rotation. The authors report a case of subaxial spine RVAO due to adjacent-segment degeneration. A 52-year-old man presented with dizziness when rotating his head to the left. Twenty years earlier, he had undergone a C4–5 anterior cervical discectomy and fusion (ACDF) for a herniated disc. Imaging studies including a dynamic CT angiography and dynamic catheter angiography revealed occlusion of the left VA at the C3–4 level when the patient turned his head to the left, in the setting of an aberrant vertebrobasilar system. Successful treatment was achieved by surgical decompression of the left VA and C3–4 ACDF. Expedited diagnosis and treatment are dependent on the recognition of this unusual manifestation of RVAO, especially when patients present with nonspecific symptoms of VBI.