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Background Fulminant idiopathic intracranial hypertension (IIH) can cause rapid vision loss. Transverse sinus stenosis is a finding commonly associated with IIH, and transverse sinus stenting has been used to rapidly reduce intracranial pressure and improve visual symptoms. Our objective was to describe a case of immediate alteration in reversed superior ophthalmic vein (SOV) flow in a fulminant IIH patient who underwent venous sinus stenting. Methods All charts, imaging, and notes spanning from the initial presentation to the post-intervention follow-up were reviewed and summarized for inclusion. Results A 24-year-old woman presented with several weeks of severe headaches and progressive vision loss. She was found to have severe papilledema and the opening pressure on lumbar puncture (LP) was 70 mm Hg. Computed tomography (CT) and magnetic resonance imaging demonstrated findings consistent with elevated intracranial pressure, and CT venography revealed stenosis of the right transverse sinus. She underwent an uncomplicated diagnostic cerebral angiogram, right venous sinus manometry, and right transverse to sigmoid sinus stenting procedure. Prior to deployment of the stent, a trans-stenotic pressure gradient of 12 mm Hg was observed within the right transverse-sigmoid junction, and flow through the bilateral SOVs was retrograde. Following stent placement, the pressure gradient normalized, and SOV flow was bidirectional. She subjectively reported improved vision, and there was improving papilledema. Repeat LP yielded an opening pressure of 21.6 mm Hg. Conclusions This case demonstrates reversed SOV flow should be considered an indicator of severe venous sinus stenosis, and restoration to normal or near normal state following stenting for IIH is likely indicative of procedural success.

Introduction External ventricular drain (EVD) placement can be performed at the bedside in the neurosurgical intensive care unit (ICU) or in the operating room (OR). Systematic review and meta-analysis may permit stronger recommendations to improve accuracy and complication rates. Methods Systematic review of PubMed was performed (inception–December 12, 2019) following PRISMA guidelines. Results Our search yielded 356 articles, of which 37 studies underwent full-text analysis. Nine studies met inclusion criteria. Studies were segregated into OR only (n = 3; 1011 patients), ICU only (n = 3; 325 patients), and OR + ICU (n = 3; 613 patients) cohorts. Studies were in addition divided by outcome measures, including catheter placement accuracy (ICU, 4 studies, n = 280 [68.29%] vs. OR, 2 studies, n = 198 [84.25%]); iatrogenic hemorrhagic complications (ICU, 4 studies, n = 112 [18.16%] vs. OR, 2 studies, n = 35 [17.50%]); and ventriculostomy-related infection rates (ICU, 4 studies, n = 48 [7.28%] vs. OR: 5 studies, n = 92 [8.06%]). Conclusions There are likely specific patient populations who would benefit from EVD placement in the ICU versus OR setting. The literature comparing efficacy and morbidity between EVDs placed in the ICU and OR settings is overall inconclusive in both sample size and congruence of methodology. Agreement in outcome metrics and data reporting on this topic is necessary to synthesize high-quality evidence to form practice-changing recommendations for this debated topic.

Background Diffusion tensor imaging (DTI), functional magnetic resonance imaging (fMRI), and intraoperative magnetic resonance imaging (iMRI) permit greater visualization and more accurate presurgical planning. Meta-analysis of these techniques for maximizing resection, postoperative functionality, and survival may further validate purported strengths of these techniques compared with standard neuronavigation. Methods A systematic search of the PubMed database was conducted in line with the PRISMA guidelines for meta-analysis with the following keywords: “Diffusion tensor imaging” OR “intraoperative MRI” OR “functional MRI” AND “glioma surgery resection outcome.” Articles found to meet inclusion criteria were segregated and analyzed and resulting data were compared with standard neuronavigation (control cohort). Results A total of 435 articles were identified, with 29 distinct studies meeting inclusion criteria, including DTI (n = 3), fMRI (n = 5), and iMRI (n = 21). Nine studies directly compared results with standard navigation. Mean gross total resection (GTR) rates were not different among cases using DTI, fMRI, iMRI, or traditional neuronavigation (P = 0.136). On controlling for covariates, more patients received GTR in the advanced imaging cohort, although statistically insignificant (46.5% [95% confidence interval, 38.0%–55.0%] vs. 30.4% [95% confidence interval, 11.6%–49.1%]; P = 0.127; partial η2 = 0.217). Patients undergoing advanced imaging showed attenuated incidence of postsurgical permanent neurologic deficits, although also statistically insignificant (11.3% vs. 13.8%; P = 0.838). Conclusions Current data are overall insufficient to support the notion that advanced imaging techniques are superior, either as a combined cohort or individually, in achieving GTR, improved symptom resolution, or survival compared with traditional neuronavigation.

Chiari malformation type I (CMI) is a common neurologic condition and surgery is the standard treatment. We aim to establish the cerebrospinal fluid (CSF) flow change as a potential objective indicator of surgical efficacy to improve symptoms.We performed a retrospective 2-center analysis of surgically treated patients with CMI. Qualitative CSF flow studies obtained preoperatively and postoperatively were analyzed by the neuroradiologist, seeking improvement in CSF flow. Symptom status, including headache and neck pain, were recorded.Forty-nine patients were identified between 2010 and 2017. The average age was 36 years, with 47 females. After decompression, CSF flow was improved in 41 patients (group A) and unchanged in 8 (group B). Group A and B had a mean age of 34 and 42 years (P0.05) and an average tonsillar herniation of 8.3 and 8.5 mm (P = 0.40), respectively. Group A had improved clinical outcomes, compared with group B (P = 0.024), more specifically, in headache (50% vs. 37%), neck pain (66% vs. 33%), dizziness (78% vs. 50%), vision symptoms (84% vs. 80%), and weakness (100% vs. 66%), respectively. Group B had the only patient who did worse on clinical follow-up.Patients with CMI often present with a constellation of symptoms. We showed a significant association between improved CSF flow after decompression and symptom alleviation. Further, our study suggests that the presence of improved CSF flow postoperatively could represent an objective indicator for improved patient outcomes.

Despite improved medical management, the incidence of spinal pathology remains high in patients with Parkinson disease (PD). Several studies have investigated lumbar spine surgery in this population, but data regarding costs and perioperative complications for patients undergoing cervical decompression/fusion on a nationwide scale are lacking.Cases of cervical spinal decompression, fusion, or exploration in years 2008-2014 were collected via the Healthcare Cost and Utilization Project National Inpatient Sample. Demographics, complications, outcome, and total charges were compared in patients with and without PD (NPD). Confounding variables were identified for multivariate analysis.Data were available for 195,341 cervical spine cases, of which PD was prevalent in 779 cases (0.4%). Cases with PD experienced greater overall complication rates (12.5 vs. 7.6%; P0.001). Multivariate analysis revealed longer lengths of stay for the PD cohort (mean = 1.21 days longer; P0.001) and decreased routine discharge (odds ratio = 0.308; P0.001). There was no significant difference in mean total charges between PD and NPD (-$1532; P = 0.337). Mortality rates did not significantly differ for either group.Although patients with PD experience greater complication rates and non-home discharges following cervical spine surgery compared with NPD patients, the overall clinical impact of these results may be minimal relative to surgery at other spinal levels in this population.

Background Parkinson disease (PD) remains a common neurodegenerative disorder. Functional neurosurgery largely arose with the introduction of deep brain stimulation (DBS) as a potential option for PD unresponsive to medical management. Biomarkers are clinical and laboratory indicators of therapeutic success or failure. Objective To examine the current and published literature relating to the development and use of biomarkers in monitoring and determining the efficacy of DBS in PD. Methods The PubMed database was systematically searched using the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines for systemic reviews. Studies that examined current or potential biomarkers measurable after DBS were included. Articles from 1952 to date were examined. Results The initial search identified 49 articles. Thirty articles met the inclusion criteria. Articles were subdivided into those addressing biomarkers with proven clinical usefulness and potential biomarkers that have future application. Conclusions Biomarkers have been identified that can help to determine the effect of DBS on patients with PD. Current studies show that there are measured differences in electrophysiologic oscillations, gene expression, neuropeptide levels, metabolic function, inflammatory activity, and others in the central nervous system after DBS in PD. Local field potential and β-band analysis stand as the clinically proven biomarkers of choice for DBS in PD. Many of the identified changes noted could be implemented as clinically useful biomarkers through which DBS may be monitored. Future studies are needed to determine which noted physiologic changes are most appropriately used as biomarkers and in which contexts they are most helpful.

Improved postoperative care for renal transplant recipients has advanced both duration and overall quality of life. However, degenerative spinal pathology is increasingly prevalent after transplant. Outcomes following spinal fusion among the renal transplant population in the United States are rarely addressed.The Healthcare Cost and Utilization Project National Inpatient Sample database was employed. Cases in years 2008-2014 for patients ≥18 years old receiving spinal fusion, exploration/decompression, and/or spinal revision/re-fusion surgeries were included. Cases were divided into kidney transplant recipients (KTR) and non-kidney transplant recipients. Complications, demographics, and socioeconomic outcomes were compared between cohorts.Of 579,726 patients who met inclusion criteria, 685 (0.1%) were KTRs. The KTR population was older and included more men compared with the non-kidney transplant recipient population (60.1 years vs. 56.6 years, P0.001; 58% male vs. 45.5% male, P0.001). KTRs experienced higher total complication rates (29.8% vs. 18.9%, P0.001). Prevalence of acute posthemorrhagic anemia and need for transfusion was markedly higher for KTRs (15.8% vs. 9.1%, P0.001; 13.6% vs. 6.2%, P0.001). Multivariate analysis revealed longer length of stay (median 1.23 days, interquartile range 0.94-1.53, P0.001), lower routine discharge (odds ratio = 0.57, 95% confidence interval 0.48-0.69, P0.001), and higher discharge to alternative care facilities (odds ratio = 1.91, 95% confidence interval 1.57-2.33, P0.001) for KTRs. The inpatient course for KTRs undergoing spinal operations was significantly costlier ($87,445 vs. $71,589, P0.001).History of renal transplant was associated with increased inpatient medical and socioeconomic complications following spinal fusion. Physicians and patients must understand and respect the potentially increased perioperative challenges facing KTRs.

Background Virtual reality (VR) simulators have become useful tools in various fields of medicine. Prominent uses of VR technologies include assessment of physician skills and presurgical planning. VR has shown effectiveness in multiple surgical specialties, yet its use in neurosurgery remains limited. Objective To examine all current literature on VR-based simulation for presurgical planning and training in cranial tumor surgeries and to assess the quality of these studies. Methods PubMed and Embase were systematically searched to identify studies that used VR for presurgical planning and/or studies that investigated the use of VR as a training tool from inception to May 25, 2017. Results The initial search identified 1662 articles. Thirty-seven full-text articles were assessed for inclusion. Nine studies were included. These studies were subdivided into presurgical planning and training using VR. Conclusions Prospects for VR are bright when surgical planning and skills training are considered. In terms of surgical planning, VR has noted and documented usefulness in the planning of cranial surgeries. Further, VR has been central to establishing reproducible benchmarks of performance in relation to cranial tumor resection, which are helpful not only in showing face and construct validity but also in enhancing neurosurgical training in a way not previously examined. Although additional studies are needed to better delineate the precise role of VR in each of these capacities, these studies stand to show the usefulness of VR in the neurosurgery and highlight the need for further investigation.