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Let Alg 𝒩 be a nest algebra associated with the nest 𝒩 on a (real or complex) Banach space 𝕏. Suppose that there exists a non-trivial idempotent P ∈ Alg 𝒩 with range P (𝕏) ∈ 𝒩, and δ : Alg 𝒩 → Alg 𝒩 is a continuous linear mapping (generalized) left derivable at P, i.e. δ (ab) = aδ (b) + bδ (a) (δ (ab) = aδ(b) + bδ(a) − baδ(I)) for any a, b ∈ Alg 𝒩 with ab = P, where I is the identity element of Alg 𝒩. We show that is a (generalized) Jordan left derivation. Moreover, in a strongly operator topology we characterize continuous linear maps on some nest algebras Alg 𝒩 with the property that δ (P ) = 2Pδ (P ) or δ (P ) = 2P δ (P ) − Pδ (I) for every idempotent P in Alg 𝒩.

Background: Studies comparing the outcomes of bariatric surgery followed by total knee arthroplasty (TKA) versus TKA alone in obese patients have disparate results. This systematic review and meta-analysis sought to compare TKA with and without prior bariatric surgery in obese patients., Methods: MEDLINE, PubMed, and Embase were searched from inception to April 9, 2023. There were twelve included studies that yielded 2,876,547 patients, of whom 62,818 and 2,813,729 underwent TKA with and without prior bariatric surgery, respectively. Primary outcomes were medical complications (ie, urinary tract infection, pneumonia, renal failure, respiratory failure, venous thromboembolism [VTE], arrhythmia, myocardial infarction, and stroke); surgical complications (ie, wound complications [eg, infection, hematoma, dehiscence, delayed wound healing, and seroma], periprosthetic joint infection, mechanical complications, periprosthetic fracture, knee stiffness, and failed hardware); revision, and mortality. Secondary outcomes were blood transfusion, length of stay (day), and readmission., Results: The odds ratios (OR) of 90-day VTE (OR = 0.75 [0.66, 0.85], P < .00001), 90-day stroke (OR = 0.58 [0.41, 0.81], P = .002), and 1-year periprosthetic fracture (OR = 0.74 [0.55, 0.99], P = .04) were lower in those who underwent bariatric surgery before TKA. Although the mean difference in hospital stays (-0.19 days [-0.23, -0.15], P < .00001) was statistically less in those who underwent bariatric surgery before TKA, it was not clinically relevant. The other outcomes were similar between the groups., Conclusions: Bariatric surgery before TKA is beneficial in terms of a lower risk of VTE, stroke, and periprosthetic fracture. This analysis suggests surgeons consider discussing bariatric surgery before TKA in obese patients, especially those who are at risk of VTE and stroke., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Spine implants are becoming increasingly diversified. Taking inspiration from other industries, three-dimensional modeling of the spinal column has helped meet the custom needs of individual patients as both en bloc replacements and pedicle screw designs. Intraoperative tailoring of devices, a common need in the operating room, has led to expandable versions of cages and interbody spacers., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Background Context: The optimal decompression time for patients presenting with acute traumatic central cord syndrome (ATCCS) has been debated, and a high level of evidence is lacking., Purpose: To compare early (<24 hours) versus late (≥24 hours) surgical decompression for ATCCS., Study Design: Systematic review and meta-analysis., Methods: Medline, PubMed, Embase, and CENTRAL were searched from inception to March 15th, 2023. The primary outcome was American Spinal Injury Association (ASIA) motor score. Secondary outcomes were venous thromboembolism (VTE), total complications, overall mortality, hospital length of stay (LOS), and ICU LOS. The GRADE approach determined certainty in evidence., Results: The nine studies included reported on 5,619 patients, of whom 2,099 (37.35%) underwent early decompression and 3520 (62.65%) underwent late decompression. The mean age (53.3 vs 56.2 years, p=.505) and admission ASIA motor score (mean difference [MD]=-0.31 [-3.61, 2.98], p=.85) were similar between the early and late decompression groups. At 6-month follow-up, the two groups were similar in ASIA motor score (MD= -3.30 [-8.24, 1.65], p=.19). However, at 1-year follow-up, the early decompression group had a higher ASIA motor score than the late decompression group in total (MD=4.89 [2.89, 6.88], p<.001, evidence: moderate), upper extremities (MD=2.59 [0.82, 4.36], p=.004) and lower extremities (MD=1.08 [0.34, 1.83], p=.004). Early decompression was also associated with lower VTE (odds ratio [OR]=0.41 [0.26, 0.65], p=.001, evidence: moderate), total complications (OR=0.53 [0.42, 0.67], p<.001, evidence: moderate), and hospital LOS (MD=-2.94 days [-3.83, -2.04], p<.001, evidence: moderate). Finally, ICU LOS (MD=-0.69 days [-1.65, 0.28], p=.16, evidence: very low) and overall mortality (OR=1.35 [0.93, 1.94], p=.11, evidence: moderate) were similar between the two groups., Conclusions: The meta-analysis of these studies demonstrated that early decompression was beneficial in terms of ASIA motor score, VTE, complications, and hospital LOS. Furthermore, early decompression did not increase mortality odds. Although treatment decision-making has been individualized, early decompression should be considered for patients presenting with ATCCS, provided that the surgeon deems it appropriate., Competing Interests: Declaration of Competing Interest Daniel Lubelski is a consultant for Carbofix, Icotec, and Mindset Medical, and receives research support from Dillon Technologies. Chetan Bettegowda is a consultant for Depuy-Synthes, Bionaut Labs, Galectin Therapeutics, Privo Technologies and Haystack Oncology. He is a co-founder of OrisDx and Belay Diagnostics and is on the board of directors for each. Louis Chang is an educator for and receives research support from Nuvasive. Timothy Witham owns stock in and is a consultant for Augmedics, Inc., is a consultant for Depuy-Synthes Spine, and is on the surgical advisory board of Augmedics, Inc. Nicholas Theodore receives royalties from and owns stock in Globus Medical. He is a consultant for Globus Medical and has served on the scientific advisory board/other office for Globus Medical. The remaining authors have no conflicts of interest to disclose., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Objective: A direct-aspiration first-pass technique (ADAPT) in mechanical thrombectomy has been described in recent studies as an efficacious strategy compared with using a stent retriever (SR). We sought to evaluate for cost differences of ADAPT technique versus SR as an initial approach., Methods: We conducted a retrospective analysis of consecutive patients with mechanical thrombectomy at our institution between 2022 and 2023. Patients were grouped into ADAPT with/without SR as a rescue strategy and SR as an initial approach with allowance of concomitant aspiration. Direct cost data (consumables) were obtained. Baseline demographics, stroke metrics, procedure outcomes and cost, and last follow-up outcomes in modified Rankin Scale were compared between 2 groups., Results: Fifty-six patients were included. Thirty-seven (66.1%) underwent ADAPT, with 11 (29.7%) eventually requiring an SR. Mean age was 64.8 years. The average National Institutes of Health Stroke Scale score was 13.2 in the ADAPT group and 14.0 in the SR group (P = 0.68), with a similar proportion of tissue plasminogen activator (P = 0.53), site of occlusion (P = 0.66), and tandem occlusion (P = 0.69) between the groups. Recanalization was achieved in 94.6% of all patients, with an average of 1.9 passes, 89.3% being TICI 2B or above, with no differences between the 2 groups. Significantly lower cost (P < 0.01) was observed in ADAPT ($14,243.4) compared with SR ($19,003.6). Average follow-up duration was 180.2 days, with mortality of 23.2%. At last follow-up, 55.4% remained functionally independent (modified Rankin Scale score <3) with no difference (P = 0.56) between the ADAPT (59.5%) and SR (47.4%) groups., Conclusions: Outcomes were comparable between the ADAPT and SR groups. ADAPT reduced procedural consumables cost by approximately $5000 (25%), even if stent retrievers were allowed to be used for rescue. Establishing ADPAT as initial approach may bring significant direct cost savings while obtaining similar outcomes., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Objective: The longitudinal management of unruptured brain arteriovenous malformation (bAVM) is crucial. To date, no study in the United States has evaluated the impact of socioeconomic status (SES) on bAVM outcome. Herein, the authors aimed to clarify the impact of SES, as indicated by the area deprivation index (ADI), on bAVM outcome., Methods: A retrospective analysis of an institutional bAVM database was conducted. Non-hereditary hemorrhagic telangiectasia patients with a single unruptured bAVM in the period from 1990 to 2021 were included in the analysis. The ADI was categorized as low (ADI ≤ 15th percentile), mid (15th percentile < ADI < 85th percentile), and high (ADI ≥ 85th percentile), with a low ADI indicating the most advantaged group. Patient baseline and follow-up data were analyzed. The primary outcome of interest was nonindependence (modified Rankin Scale [mRS] score > 2) at the last follow-up. A multivariable logistic regression model was performed., Results: A total of 589 patients with unruptured bAVMs were included in the study. The mean patient age at diagnosis was 37.2 years, and 283 patients (48.0%) were male. Of the bAVMs, 238 (40.4%) had a low Spetzler-Martin grade (SMG < III), 194 (32.9%) had a moderate grade (SMG III), and 157 (26.7%) had a high grade (SMG > III). Sixty-nine patients (11.7%) were in the low-ADI group, 476 (80.8%) in the mid-ADI group, and 44 (7.5%) in high-ADI group. Increasing age (OR 1.02, 95% CI 1.01-1.04, p < 0.001), poor baseline mRS score (OR 3.27, 95% CI 1.32-7.88, p = 0.008), treatment with surgery plus radiosurgery with or without embolization (OR 3.21, 95% CI 1.03-9.81, p = 0.041), mid SMG (OR 1.94, 95% CI 1.11-3.44, p = 0.021), high SMG (OR 2.08, 95% CI 1.13-3.88, p = 0.020), longer follow-up (OR 1.05, 95% CI 1.03-1.08, p < 0.001), and mid ADI (OR 3.08, 95% CI 1.34-8.39, p = 0.015) were significantly associated with a poor outcome. A high ADI tended toward a poor outcome (OR 2.93, 95% CI 0.92-9.88, p = 0.071). Eventual obliteration of a bAVM was the only protective predictor of poor outcome (OR 0.55, 95% CI 0.30-0.98, p = 0.046)., Conclusions: This study revealed that relatively disadvantaged patients with unruptured bAVMs are more likely to experience nonindependent outcomes at the last follow-up, after adjusting for confounding variables. An emphasis on social support may be beneficial for patients with a lower SES.

Background and Objectives: Natural history of hemorrhage in brain arteriovenous malformations (bAVM) is reported at 2%-4% per year. Published studies using survival analysis fail to account for recurrent hemorrhagic events. In this study, we present a large, single institution series to elucidate the natural history of bAVM using multivariable Poisson regression., Methods: This is a retrospective cohort study. All patients with bAVM seen at our institution from 1990 to 2021 were included. Hemorrhages after detection of bAVM during the untreated interval were recorded. Natural history of hemorrhage was calculated by dividing number of hemorrhages by untreated interval. The frequency of hemorrhages followed a Poisson distribution. Multivariable Poisson regression with an offset variable of untreated interval in patient-years was constructed. Model selection was through a stepwise Akaike information criterion method. Stratified hemorrhagic rate was presented using different combinations of significant factors., Results: A total of 1066 patients with nonhereditary hemorrhagic telangiectasia harboring a single bAVM were included. Ninety (8.44%) patients had 101 hemorrhages during an untreated interval of 3596.3344 patient-years, translating to an overall hemorrhagic rate of 2.81% per year. Significant factors increasing hemorrhage risk included ruptured presentation ( P < .001), increasing age ( P < .001), female sex ( P = .043), and deep location ( P = .040). Adult male patients with ruptured presentation and deep bAVMs sustained the highest annual risk at 10.81%, whereas no hemorrhages occurred in unruptured pediatric male patients or ruptured pediatric (younger than 18 years) male patients with superficial bAVMs., Conclusion: Hemorrhage after bAVM detection occurs in 8.41% of all patients, and the rate averages 2.81% per year. However, this risk varies from 0.00% to 10.81% per year depending on various risk factor combinations. Efforts should be made to stratify bAVM hemorrhage rate by risk factors for more precise estimation of bleeding risk if left untreated., (Copyright © Congress of Neurological Surgeons 2023. All rights reserved.)

Background and Objectives: Awake vs asleep craniotomy for patients with eloquent glioma is debatable. This systematic review and meta-analysis sought to compare awake vs asleep craniotomy for the resection of gliomas in the eloquent regions., Methods: MEDLINE and PubMed were searched from inception to December 13, 2022. Primary outcomes were the extent of resection (EOR), overall survival (month), progression-free survival (month), and rates of neurological deficit, Karnofsky performance score, and seizure freedom at the 3-month follow-up. Secondary outcomes were duration of operation (minute) and length of hospital stay (LOS) (day)., Results: Fifteen studies yielded 2032 patients, from which 800 (39.4%) and 1232 (60.6%) underwent awake and asleep craniotomy, respectively. The meta-analysis concluded that the awake group had greater EOR (mean difference [MD] = MD = 8.52 [4.28, 12.76], P < .00001), overall survival (MD = 2.86 months [1.35, 4.37], P = .0002), progression-free survival (MD = 5.69 months [0.75, 10.64], P = .02), 3-month postoperative Karnofsky performance score (MD = 13.59 [11.08, 16.09], P < .00001), and 3-month postoperative seizure freedom (odds ratio = 8.72 [3.39, 22.39], P < .00001). Furthermore, the awake group had lower 3-month postoperative neurological deficit (odds ratio = 0.47 [0.28, 0.78], P = .004) and shorter LOS (MD = -2.99 days [-5.09, -0.88], P = .005). In addition, the duration of operation was similar between the groups (MD = 37.88 minutes [-34.09, 109.86], P = .30)., Conclusion: Awake craniotomy for gliomas in the eloquent regions benefits EOR, survival, postoperative neurofunctional outcomes, and LOS. When feasible, the authors recommend awake craniotomy for surgical resection of gliomas in the eloquent regions., (Copyright © Congress of Neurological Surgeons 2023. All rights reserved.)

Background: This systematic review and meta-analysis were conducted to objectively evaluate the evidence of machine learning (ML) in the patient diagnosis of Intracranial Hemorrhage (ICH) on computed tomography (CT) scans., Methods: Until May 2023, systematic searches were conducted in ISI Web of Science, PubMed, Scopus, Cochrane Library, IEEE Xplore Digital Library, CINAHL, Science Direct, PROSPERO, and EMBASE for studies that evaluated the diagnostic precision of ML model-assisted ICH detection. Patients with and without ICH as the target condition who were receiving CT-Scan were eligible for the research, which used ML algorithms based on radiologists' reports as the gold reference standard. For meta-analysis, pooled sensitivities, specificities, and a summary receiver operating characteristics curve (SROC) were used., Results: At last, after screening the title, abstract, and full paper, twenty-six retrospective and three prospective, and two retrospective/prospective studies were included. The overall (Diagnostic Test Accuracy) DTA of retrospective studies with a pooled sensitivity was 0.917 (95% CI 0.88-0.943, I 2  = 99%). The pooled specificity was 0.945 (95% CI 0.918-0.964, I 2  = 100%). The pooled diagnostic odds ratio (DOR) was 219.47 (95% CI 104.78-459.66, I 2  = 100%). These results were significant for the specificity of the different network architecture models (p-value = 0.0289). However, the results for sensitivity (p-value = 0.6417) and DOR (p-value = 0.2187) were not significant. The ResNet algorithm has higher pooled specificity than other algorithms with 0.935 (95% CI 0.854-0.973, I 2  = 93%)., Conclusion: This meta-analysis on DTA of ML algorithms for detecting ICH by assessing non-contrast CT-Scans shows the ML has an acceptable performance in diagnosing ICH. Using ResNet in ICH detection remains promising prediction was improved via training in an Architecture Learning Network (ALN)., (© 2023. The Author(s).)

Background and Objectives: Flow diversion of intracranial aneurysms results in high occlusion rates. However, 10% to 20% remain persistently filling at 1 year. Often, these are retreated, but benefits of retreatment are not well established. A better understanding of the long-term rupture risk of persistently filling aneurysms after flow diversion is needed., Methods: Our institutional database of 974 flow diversion cases was queried for persistently filling saccular aneurysms of the clinoidal, ophthalmic, and communicating segments of the internal carotid artery treated with the pipeline embolization device (PED, Medtronic). Persistent filling was defined as continued flow into the aneurysm on 1 year catheter angiogram. The clinical record was queried for retreatments and delayed ruptures. Clinical follow-up was required for at least 2 years., Results: Ninety-four persistent aneurysms were identified. The average untreated aneurysm size was 5.6 mm. A branch vessel originated separately in 55% of cases from the body of the aneurysm in 10.6% of cases and from the neck in 34% of cases. Eighteen percent of aneurysms demonstrated >95% filling at 1 year, and 61% were filling 5% to 95% of their original size. The mean follow-up time was 4.9 years, including 41 cases with >5 years. No retreatment was undertaken in 91.5% of aneurysms. There were no cases of delayed subarachnoid hemorrhage., Conclusion: Among saccular internal carotid artery aneurysms treated with PED that demonstrated persistent aneurysm filling at 1 year, there were no instances of delayed rupture on long-term follow-up. These data suggest that observation may be appropriate for continued aneurysm filling at least in the first several years after PED placement., (Copyright © Congress of Neurological Surgeons 2023. All rights reserved.)

Technological advancements, particularly in the realm of augmented reality (AR), may facilitate more accurate and precise pedicle screw placement. AR integrates virtual data into the operator's real-world view, allowing for the visualization of patient-specific anatomy and navigated trajectories. We aimed to conduct a meta-analysis of the accuracy of pedicle screw placement using AR-based systems. A systematic review of the literature and meta-analysis was performed using the PubMed/MEDLINE database, including studies reporting the accuracy of pedicle screw placement using AR. In total, 8 studies with 163 patients and 1259 screws were included in the analysis. XVision (XVS) was the most commonly used AR system (595 screws) followed by the Allura AR surgical navigation system (ARSN) (462 screws). The overall accuracy was calculated as 97.2% (95% CI 96.2-98.1% p < 0.001). Subgroup analysis revealed that there was no statistically significant difference in the accuracy rates achieved by XVS and Allura ARSN ( p = 0.092). AR enables reliable, accurate placement of spinal instrumentation. Future research efforts should focus on comparative studies, cost effectiveness, operative time, and radiation exposure.

Background: Treatment decision-making for brain arteriovenous malformations (bAVMs) with microsurgery or stereotactic radiosurgery (SRS) is controversial., Objective: To conduct a systematic review and meta-analysis to compare microsurgery vs SRS for bAVMs., Method: Medline and PubMed were searched from inception to June 21, 2022. The primary outcomes were obliteration and follow-up hemorrhage, and secondary outcomes were permanent neurological deficit, worsened modified Rankin scale (mRS), follow-up mRS > 2, and mortality. The GRADE approach was used for grading the level of evidence., Results: Eight studies were included, which yielded 817 patients, of which 432 (52.8%) and 385 (47.1%) patients underwent microsurgery and SRS, respectively. Two cohorts were comparable in age, sex, Spetzler-Martin grade, nidus size, location, deep venous drainage, eloquence, and follow-up. In the microsurgery group, the odds ratio (OR) of obliteration was higher (OR = 18.51 [11.05, 31.01], P < .000001, evidence: high) and the hazard ratio of follow-up hemorrhage was lower (hazard ratio = 0.47 [0.23, 0.97], P = .04, evidence: moderate). The OR of permanent neurological deficit was higher with microsurgery (OR = 2.85 [1.63, 4.97], P = .0002, evidence: low), whereas the OR of worsened mRS (OR = 1.24 [0.65, 2.38], P = .52, evidence: moderate), follow-up mRS > 2 (OR = 0.78 [0.36, 1.7], P = .53, evidence: moderate), and mortality (OR = 1.17 [0.41, 3.3], P = .77, evidence: moderate) were comparable between the groups., Conclusion: Microsurgery was superior at obliterating bAVMs and preventing further hemorrhage. Despite a higher rate of postoperative neurological deficit with microsurgery, functional status and mortality were comparable with patients who underwent SRS. Microsurgery should remain a first-line consideration for bAVMs, with SRS reserved for inaccessible locations, highly eloquent areas, and medically high-risk or unwilling patients., (Copyright © Congress of Neurological Surgeons 2023. All rights reserved.)

Objective: Decision-making for the management of ruptured deep-seated brain arteriovenous malformations (bAVMs) is controversial. This study aimed to shed light on the treatment outcomes of patients with ruptured deep-seated bAVMs., Methods: Data on bAVM patients were retrieved from the authors' institutional database, spanning 1990-2021. The outcomes were annual hemorrhage risk (before and after intervention), number of follow-up hemorrhages, bAVM obliteration, poor modified Rankin Scale (mRS) score (i.e., mRS score > 2), worsened mRS score, and mortality. Multivariable Cox and logistic regression analyses were conducted to determine predictors of time-to-event and categorical outcomes, respectively., Results: Of the 1066 patients in the database with brain bAVM, 177 patients harboring ruptured deep-seated bAVMs were included. The pretreatment annual hemorrhage risk was 8.24%, and the posttreatment risk was lowered to 1.65%. In multivariable Cox regression analysis, a prenidal aneurysm (HR 2.388, 95% CI 1.057-5.398; p = 0.036) was associated with a higher risk of follow-up hemorrhage, while definitive treatment (i.e., either surgery or radiosurgery vs endovascular embolization or conservative management) (HR 0.267, 95% CI 0.118-0.602; p = 0.001) was associated with a lower risk of follow-up hemorrhage. In multivariable logistic regression analysis, Spetzler-Martin grades IV and V (OR 0.404, 95% CI 0.171-0.917; p = 0.033) and brainstem arteriovenous malformation (AVM) (OR 0.325, 95% CI 0.128-0.778; p = 0.014) were associated with lower odds of obliteration, while definitive treatment (OR 8.864, 95% CI 3.604-25.399; p = 0.008) was associated with higher obliteration odds. Controlling for baseline mRS score, cerebellar AVM (OR 0.286, 95% CI 0.098-0.731; p = 0.013) and definitive treatment (OR 0.361, 95% CI 0.160-0.807; p = 0.013) were associated with lower odds of a poor mRS score, and definitive treatment (OR 0.208, 95% CI 0.076-0.553; p = 0.001) was associated with lower odds of a worsened mRS score. Furthermore, smoking (OR 6.068, 95% CI 1.531-25.581; p = 0.01) and definitive treatment (OR 0.101, 95% CI 0.024-0.361; p = 0.007) were associated with higher and lower mortality odds, respectively., Conclusions: A definitive treatment strategy seems to be beneficial in achieving higher obliteration and lower hemorrhage rates while decreasing the odds of a poor mRS score, worsened mRS score, and mortality. In this category of patients, prenidal aneurysms warrant treatment, and smoking cessation should be encouraged.

Objective: Trigeminal neuralgia as the presenting symptom of brain arteriovenous malformation (bAVM) has been rarely reported. Treatment of reported cases has been skewed toward surgery for these scarce, deeply located bAVMs. Here, the authors report their management and outcomes of bAVM patients presenting with ipsilateral trigeminal neuralgia (TN) at their institution., Methods: This is a retrospective cohort study. The authors' institutional bAVM database was queried for non-hereditary hemorrhagic telangiectasia bAVMs in pontine, cistern, brainstem, trigeminal nerve, or tentorial locations. Patients with complete data were included in a search for trigeminal neuralgia or "facial pain" as the presenting symptom with TN being on the same side as the bAVM. Demographics, TN and bAVM characteristics, management strategies, and outcomes of bAVM and TN management were analyzed., Results: Fifty-seven peripontine bAVMs were identified; 8 (14.0%) of these bAVMs were discovered because of ipsilateral TN, including 4 patients (50%) with facial pain in the V2 distribution. Five patients (62.5%) were treated with carbamazepine as the initial medical therapy, 2 (25%) underwent multiple rhizotomies, and 1 (12.5%) underwent microvascular decompression. None of the patients with TN-associated bAVMs presented with hemorrhage, compared with 25 patients (51%) with bAVMs that were not associated with TN (p < 0.01). TN-associated bAVMs were overall smaller than non-TN-associated bAVMs, but the difference was not statistically significant (1.71 cm vs 2.22 cm, p = 0.117), and the Spetzler-Martin grades were similar. Six patients (75%) underwent radiosurgery to the bAVM (mean dose 1800 cGy, mean target volume 0.563 cm3) and had complete resolution of TN symptoms (100%). The mean time from radiosurgery to TN resolution was 193 (range 21-360) days, and 83.3% of treated TN-associated bAVMs were obliterated via radiosurgery. Two patients (12.5%) were recommended for conservative management, with one undergoing subsequent rhizotomies and another patient died of hemorrhage during follow-up., Conclusions: TN-associated bAVM is a rare condition with limited evidence for management guidance. Radiosurgery can be safe and effective in achieving durable TN control in patients with TN-associated bAVMs. Despite their deep location and unruptured presentation, obliteration can reach 83.3% with radiosurgery.

Background and Objective: Although randomized controlled trials have compared surgery versus endovascular treatment for intracranial aneurysms, the literature is sparse in terms of subgroup analysis for anterior communicating artery (ACoA) aneurysm management. This systematic review and meta-analysis sought to compare surgical versus endovascular treatment for ACoA aneurysms., Methods: Medline, PubMed, and Embase were searched from inception to December 12, 2022. Primary outcomes were post-treatment modified Rankin Scale (mRS) >2 and mortality. Secondary outcomes were aneurysm obliteration, retreatment and recurrence, rebleeding, technical failure, vessel rupture, aneurysmal subarachnoid hemorrhage-related hydrocephalus, symptomatic vasospasm, and stroke., Results: Eighteen studies yielded 2368 patients, from which 1196 (50.5%) and 1172 (49.4%) patients underwent surgery and endovascular treatment, respectively. The odds ratio (OR) of mortality was similar in total (OR = 0.92 [0.63-1.37], P = 0.69), ruptured (OR = 0.92 [0.62-1.36], P = 0.66), and unruptured cohorts (OR = 1.58 [0.06-39.60], P = 0.78). The OR of mRS > 2 was similar in total (OR = 0.75 [0.50-1.13], P = 0.17), ruptured (OR = 0.77 [0.49-1.20], P = 0.25), and unruptured cohorts (OR = 0.64 [0.21-1.96], P = 0.44). The OR of obliteration was higher with surgery in the total (OR = 2.52 [1.49-4.27], P = 0.0008) and ruptured cohorts (OR = 2.61 [1.33-5.10], P = 0.005) and unruptured group (OR = 3.46 [1.30-9.20], P = 0.01). The OR of retreatment was lower with surgery in the total (OR = 0.37 [0.17-0.76], P = 0.007) and ruptured cohorts (OR = 0.31 [0.11-0.89], P = 0.03), thought it was similar in the unruptured group (OR = 0.51 [0.08-3.03], P = 0.46). The OR of recurrence was lower with surgery in the total (OR = 0.22 [0.10, 0.47], P = 0.0001), ruptured (OR = 0.16 [0.03, 0.90], P = 0.04), and mixed (un) ruptured cohorts (OR = 0.22 [0.09-0.53], P = 0.0009). The OR of rebleeding in ruptured group was similar (OR = 0.66 [0.29-1.52], P = 0.33). The ORs of other outcomes were similar., Conclusions: ACoA aneurysms may be safely treated with either surgery or endovascular treatment, although microsurgical clipping demonstrates higher obliteration rates and lower rates of retreatment and recurrence., (Published by Elsevier Inc.)

Background: The results from studies that compare middle meningeal artery (MMA) embolization vs conventional management for patients with chronic subdural hematoma are varied., Objective: To conduct a systematic review and meta-analysis on studies that compared MMA embolization vs conventional management., Methods: Medline, PubMed, and Embase databases were searched. Primary outcomes were treatment failure and surgical rescue; secondary outcomes were complications, follow-up modified Rankin scale > 2, mortality, complete hematoma resolution, and length of hospital stay (day). The certainty of the evidence was determined using the GRADE approach., Results: Nine studies yielding 1523 patients were enrolled, of which 337 (22.2%) and 1186 (77.8%) patients received MMA embolization and conventional management, respectively. MMA embolization was superior to conventional management for treatment failure (relative risk [RR] = 0.34 [0.14-0.82], P = .02), surgical rescue (RR = 0.33 [0.14-0.77], P = .01), and complete hematoma resolution (RR = 2.01 [1.10-3.68], P = .02). There was no difference between the 2 groups for complications (RR = 0.93 [0.63-1.37], P = .72), follow-up modified Rankin scale >2 (RR = 0.78 [0.449-1.25], P = .31), mortality (RR = 1.05 [0.51-2.14], P = .89), and length of hospital stay (mean difference = -0.57 [-2.55, 1.41], P = .57). For MMA embolization, the number needed to treat for treatment failure, surgical rescue, and complete hematoma resolution was 7, 9, and 3, respectively. The certainty of the evidence was moderate to high for primary outcomes and low to moderate for secondary outcomes., Conclusion: MMA embolization decreases treatment failure and the need for surgical rescue without furthering the risk of morbidity and mortality. The authors recommend considering MMA embolization in the chronic subdural hematoma management., (Copyright © Congress of Neurological Surgeons 2023. All rights reserved.)

Spinal cord injury (SCI) is a prevalent devastating condition causing significant morbidity and mortality, especially in developing countries. The pathophysiology of SCI involves ischemia, neuroinflammation, cell death, and scar formation. Due to the lack of definitive therapy for SCI, interventions mainly focus on rehabilitation to reduce deterioration and improve the patient's quality of life. Currently, rehabilitative exercises and neuromodulation methods such as functional electrical stimulation, epidural electrical stimulation, and transcutaneous electrical nerve stimulation are being tested in patients with SCI. Other spinal stimulation techniques are being developed and tested in animal models. However, often these methods require complex surgical procedures and solely focus on motor function. Vagus nerve stimulation (VNS) is currently used in patients with epilepsy, depression, and migraine and is being investigated for its application in other disorders. In animal models of SCI, VNS significantly improved locomotor function by ameliorating inflammation and improving plasticity, suggesting its use in human subjects. SCI patients also suffer from nonmotor complications, including pain, gastrointestinal dysfunction, cardiovascular disorders, and chronic conditions such as obesity and diabetes. VNS has shown promising results in alleviating these conditions in non-SCI patients, which makes it a possible therapeutic option in SCI patients., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Background: Randomized controlled trials comparing endovascular thrombectomy (EVT) versus EVT preceded by intravenous thrombolysis (EVT + IVT) for acute ischemic stroke due to large artery occlusion remain controversial. This systematic review and meta-analysis seek to compare these 2 modalities., Methods: Online Protocol is available at PROSPERO (york.ac.uk) (registration# CRD42022357506). MEDLINE, PubMed, and Embase were searched. The primary outcome was 90-day modified Rankin scale (mRS) ≤2. Secondary outcomes were 90-day mRS ≤1, 90-day mean mRS, National Institutes of Health Stroke Scale (NIHSS) at 1-3 and 3-7 days, 90-day Barthel Index, 90-day EQ-5D-5L (EuroQoL Group 5-Dimension 5-Level), the volume of infarction (mL), successful reperfusion, complete reperfusion, recanalization, 90-day mortality, any intracranial hemorrhage (ICH), symptomatic ICH, embolization in new territory, new infarction, puncture site complications, vessel dissection, and contrast extravasation. The certainty in the evidence was determined by the GRADE (Grading of Recommendations Assessment, Development and Evaluation) approach., Results: Six randomized controlled trials yielding 2332 patients were included, of which 1163 and 1169 underwent EVT and EVT + IVT, respectively. The relative risk (RR) of 90-day mRS ≤2 was similar between the groups (RR = 0.96[0.88, 1.04]; P = 0.28). EVT was non-inferior to EVT + IVT because the lower bond of 95% confidence interval of the risk difference (RD = -0.02 [-0.06, 0.02]; P = 0.36) exceeded the -0.1 non-inferiority margin. The certainty in the evidence was high. The RR of successful reperfusion (RR = 0.96 [0.93, 0.99]; P = 0.006), any ICH (RR = 0.87 [0.77, 0.98]; P = 0.02), and puncture site complications (RR = 0.47 [0.25, 0.88]; P = 0.02) were lower with EVT. For EVT + IVT, the number needed to treat for successful reperfusion was 25, and the number needed to harm for any ICH was 20. The 2 groups were similar in other outcomes., Conclusion: EVT is non-inferior to EVT + IVT. In centers capable of both EVT and IVT, if timely EVT is feasible, it is reasonable to skip bridging IVT and keep rescue thrombolysis at the discretion of the interventionist for patients presenting within 4.5 hours of anterior ischemic stroke., (Copyright © 2023 Elsevier Inc. All rights reserved.)

There is no systematic review investigating the utility of Diffusion tensor-based tractography findings for treating brain arteriovenous malformations (bAVMs). This systematic review aims to investigate the outcomes following bAVM treatment when tractography data is incorporated into treatment planning. PubMed/MEDLINE, Scopus, and Cochrane Library, were searched for published studies. Prospective or retrospective studies involving at least one patient with confirmed bAVM and available data on tractography and clinical outcomes were included. A total of 16 studies were eligible for this review, consisting of 298 patients. 48.2% of patients were female. The mean age of the patients was 27.5 years (range: 5-77). Stereotactic radiosurgery (SRS) and microsurgical resection each were the treatment of choice in eight studies, respectively. Two-hundred forty-eight patients underwent SRS as the primary treatment, while microsurgery was used to resect the bAVMs in 50 patients. The corticospinal tract, optic pathway, and arcuate fasciculus were the most widely investigated white matter tracts. Tractography disruption and failure frequencies were 19.1% and 1.8%, respectively. The pooled proportions (95% CI) of obliteration rates were 88.78% (73.51-95.76) for microsurgery and 51.45% (13-17-88.10) following SRS. Treatment-related non-hemorrhagic complications rates occurred in 24.2% and 9.9% of patients who underwent microsurgical resection and SRS, respectively. Tractography findings can contribute to providing a more accurate dosimetry analysis of functional white matter tracts at risk prior to SRS and minimizing the surgical morbidity following microsurgical resection., (© 2023. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Objective: To conduct a systematic review and meta-analysis of randomized controlled trials compared laparoscopic pancreatoduodenectomy (LPD) versus open pancreatoduodenectomy (OPD) in patients with periampullary tumors., Background: LPD has gained attention; however, its safety and efficacy versus OPD remain debatable., Methods: We searched PubMed and Embase. Primary outcomes were the length of hospital stay (LOS) (day), Clavien-Dindo grade ≥III complications, and 90-day mortality. Secondary outcomes were blood loss (milliliter), blood transfusion, duration of operation (minute), readmission, reoperation, comprehensive complication index score, bile leak, gastrojejunostomy or duodenojejunostomy leak, postoperative pancreatic fistula, postpancreatectomy hemorrhage, delayed gastric emptying, surgical site infection, intra-abdominal infection, number of harvested lymph nodes, and R0 resection. Pooled odds ratio (OR) or mean difference (MD) of data was calculated using the random-effect model. The grading of recommendations, assessment, development and evaluation approach was used for grading the level of evidence., Results: Four randomized controlled trials yielding 818 patients were included, of which 411 and 407 patients underwent LPD and OPD, respectively. The meta-analysis concluded that 2 approaches were similar, except in the LPD group, the LOS tended to be shorter [MD=-2.54 (-5.17, 0.09), P =0.06], LOS in ICU was shorter [MD=-1 (-1.8, -0.2), P =0.01], duration of operation was longer [MD=75.16 (23.29, 127.03), P =0.005], blood loss was lower [MD=-115.40 (-152.13, -78.68), P <0.00001], blood transfusion was lower [OR=0.66 (0.47, 0.92), P =0.01], and surgical site infection was lower [OR=0.35 (0.12, 0.96), P =0.04]. The overall certainty of the evidence was moderate., Conclusions: Within the hands of highly skilled surgeons in high-volume centers, LPD is feasible and as safe and efficient as OPD., Competing Interests: The authors report no conflicts of interest., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Objective: To compare internal fixation (IF) versus hemiarthroplasty (HA) for elderly individuals (ie, older than 65 years) with nondisplaced (ie, Garden type I or II) femoral neck fracture (FNF)., Data Source: We searched English literature of MEDLINE, PubMed, and Embase from inception to December 4, 2021., Study Selection: Eligibility criteria were randomized controlled trials (RCTs) compared IF versus HA for elderly individuals with nondisplaced FNF. Primary outcomes were Harris hip score (HHS), quality of life per European Quality of Life 5 Dimension (EQ-5D), and mortality. Secondary outcomes were complications, reoperation, intraoperative bleeding, operation duration, and length of hospital stay., Data Extraction: Two authors separately extracted data and assessed the risk of bias of the included studies using Cochrane risk-of-bias tool., Data Synthesis: Three RCTs yielding 400 patients were enrolled, of which 203 (50.7%) underwent IF. Internal fixation was inferior to HA with respect to 6-month HHS [mean difference (MD) = -8.28 (-14.46, -2.10), P = 0.009] and 1-year EQ-5D [MD = -0.07 (-0.14, -0.00), P = 0.04]. The 2 techniques were comparable regarding length of hospital stay (day), HHS at 1 and 2 years, EQ-5D at 2 years, and mortality. IF was inferior to HA in implant-related complication [20.1% vs. 6.0%, relative risk (RR) = 3.18 (1.72, 5.88), P = 0.0002] and reoperation rate [20.1% vs. 6.0%, RR = 3.30 (1.79, 6.08), P = 0.0001]. Hemiarthroplasty had a greater blood loss (mL) [MD = -138.88 (-209.58, -68.18), P = 0.001] and operation duration (min) [MD = -23.27 (-44.95, -1.60), P = 0.04] compared with IF., Conclusion: HA is the preferred technique for nondisplaced FNF if early recovery, higher mobility, and better quality of life are priorities. The choice of fixation should be weighed on an individual patient level., Level of Evidence: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence., Competing Interests: The authors report no conflict of interest., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Objective: The optimal surgical approach for patients with multilevel degenerative cervical myelopathy (DCM) remains unknown. This systematic review and meta-analysis sought to compare anterior cervical discectomy and fusion (ACDF) versus posterior decompression (PD) in patients with DCM spanning ≥ 2 levels without ossification of the posterior longitudinal ligament., Methods: MEDLINE and PubMed were searched from inception to February 22, 2022. The primary outcomes were Neck Disability Index (NDI), SF-36 Physical Component Summary (PCS), modified Japanese Orthopaedic Association (mJOA) scale, visual analog scale (VAS), and EQ-5D scores. Secondary outcomes were operative bleeding, operative duration, hospital length of stay (LOS), postoperative morbidity (including hematoma, surgical site infection [SSI], CSF leakage, dysphagia, dysphonia, C5 palsy, and fusion failure), mortality, readmission, reoperation, and Cobb angle., Results: Nineteen studies comprising 8340 patients were included, of whom 4118 (49.4%) and 4222 (50.6%) underwent ACDF and PD, respectively. The mean number of involved spinal levels was comparable between the groups (3.1 vs 3.5, p = 0.15). The mean differences (MDs) of the primary outcomes were the mean of each index in the ACDF group minus that of the PD group. At the 1-year follow-up, the MDs of the NDI (-1.67 [95% CI -3.51 to 0.18], p = 0.08), SF-36 PCS (2.48 [95% CI -0.59 to 5.55], p = 0.11), and VAS (-0.32 [95% CI -0.97 to 0.34], p = 0.35) scores were similar between the groups. While the MDs of the mJOA (0.71 [95% CI 0.27 to 1.16], p = 0.002) and EQ-5D (0.04 [95% CI 0.01 to 0.08], p = 0.02) scores were greater in the ACDF group, the differences were not clinically significant given the minimal clinically important differences (MCIDs) of 2 and 0.05 points, respectively. In the ACDF group, the MDs for operative bleeding (-102.77 ml [95% CI -169.23 to -36.30 ml], p = 0.002) and LOS (-1.42 days [95% CI -2.01 to -0.82 days], p < 0.00001) were lower, the dysphagia OR (11.10 [95% CI 5.43-22.67], p < 0.0001) was higher, and the ORs for SSI (0.43 [95% CI 0.24-0.78], p = 0.006) and C5 palsy (0.32 [95% CI 0.15-0.70], p = 0.004) were lower. The other outcomes were similar between the groups. Overall evidence according to the GRADE (Grading of Recommendations, Assessment, Development and Evaluations) approach was moderate., Conclusions: ACDF and PD are similar regarding functional outcomes. ACDF is beneficial in terms of less bleeding, shorter LOS, and lower odds of SSI and C5 palsy, while the procedure carries higher odds of dysphagia. The authors recommend individualized treatment decision-making.

Background: Preoperative embolization has traditionally been regarded as a safe and effective adjunct to microsurgical treatment of brain arteriovenous malformations (bAVM). However, there is currently no high-level evidence to ascertain this presumption., Objective: To compare the outcomes of microsurgery (MS) vs microsurgery with preoperative embolization (E + MS) in patients with bAVM through systematic review., Methods: We searched MEDLINE, PubMed, and Embase. The primary outcome was bAVM obliteration. Secondary outcomes were intraoperative bleeding (mL), complications, worsened modified Rankin Scale (mRS), and mortality. The pooled proportions of outcomes were calculated through the logit transformation method. The odds ratio (OR) of categorical data and mean difference of continuous data were estimated through the Mantel-Haenszel and the inverse variance methods, respectively., Results: Thirty-two studies met the eligibility criteria. One thousand eight hundred twenty-eight patients were treated by microsurgery alone, and 1088 were treated by microsurgery with preoperative embolization, respectively. The meta-analysis revealed no significant difference in AVM obliteration (94.1% vs 95.6%, OR = 1.15 [0.63-2.11], P = .65), mortality (1.7% vs 2%, OR = 0.88 [0.30-2.58], P = .82), procedural complications (18.2% vs 27.2%, OR = 0.47 [0.19-1.17], P = .10), worsened mRS (21.2% vs 18.5%, OR = 1.08 [0.33-3.54], P = .9), and intraoperative blood loss (mean difference = 182.89 [-87.76, 453.55], P = .19)., Conclusion: The meta-analysis showed no significant difference in AVM obliteration, mortality, complications, worse mRS, and intraoperative blood loss between MS and E + MS groups. For AVMs where MS alone has acceptable results, it is reasonable to bypass unnecessary preoperative embolization given higher postoperative complication risk., (Copyright © Congress of Neurological Surgeons 2022. All rights reserved.)

Background: For arteriovenous fistula (AVF) presence of a venous segment with adequate diameter is essential which is lacking in many patients. To find the optimal augmentation technique in patients with small-caliber cephalic vein (i.e., cephalic vein diameter <3 mm), studies compared primary balloon angioplasty (PBA) versus hydrostatic dilation (HD); however, it remained debatable. This systematic review seeks to determine which technique is preferable., Methods: We searched MEDLINE, PubMed, Embase, and Google Scholar. Primary outcomes were 6-month primary patency, reintervention, and working AVF. Secondary outcomes were immediate success, the AVF's maturation time (day), and surgical site infection., Results: Three randomized controlled trials yielding 180 patients were included, of which 89 patients were in the PBA group. The odds ratio (OR) of primary patency was significantly higher in the PBA group (OR 6.09, 95% confidence interval [CI], 2.36-15.76, P = 0.0002), the OR of reintervention was significantly lower in the PBA group (OR 0.16, 95% CI, 0.06-0.42, P = 0.0002), and the OR of working AVF was greater in PBA group (OR 4.22, 95% CI, 1.31-13.59, P = 0.02). The OR of immediate success was significantly greater in the PBA group (OR 11.42, 95% CI, 2.54-51.42, P = 0.002), and the AVF maturation time was significantly shorter in patients who underwent PBA (mean difference -20.32 days, 95% CI, -30.12 to -10.52, P = 0.0001). The certainty of the evidence was high., Conclusions: PBA of small cephalic veins with diameter ≤2.5 cm is a safe, feasible, and efficacious augmentation method for AVF creation. This technique achieves favorable maturation outcomes, and PBA is superior to the standard hydrostatic dilatation technique., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Objective: Pediatric deep brain arteriovenous malformations (bAVMs) represent a unique management challenge given their higher cumulative risk of hemorrhage as well as a higher risk of treatment. Better understanding of hemorrhage risk in this patient population will lead to a better decision-making process for patient management., Methods: The authors retrospectively reviewed their institutional bAVM database from 1990 to 2019 and included patients younger than 21 years who had deep-seated bAVMs. They present the annual hemorrhage risk, during the natural history and after treatment, and functional outcomes., Results: Thirty-one pediatric patients were included in this study (13 males and 18 females) with a mean age of 11.8 (SD 4.4) years. The most frequent presenting symptoms were headache (54.8%), weakness (38.7%), and seizure (22.6%). The mean follow-up duration was 13.14 (SD 12.5) years, during which 7 (22.6%) AVMs were obliterated, 10 (32.3%) individuals experienced hemorrhage, and the modified Rankin Scale score worsened in 8 (25.8%) patients. The annual natural history risk of hemorrhage was 3.24% per patient, and the overall annual hemorrhage risk after treatment was 1.98% per patient. In particular, the risk was reduced to 0.64% per patient in the stereotactic radiosurgery (SRS) group. Non-White race showed a trend of higher rupture at presentation (OR 5 [95% CI 0.84-41.68], p = 0.09). Female sex was associated with higher odds (OR 13.076 [95% CI 1.424-333.591], p = 0.048) and SRS was associated with lower odds (OR 0.122 [95% CI 0.011-0.862], p = 0.049) of follow-up hemorrhage., Conclusions: Given the substantial cumulative risk of lifelong hemorrhagic stroke in pediatric patients, timely definitive treatment is warranted. SRS may be beneficial when the risk-benefit profile is deemed acceptable.

Objective: The objective of the study was to determine home program matching percentage (staying in a program affiliated with one's medical school) for each neurosurgical residency program in the United States. Secondarily, it was to elucidate both program-level and resident characteristics associated with home program matching., Methods: Demographic and bibliometric characteristics were collected for 1572 residents in U.S.-based and Accreditation Council for Graduate Medical Education-accredited neurosurgery programs over the 2014-2020 match period using publicly available websites. Program characteristics were collected, including number of clinical faculty, top 20 Doximity research ranking, top 10 Doximity reputation ranking, top 10 U.S. News department ranking, affiliation with a U.S. News top 10 medical school, and geographic region. Programs were ranked according to home program matching percentage, and associations were statistically evaluated., Results: The average home program matching percentage per residency was 18.6%. NewYork-Presbyterian/Columbia retained the largest percentage of its own medical students with a home program matching percentage of 57.14%. From the resident frame of reference, only a higher preresidency H-index (3.7 ± 4.0 vs. 3.2 ± 3.7, P = 0.033) was significantly associated with home program matching. From a program perspective, program size (standardized β = 0.234, P = 0.006), Doximity research (standardized β = 0.206, P = 0.031), Doximity reputation (standardized β = 0.196, P = 0.040), and U.S. News program rankings (standardized β = 0.200, P = 0.036) were all significantly associated with home program matching. Overall home program matching percentage remained relatively constant over the 2014-2020 time period., Conclusions: The results of this study delineate home program matching patterns on a program-by-program level for U.S. neurosurgical residency programs., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Introduction: Bleeding events are the most common complications after kidney biopsy. This study aims to evaluate the effect of desmopressin administration on bleeding complication, in native kidney biopsy candidates with reduced kidney function., Methods: This double-blind randomized clinical trial enrolled 18 to 80 years old patients with 15 < eGFR < 90 mL/min/ 1.73m² from July 2017 to August 2020. Patients were randomly assigned to receive either 3 µg/kg of intranasal desmopressin acetate or 1 mL/kg of intranasal sodium chloride 0.65%, one hour before ultrasound-guided, percutaneous native kidney biopsy. The primary outcome was the post-biopsy bleeding complications, and secondary outcomes were the volume of perirenal hematoma, and changes of post-biopsy hemoglobin and hematocrit level, plasma sodium and blood pressure (Clinical Trial Registration ID: IRCT20090701002112N3)., Results: A total of 120 patients (58 men and 62 women), 60 patients in each group, were analyzed. The mean age and eGFR of the patients were 45.29 ± 15.95 years and 51.77 ± 18.02 ml/min/ 1.73m², respectively. Desmopressin administration significantly decreased post-biopsy perirenal hematoma compared to placebo (7/60 [11.6%]) vs. 33/60 [40%]; P < .05), and the hematoma volume was significantly smaller in the desmopressin group, in case of hematoma formation (2.31 ± 1.17 vs. 7.72 ± 5.45 mm³, P < .05)., Conclusion: Desmopressin administration before kidney biopsy is a safe and effective strategy to prevent bleeding complications. Considering absolute risk reduction of about 28%, the number needed to treat is about 4 procedures. We recommend considering desmopressin administration before percutaneous native kidney biopsy.  DOI: 10.52547/ijkd.6966.

Objective: In microvascular decompression (MVD) surgery through the retrosigmoid approach, the surgeon may have to sacrifice the superior petrosal vein (SPV). However, this is a controversial maneuver. To date, high-level evidence comparing the operative outcomes of patients who underwent MVD with and without SPV sacrifice is lacking. Therefore, this study sought to bridge this gap., Methods: The authors searched the Medline and PubMed databases with appropriate Medical Subject Heading (MeSH) terms and keywords. The primary outcome was vascular-related complications; secondary outcomes were new neurological deficit, cerebrospinal fluid (CSF) leak, and neuralgia relief. The pooled proportions of outcomes and OR (95% CI) for categorical data were calculated by using the logit transformation and Mantel-Haenszel methods, respectively., Results: Six studies yielding 1143 patients were included, of which 618 patients had their SPV sacrificed. The pooled proportion (95% CI) values were 3.82 (0.87-15.17) for vascular-related complications, 3.64 (1.0-12.42) for new neurological deficits, 2.85 (1.21-6.58) for CSF leaks, and 88.90 (84.90-91.94) for neuralgia relief. The meta-analysis concluded that, whether the surgeon sacrificed or preserved the SPV, the odds were similar for vascular-related complications (2.5% vs 1.5%, OR [95% CI] 1.01 [0.33-3.09], p = 0.99), new neurological deficits (1.2% vs 2.8%, OR [95% CI] 0.55 [0.18-1.66], p = 0.29), CSF leak (3.1% vs 2.1%, OR [95% CI] 1.16 [0.46-2.94], p = 0.75), and neuralgia relief (86.6% vs 87%, OR [95% CI] 0.96 [0.62-1.49], p = 0.84)., Conclusions: SPV sacrifice is as safe as SPV preservation. The authors recommend intentional SPV sacrifice when gentle retraction fails to enhance surgical field visualization and if the surgeon encounters SPV-related neurovascular conflict and/or anticipates impeding SPV-related bleeding.

Objective: The authors aimed to characterize which US medical schools have the most female neurosurgery residents and to identify potential associations between medical school characteristics and successful recruitment of women pursuing a neurosurgery career., Methods: The authors evaluated a total of 1572 residents in US neurosurgery programs accredited by the Accreditation Council for Graduate Medical Education as of February 2021, representing match cohorts from 2014 to 2020. The authors extracted US medical school characteristics and ranked schools based on the percentages of women graduates entering neurosurgery. They additionally studied yearly trends of the percentage of women constituting incoming neurosurgery resident cohorts as well as associations between female recruitment percentage and medical school characteristics using univariable and stepwise multivariable linear regression (including significant univariable factors)., Results: The cohort consisted of 1255 male and 317 (20%) female residents. Yearly trends indicated a significant drop in incoming female residents in 2016, followed by significant increases in 2017 and 2019. On multivariable analysis, the following factors were associated with a higher average percentage of female graduates entering neurosurgery: total affiliated neurosurgery clinical faculty (β = 0.006, 95% CI 0.001-0.011, p = 0.01), allopathic versus osteopathic schools (β = 0.231, 95% CI 0.053-0.409, p = 0.01), and top 10 U.S. News & World Report ranking (β = 0.380, 95% CI 0.129-0.589, p < 0.01). When the number of female clinical faculty was added to the model, the variable was not statistically significant. Multivariable bibliometric analyses indicated a higher mean preresidency H-index for men, with an even greater gender difference identified in the 2021 H-index., Conclusions: This study characterizes which medical schools are most successful at recruiting female students who constituted the total neurosurgery resident workforce of the 2020-2021 academic year. The overall number of clinical neurosurgery faculty rather than faculty gender was independently associated with female recruitment. Gender differences in research productivity persisted with control for confounders and increased between preresidency and 2021 time points. Such understanding of factors that influence the recruitment of women can help improve female representation in neurosurgery residency training moving forward.

Background: Interest in machine learning (ML)-based predictive modeling has led to the development of models predicting outcomes after aneurysmal subarachnoid hemorrhage (aSAH), including the Nijmegen acute subarachnoid hemorrhage calculator (Nutshell). Generalizability of such models to external data remains unclear., Objective: To externally validate the performance of the Nutshell tool while comparing it with the conventional Subarachnoid Hemorrhage International Trialists (SAHIT) models and to review the ML literature on outcome prediction after aSAH and aneurysm treatment., Methods: A prospectively maintained database of patients with aSAH presenting consecutively to our institution in the 2013 to 2018 period was used. The web-based Nutshell and SAHIT calculators were used to derive the risks of poor long-term (12-18 months) outcomes and 30-day mortality. Discrimination was evaluated using the area under the curve (AUC), and calibration was investigated using calibration plots. The literature on relevant ML models was surveyed for a synopsis., Results: In 269 patients with aSAH, the SAHIT models outperformed the Nutshell tool (AUC: 0.786 vs 0.689, P = .025) in predicting long-term functional outcomes. A logistic regression model of the Nutshell variables derived from our data achieved adequate discrimination (AUC = 0.759) of poor outcomes. The SAHIT models outperformed the Nutshell tool in predicting 30-day mortality (AUC: 0.810 vs 0.636, P < .001). Calibration properties were more favorable for the SAHIT models. Most published aneurysm-related ML-based outcome models lack external validation and usable testing platforms., Conclusion: The Nutshell tool demonstrated limited performance on external validation in comparison with the SAHIT models. External validation and the dissemination of testing platforms for ML models must be emphasized., (Copyright © Congress of Neurological Surgeons 2022. All rights reserved.)

The role of microsurgery and radiosurgery in the management of low-grade (Spetzler-Martin grade 1 and 2) arteriovenous malformations (AVMs) remains controversial. We aimed to compare outcomes of low-grade AVMs following microsurgery and radiosurgery using a database of AVM patients presenting between 1990 and 2017. Procedure-related complications, obliteration, and functional status at last follow-up were compared between groups. Hemorrhage-free survival was compared using Kaplan-Meier analysis with subgroup analyses by rupture status on presentation. The study involved 233 patients, of which 113 and 120 were treated with microsurgery and radiosurgery, respectively. The complication rates were statistically comparable between both treatment modalities. Mean follow-up time was 5.1 ± 5.2 years. In the complete cohort, there was no significant difference in hemorrhage-free survival between microsurgery and radiosurgery (log-rank p = 0.676, Breslow p = 0.493). When excluding procedure-related hemorrhage and partial resection, hemorrhage-free survival was significantly higher in the surgically treated cohort (log-rank = 0.094, Breslow p = 0.034). The obliteration rate was significantly higher in the surgical cohort (96% vs. 57%, p < 0.001), while functional status was similar. Microsurgery may offer superior hemorrhage-free survival in the early post-treatment period and demonstrates equivalent long-term hemorrhage control and functional outcome at 5 years compared to radiosurgery with nearly complete obliteration rates. Persistent neurologic deficits following microsurgery and symptomatic cerebral edema represent important treatment risks despite low SM grading. Appropriate patient selection even when dealing with low-grade AVMs is advised, as judicious patient selection and emphasis on technical success can minimize procedure-related hemorrhage and the incidence of subtotal resection., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2021 Elsevier Ltd. All rights reserved.)

Objective: In this study, the authors sought to determine which US medical schools have produced the most neurosurgery residents and to evaluate potential associations between recruitment and medical school characteristics., Methods: Demographic and bibliometric characteristics were collected for 1572 residents in US-based and Accreditation Council for Graduate Medical Education (ACGME)-accredited neurosurgery programs over the 2014 to 2020 match period using publicly available websites. US medical school characteristics were collected, including class size, presence of a home neurosurgery program, number of clinical neurosurgery faculty, research funding, presence of a neurosurgery interest group, and a top 10 ranking via U.S. News & World Report or Doximity. Correlations and associations were then evaluated using Pearson's correlation coefficient (PCC), independent-samples t-test, and univariable or stepwise multivariable linear regression, as appropriate., Results: Vanderbilt University produced the most neurosurgery residents as a percentage of medical graduates at 3.799%. Case Western Reserve University produced the greatest absolute number of neurosurgery residents (n = 40). The following factors were shown to be associated with a higher mean percentage of graduates entering neurosurgery: number of clinical neurosurgery faculty (PCC 0.509, p < 0.001), presence of a neurosurgery interest group (1.022% ± 0.737% vs 0.351% ± 0.327%, p < 0.001) or home neurosurgery program (1.169% ± 0.766% vs 0.428% ± 0.327%, p < 0.001), allopathic compared with osteopathic school (0.976% ± 0.719% vs 0.232% ± 0.272%, p < 0.001), U.S. News top 10 ranking for neurology and neurosurgery (1.923% ± 0.924% vs 0.757% ± 0.607%, p < 0.001), Doximity top 10 residency program ranking (1.715% ± 0.803% vs 0.814% ± 0.688%, p < 0.001), and amount of NIH funding (PCC 0.528, p < 0.001)., Conclusions: The results of this study have delineated which medical schools produced the most neurosurgery residents currently in training, and the most important independent factors predicting the percentage of graduates entering neurosurgery and the preresidency h-index.

Deep-seated intracranial arteriovenous malformations (AVMs) represent a subset of AVMs characterized by variably reported outcomes regarding the risk of hemorrhage, microsurgical complications, and response to stereotactic radiosurgery (SRS). We aimed to compare outcomes of microsurgery, SRS, endovascular therapy, and conservative follow-up in deep-seated AVMs. A prospectively maintained database of AVM patients (1990-2017) was queried to identify patients with ruptured and unruptured deep-seated AVMs (extension into thalamus, basal ganglia, or brainstem). Comparisons of hemorrhage-free survival and poor functional outcome (modified Rankin scale [mRS] > 2) were performed between conservative management, microsurgery (±pre-procedural embolization), SRS (±pre-procedural embolization), and embolization utilizing multivariable Cox and logistic regression analyses controlling for univariable factors with p < 0.05. Of 789 AVM patients, 102 had deep-seated AVMs (conservative: 34; microsurgery: 6; SRS: 54; embolization: 8). Mean follow-up time was 6.1 years and did not differ significantly between management groups (p = 0.393). Complete obliteration was achieved in 49% of SRS patients. Upon multivariable analysis controlling for baseline rupture with conservative management as a reference group, embolization was associated with an increased hazard of hemorrhage (HR = 6.2, 95%CI [1.1-40.0], p = 0.037), while microsurgery (p = 0.118) and SRS (p = 0.167) provided no significant protection from hemorrhage. Controlling for baseline mRS, microsurgery was associated with an increased risk of poor outcome (OR = 9.2[1.2-68.3], p = 0.030), while SRS (p = 0.557) and embolization (p = 0.541) did not differ significantly from conservative management. Deep AVMs harbor a high risk of hemorrhage, but the benefit from intervention Remains uncertain. SRS may be a relatively more effective approach if interventional therapy is indicated., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2021 Elsevier Ltd. All rights reserved.)

We evaluated the effect of insulin resistance and free androgen index (FAI) in non-PCOS (polycystic ovary syndrome) infertile women following controlled ovarian hyperstimulation. A prospective study was done on 144 infertile non-PCOS women with regular menstrual cycle. At first, insulin resistance (IR), free androgen index (FAI), PCOM (polycystic ovary morphology), AFC (antral follicle count), and AMH (anti-Müllerian hormone) were assessed. The patients underwent assisted reproductive technology (ART), and then preovulatory follicles and oocytes retrieved were recorded. The variables of the study were compared between two groups of patients with ovarian hyperstimulation syndrome (OHSS) (n=66) and non-OHSS patients (n=78). Of the 9 variables: BMI, HOMA-IR, FAI, AFC, AMH, PCOM, and preovulatory follicles were risk factors, while the age and retrieved oocytes were not. The 7 variables that showed significance in the univariate analyses were determined as independent variables included in the multivariable logistic regression analysis, as a result, a total of 5 risk factors, BMI, HOMA-IR, FAI, PCOM, and preovulatory follicles entered the equation. The maximum contribution was HOMA-IR followed by PCOM, FAI, preovulatory follicles and BMI. Patients with OHSS had higher chance to have ovaries with polycystic morphology (74%), about three times more than patients who did not develop OHSS (29%) (p<0.001). The best cut-points for IR, FAI, AFC, AMH, and preovulatry follicles were 2.36, 3.9, 8, 3.3 ng/ml, and 10, respectively. Patients with a higher value of BMI, FAI, HOMA-IR, and preovulatory follicles and the presence of PCOM are more likely to develop OHSS, which are not confined to PCOS patients., Competing Interests: The authors declare that they have no conflict of interest., (© Georg Thieme Verlag KG Stuttgart · New York.)

Introduction: Contrast-induced nephropathy (CIN) is a frequent complication of contrast exposure. A recent study suggested that Na/K citrate might have a preventive role. We investigated the efficacy of Na/K citrate to prevent CIN in patients with renal dysfunction undergoing coronary intervention., Methods: The randomized, double-blind, placebo-controlled trial included 201 patients with estimated creatinine clearance < 90 mL/ min, randomized to receive oral Na/K citrate plus saline infusion (treatment group, 104 patients) or oral water plus saline infusion (placebo group, 97 patients). CIN was defined as an absolute increase of serum creatinine ≥ 0.5 mg/dL or a relative increase ≥ 25% or a relative decrease of estimated GFR ≥ 25% within 5 days., Results: CIN occurred in 22 patients (12.29%); 10 (11%) in treatment group and 12 (13.6%) in placebo group (P > .05). Post-exposure Cr values were not significantly different between the two groups (1.18 ± 0.28 mg/dL in the placebo vs. 1.15 ± 0.29 mg/dL in the treatment group, P > .05). CIN-negative patients in the treatment group showed a significantly higher increase in urine pH than that of CIN-positive patients (1.642 ± 0.577 vs. 1.20 ± 0.422, P < .05)., Conclusion: Na/K citrate solution is not effective for prophylaxis of CIN in patients with renal dysfunction. However, a probable preventive effect might exist in a subgroup of patients with at least 1.6 units increase in urine pH values following Na/K citrate administration.

Introduction: According to the non-specific presentation of atherosclerotic renal artery stenosis (ARAS), this disease is usually an under-diagnosed in clinical conditions., Objectives: The aim of the presence study was to evaluate the prevalence of renal artery stenosis (RAS) and its related risk factors in hypertensive patients undergoing coronary angiography., Patients and Methods: In a cross-sectional study, between March 2009 and October 2010, all of hypertensive patients candidate for diagnostic cardiac catheterization, underwent nonselective renal angiography before completion of their coronary angiography procedure. A standardized questionnaire was used to collect demographics, cardiac history, indications for cardiac catheterization and angiographic data. The degree of ARAS was estimated visually by skilled cardiologist. Narrowing greater than 50% of the arterial lumen considered as arterial stenosis. Data was analyzed by SPSS version 19, and by chi-square test and logistic regression model., Results: In overall 274 patients with mean age of 60.75 ± 10.92 years 108 (39.4%) were male and 166 (60.61%) were female. The prevalence of ARAS calculated 18.2%. According to the present study, heart failure and smoking were predictors of ARAS. However, old age, gender, diabetes mellitus, hyperlipidemia and family history of cardiovascular disease were not clinical predictors of significant ARAS in hypertensive patients, candidate for coronary angiography., Conclusion: According to present data, we suggest to consider renal artery angiography in combination with coronary artery angiography especially in hypertensive patients who are smoker or individuals who have heart failure.