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Objective Syrinx development in patients with spontaneous intracranial hypotension (SIH) has rarely been described. To better understand this entity, we compared the clinical and radiographic findings in a series of patients with SIH and acquired Chiari-like tonsillar herniation with and without syrinx formation. Methods Six patients with syrinx in the setting of SIH and Chiari-like tonsillar herniation were retrospectively identified. The clinical and radiographic findings and outcomes were compared with those from a control group of patients with SIH and Chiari-like tonsillar herniation without syrinx. Results The patients with SIH and syrinx had had a higher opening pressure than had the control group (mean, 14.0 cm H2O vs. 7.4 cm H2O; P = 0.02) and a higher body mass index (mean, 33 kg/m2 vs. 26 kg/m2; P = 0.01). The patients with syrinx had had an average obex displacement of 3.7 ± 2.2 mm below the plane of the foramen magnum compared with a position of 1.9 ± 3.1 mm above the plane of the foramen magnum in the control group (P = 0.004). The mean tonsillar descent was 12.7 ± 4.7 mm below the foramen magnum in those with syrinx compared with 5.9 ± 2.5 in the control group (P = 0.009). The clinical symptoms had improved in 83.3% of the patients with syrinx and 75% of the control patients after spinal cerebrospinal fluid leak closure. Three patients (50%) also had radiographic syrinx reduction. Conclusion Our results have shown that SIH can be an underrecognized cause of syrinx with key differences in body habitus and obex displacement compared with SIH without syrinx. In patients with tonsillar herniation into the foramen magnum associated with syrinx, the presence of SIH should be considered to avoid unnecessary foramen magnum decompression, even in those with a normal opening pressure.

Objective To investigate the accessibility and content of interventional neuroradiology (INR) fellowship program websites in North America. Methods We obtained a list of INR/endovascular surgical neuroradiology (ESN) fellowship programs from the Accreditation Council for Graduate Medical Education, the Committee on Advanced Subspecialty Training, the Society of NeuroInterventional Surgery, and the Neurosurgical Fellowship Training Program Directory websites. Individual program websites were evaluated for 27 different fellow recruitment and education criteria. U.S. programs were grouped based on census region and national ranking, and differences between these groups with regard to fellow recruitment and education characteristics were analyzed using nonparametric statistics. Results A total of 79 INR/ESN fellowship websites were evaluated for presence of fellow recruitment and education features. Approximately one third of all features pertinent to recruitment (32.11%) and approximately 1 in 5 features regarding education (19.11%) were described in these websites. Program description (69.6%), program coordinator/administrator contact e-mail (59.5%), program director's name (59.5%), program eligibility requirements (51.9%), research opportunities (40.5%), and faculty listing (39.2%) were among the most frequently described features, whereas details about parking (1.3%), interview day itinerary (1.3%), meal allowance (2.5%), retirement and benefits (3.8%), and call schedule (5.1%) were the least frequently described features. There was no significant difference between surveyed features and programs when stratified by U.S. census region, neurosurgery/neurology hospital rankings, or accreditation status. Conclusions INR/ESN fellowship website content is variable across North America and there is room for improvement to develop and enhance comprehensiveness of program website content.

Objective First-line treatment for prolactin-producing pituitary adenomas is dopamine agonist (DA) therapy. This is the first study to analyze the rate of radiographic and hormonal regression of prolactinomas in response to DA therapy to better understand what time frame we consider DA treatment failure. Methods We searched the electronic medical records of 3 tertiary care medical institutions for patients with prolactinomas. The primary outcome was tumor volume and prolactin (PRL) levels at various time points. The secondary outcome was indicators of treatment failure. Modeling by both linear and exponential models was tested to determine potential predictors of response magnitude and treatment failure by multivariate and regression analyses respectively. Results There were 99 patients (53% male) included in this analysis. The mean patient age was 42.7 years ± 14.5, and mean width/volume of tumor at diagnosis was 12.3 mm and 1.3 cm3, respectively. The mean PRL level at diagnosis was 593.2 ng/mL (79–7913). Modeling indicated a plateau at 68.2% initial volume (95% confidence interval 61.7–73.5) by 12.6 months and a PRL plateau of 21.4 ng/mL (95% confidence interval 0–92.5) by 3.3 months. Multivariate analyses revealed male sex (odds ratio 0.168; P = 0.036) to be a predictor of faster PRL response to DA therapy. Conclusions Prolactinomas plateau in PRL levels and the rate of size regression within the first year of DA treatment. Prolactinomas with lack of size regression and failure to reach normalization of PRL levels by 12 months may be considered for other management strategies.

Background Classic trigeminal neuralgia is an often debilitating condition that frequently results from vascular compression at the root entry zone of the trigeminal nerve. We report a case of dural arteriovenous fistula surrounding the trigeminal nerve from near the root entry zone extending as far ventral as the Meckel cave treated solely with Gamma Knife radiosurgery. Case Description A 71-year-old woman presented with a history of persistent attacks of right facial pain after failed conservative management. Magnetic resonance imaging of the brain demonstrated dilated vasculature in the right cerebellopontine angle, and diagnostic cerebral angiography revealed a dural arteriovenous fistula surrounding the right trigeminal nerve. Stereotactic radiosurgery using Gamma Knife was performed. At 6-month follow-up, she was symptom-free with decreased caliber of abnormal vascularity surrounding the trigeminal nerve on magnetic resonance imaging. Conclusions This case suggests that trigeminal neuralgia associated with dural arteriovenous fistula can potentially be treated with Gamma Knife radiosurgery; however, more extensive studies and long-term follow-up to evaluate vessel patency will be necessary to elucidate further the role of stereotactic radiosurgery alone in treating this entity.