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Pediatric low-grade gliomas (pLGGs) exhibit heterogeneous prognoses and variable responses to treatment, leading to tumor progression and adverse outcomes in cases where complete resection is unachievable. Early prediction of treatment responsiveness and suitability for immunotherapy has the potential to improve clinical management and outcomes. Here, we present a radiogenomic analysis of pLGGs, integrating MRI and RNA sequencing data. We identify three immunologically distinct clusters, with one group characterized by increased immune activity and poorer prognosis, indicating potential benefit from immunotherapies. We develop a radiomic signature that predicts these immune profiles with over 80% accuracy. Furthermore, our clinicoradiomic model predicts progression-free survival and correlates with treatment response. We also identify genetic variants and transcriptomic pathways associated with progression risk, highlighting links to tumor growth and immune response. This radiogenomic study in pLGGs provides a framework for the identification of high-risk patients who may benefit from targeted therapies. Understanding the molecular and pathological features of paediatric low-grade glioma (pLGG) is crucial to develop targeted therapies. Here, the authors perform a radiogenomic analysis of pLGGs combining treatment-naïve multiparametric MRI and RNA sequencing, enabling prognostication based on immune profiles as well as prediction of treatment response. [ABSTRACT FROM AUTHOR]

This article discusses the potential impact of artificial intelligence (AI) on the field of neurosurgery. The authors conducted a study using AI-equipped panoramic vision systems to monitor and quantify the learning curve associated with the placement of an External Ventricular Drain (EVD) on a trainer head. The AI successfully identified and recorded fundamental parameters of the procedure, such as the number of catheter insertion attempts and time taken. The study validates the use of AI in calculating and assessing objective scoring systems for surgical procedures, which could provide valuable performance metrics for training and education purposes. [Extracted from the article]

Introduction: Degenerative lumbar spondylolisthesis (DS) patients are treated with instrumented fusion, following EBM guidelines, and typically have excellent clinical outcomes. However, not all lumbar fusion procedures adhere to EBM guidelines, typically due to a lack of prospective data. Objective: This retrospective study compared outcomes of DS lumbar fusion patients treated according to EBM guidelines (EBM concordant) to lumbar fused patients with procedures that did not have clear EBM literature that supported this treatment, the goal being to examine the value of present EBM to guide clinical care. Methods: A total of 125 DS patients were considered EBM concordant, while 21 patients were EBM discordant. Pre- and postsurgical ODI scores were collected. Clinical outcomes were stratified into substantial clinical benefit (SCB ΔODI >10 points), minimal clinical importance benefit (MCID ΔODI ≥ 5 points), no MCID (ΔODI < 5 points), and a group that showed no change or worsening ODI. Fisher's exact and χ2 tests for categorical variables, Student's t-test for continuous variables, and descriptive statistics were used. Statistical tests were computed at the 95% level of confidence. Results: Analysis of 125 degenerative spondylolisthesis patients was performed comparing preoperative and postoperative (6 months) ODI scores. ODI improved by 8 points in the EBM concordant group vs. 2.1 points in the EBM discordant group (p = 0.002). Compliance with EBM guidelines was associated with an odds ratio (OR) of 2.93 for achieving MCID ([CI]: 1.12–7.58, p = 0.027). Conclusions: Patients whose lumbar fusions met EBM criteria had better self-reported outcomes at six months than those who did not meet the requirements. A greater knowledge set is needed to help further support EBM-guided patient care. [ABSTRACT FROM AUTHOR]

Rheumatoid arthritis (RA) is a chronic inflammatory polyarthropathy that affects many synovial joints favoring the hands, knees, and vertebral articulations. Joint laxity manifests as subaxial instability, atlantoaxial instability, and cranial settling (CS). A 70-year-old woman with past medical history of RA, Hashimoto's thyroiditis, osteoporosis, history of C1-2 fusion for instability 15 years prior, with subsequent revision cervicothoracic fusion for degeneration, and trauma 2 years prior presents with new onset headache, nausea, and vomiting of 36-hour duration. Neurologic examination was only notable for mild right dysmetria. Workup revealed acute hemorrhage in the posterior fossa with migration of the right rod implant and screw tulip, as a result of CS. The patient underwent occipital-cervical fusion with removal of the migratory hardware. Intracranial rod migration and hemorrhage secondary to CS is a rare complication that must be brought to the attention of surgeons operating on patients with RA. [ABSTRACT FROM AUTHOR]

Pallister-Hall syndrome (PHS) is an extremely rare syndrome of unknown prevalence with autosomal dominant inheritance due to GLI3 gene mutations classically characterized by the presence of a hypothalamic hamartoma and polydactyly. Additional diagnostic criteria include bifid epiglottis, imperforate anus, small nails, hypopituitarism, growth hormone deficiency, and genital hypoplasia. It is typically diagnosed in infancy and early childhood, presenting with seizures and/or precocious puberty due to the hypothalamic hamartoma, and with limb anomalies due to central polydactyly. Our patient had presented with polysyndactyly at birth. However, as this is not uncommon in infants and is usually as part of the sporadic, isolated form of polydactyly, no further work up was done. He then presented at age 16 years with a headache and subjective visual changes, with brain imaging revealing a hypothalamic hamartoma. He did not have a history of seizures or central precocious puberty. Genotyping revealed a pathogenic variant affecting the GLI3 gene. We encourage all clinicians to consider PHS or an associated syndrome with a clinical finding of polydactyly. Further, as the natural history continues to reveal itself, this patient's presentation provides important new data to the broad phenotypic spectrum of PHS. [ABSTRACT FROM AUTHOR]

Dispersal of Glioblastoma (GBM) renders localized therapy ineffective and is a major cause of recurrence. Previous studies have demonstrated that Dexamethasone (Dex), a drug currently used to treat brain tumor–related edema, can also significantly reduce dispersal of human primary GBM cells from neurospheres. It does so by triggering α5 integrin activity, leading to restoration of fibronectin matrix assembly (FNMA), increased neurosphere cohesion, and reduction of neurosphere dispersal velocity (DV). How Dex specifically activates α5 integrin in these GBM lines is unknown. Several chaperone proteins are known to activate integrins, including calreticulin (CALR).We explore the role of CALR as a potential mediator of Dex-dependent induction of α5 integrin activity in primary human GBM cells. We use CALR knock-down and knock-in strategies to explore the effects on FNMA, aggregate compaction, and dispersal velocity in vitro, as well as dispersal ex vivo on extirpated mouse retina and brain slices. We show that Dex increases CALR expression and that siRNA knockdown suppresses Dex-mediated FNMA. Overexpression of CALR in GBM cells activates FNMA, increases compaction, and decreases DV in vitro and on explants of mouse retina and brain slices. Our results define a novel interaction between Dex, CALR, and FNMA as inhibitors of GBM dispersal. [ABSTRACT FROM AUTHOR]

Glioblastoma is highly aggressive. Early dispersal of the primary tumor renders localized therapy ineffective. Recurrence always occurs and leads to patient death. Prior studies have shown that dispersal of Glioblastoma can be significantly reduced by Dexamethasone (Dex), a drug currently used to control brain tumor related edema. However, due to high doses and significant side effects, treatment is tapered and discontinued as soon as edema has resolved. Prior analyses of the dispersal inhibitory effects of Dex were performed on tissue culture plastic, or polystyrene filters seeded with normal human astrocytes, conditions which inherently differ from the parenchymal architecture of neuronal tissue. The aim of this study was to utilize an ex-vivo model to examine Dex-mediated inhibition of tumor cell migration from low-passage, human Glioblastoma neurospheres on multiple substrates including mouse retina, and slices of mouse, pig, and human brain. We also determined the lowest possible Dex dose that can inhibit dispersal. Analysis by Two-Factor ANOVA shows that for GBM-2 and GBM-3, Dex treatment significantly reduces dispersal on all tissue types. However, the magnitude of the effect appears to be tissue-type specific. Moreover, there does not appear to be a difference in Dex-mediated inhibition of dispersal between mouse retina, mouse brain and human brain. To estimate the lowest possible dose at which Dex can inhibit dispersal, LogEC50 values were compared by Extra Sum-of-Squares F-test. We show that it is possible to achieve 50% reduction in dispersal with Dex doses ranging from 3.8 x10-8M to 8.0x10-9M for GBM-2, and 4.3x10-8M to 1.8x10-9M for GBM-3, on mouse retina and brain slices, respectively. These doses are 3-30-fold lower than those used to control edema. This study extends our previous in vitro data and identifies the mouse retina as a potential substrate for in vivo studies of GBM dispersal. [ABSTRACT FROM AUTHOR]

Background: Dispersal of glioblastoma (GBM) cells leads to recurrence and poor prognosis. Accordingly, molecular pathways involved in dispersal are potential therapeutic targets. The mitogen activated protein kinase/extracellular signal regulated kinase (MAPK/ERK) pathway is commonly dysregulated in GBM, and targeting this pathway with MEK inhibitors has proven effective in controlling tumor growth. Since this pathway also regulates ECM remodeling and actin organization - processes crucial to cell adhesion, substrate attachment, and cell motility - the aim of this study was to determine whether inhibiting this pathway could also impede dispersal.Methods: A variety of methods were used to quantify the effects of the MEK inhibitor, PD0325901, on potential regulators of dispersal. Cohesion, stiffness and viscosity were quantified using a method based on ellipsoid relaxation after removal of a deforming external force. Attachment strength, cell motility, spheroid dispersal velocity, and 3D growth rate were quantified using previously described methods.Results: We show that PD0325901 significantly increases aggregate cohesion, stiffness, and viscosity but only when tumor cells have access to high concentrations of fibronectin. Treatment also results in reorganization of actin from cortical into stress fibers, in both 2D and 3D culture. Moreover, drug treatment localized pFAK at sites of cell-substratum adhesion. Collectively, these changes resulted in increased strength of substrate attachment and decreased motility, a decrease in aggregate dispersal velocity, and in a marked decrease in growth rate of both 2D and 3D cultures.Conclusions: Inhibition of the MAPK/ERK pathway by PD0325901 may be an effective therapy for reducing dispersal and growth of GBM cells. [ABSTRACT FROM AUTHOR]

Background. Infectious endocarditis (IE) typically occurs in the setting of intravenous drug use, prosthetic heart valves, or rheumatic heart disease. However, there are a few reports of IE occurring in the setting of immunosuppression secondary to cancer and/or chemotherapy. Here, we present a case of a cancer patient who developed anterior spinal artery (ASA) syndrome secondary to a septic embolus from IE. Case Presentation. A 78-year-old male with a history of gastroesophageal cancer treated with chemotherapy and radiation presented to the hospital after a fall at home. He reported experiencing dyspnea and orthopnea for two weeks prior to presentation. In the ED, his vital signs were stable, and his examination was significant for a flaccid paralysis of the right lower extremity. Diagnosis of septic emboli secondary to IE was made after the echocardiogram showed the presence of vegetations on the aortic valve, blood cultures were positive for Streptococcus mitis, and thoracic spine MRI was indicative of an infarction at T10. Discussion. This case highlights the presence of IE in the setting of cancer and chemotherapy. Although cancer is a rare cause of IE, clinicians must maintain a high index of suspicion in order to minimize the sequelae of IE. [ABSTRACT FROM AUTHOR]

Purpose. To describe a case of peripheral ulcerative keratitis in the setting of autoimmune hepatitis and possible overlap syndrome with primary sclerosing cholangitis. Case Report. A 48-year-old African American female with autoimmune hepatitis with possible overlap syndrome with primary sclerosing cholangitis presented with tearing, irritation, and injection of the left eye that was determined to be peripheral ulcerative keratitis. The patient was treated with topical and systemic steroids, immunosuppressant drugs (azathioprine and mycophenolate mofetil), a biologic (rituximab), and surgery (conjunctival resection), and the peripheral ulcerative keratitis epithelialized but ultimately led to corneal perforation. Conclusion. In this unique case, a patient with peripheral ulcerative keratitis who underwent treatment ultimately had a corneal perforation. This case may suggest a possible relationship between autoimmune hepatitis and peripheral ulcerative keratitis. [ABSTRACT FROM AUTHOR]

Background: Cholesterol granulomas (GC) of the petrous apex are benign cystic lesions that occur due to a foreign body reaction to blood by-products and cholesterol crystals. They cause erosion and expansion of the petrous apex and lead to cranial nerve deficits. Case Description: We present an operative video of a 28-year-old male whose work-up for horizontal diplopia revealed a right petrous apex GC. He originally underwent a subtemporal and later a transmastoid approach at outside institutions before he presented to us with diplopia due to recurrence. An endoscopic transsphenoidal transclival approach was done for drainage and resection of the GC. The patient did well and his diplopia resolved. A follow-up MRI showed no recurrence of the granuloma. Conclusion: This case illustrates an endoscopic transsphenoidal transclival approach for a recurrent petrous apex CG, which may lead to symptom resolution if done in a timely fashion. [ABSTRACT FROM AUTHOR]

Anterior cervical spine surgeries have low morbidity, sufficient surgical corridor, and quick recovery times. Although largely considered a safe and effective procedure to address cervical myelopathy, radiculopathy, and deformity, dysphagia is a frequent yet poorly understood adverse event. One treatment is cricopharyngeal myotomy (CPM), which aids in swallowing for patients with refractory issues after anterior cervical decompression and fusion (ACDF). Here we describe our experience with 6 patients requiring revision ACDF with preoperative dysphagia who were treated with concurrent revision and CPM. Our series demonstrated that CPM is an effective and safe procedure used in combination with an ACDF. In our series, we had 6 patients with dysphagia preoperatively who were all able to undergo ACDF without worsening of their dysphagia despite having risk factors predisposing them to this complication. In our series, 83% of patients either improved or experienced resolution of their symptoms with only 1 patient failing to improve. Given its efficacy and safety, patients planned for ACDF with preoperative dysphagia should be evaluated by ENT for potential CPM. [ABSTRACT FROM AUTHOR]

Background: Diffuse midline gliomas (DMG) are aggressive pediatric brain tumors that are diagnosed and monitored through MRI. We developed an automatic pipeline to segment subregions of DMG and select radiomic features that predict patient overall survival (OS)., Methods: We acquired diagnostic and post-radiation therapy (RT) multisequence MRI (T1, T1ce, T2, T2 FLAIR) and manual segmentations from two centers of 53 (internal cohort) and 16 (external cohort) DMG patients. We pretrained a deep learning model on a public adult brain tumor dataset, and finetuned it to automatically segment tumor core (TC) and whole tumor (WT) volumes. PyRadiomics and sequential feature selection were used for feature extraction and selection based on the segmented volumes. Two machine learning models were trained on our internal cohort to predict patient 1-year survival from diagnosis. One model used only diagnostic tumor features and the other used both diagnostic and post-RT features., Results: For segmentation, Dice score (mean [median]±SD) was 0.91 (0.94)±0.12 and 0.74 (0.83)±0.32 for TC, and 0.88 (0.91)±0.07 and 0.86 (0.89)±0.06 for WT for internal and external cohorts, respectively. For OS prediction, accuracy was 77% and 81% at time of diagnosis, and 85% and 78% post-RT for internal and external cohorts, respectively. Homogeneous WT intensity in baseline T2 FLAIR and larger post-RT TC/WT volume ratio indicate shorter OS., Conclusions: Machine learning analysis of MRI radiomics has potential to accurately and non-invasively predict which pediatric patients with DMG will survive less than one year from the time of diagnosis to provide patient stratification and guide therapy., Competing Interests: CONFLICT OF INTEREST: None declared

Background: Subependymal giant cell astrocytoma (SEGA) is a benign intraventricular tumor classically arising near the Foramen of Monro. SEGAs almost always present as a component of tuberous sclerosis complex (TSC), an autosomal dominant disorder characterized by lesions in multiple organs., Observations: A 22-year-old female with no past medical history presented with new-onset right-eye pressure, floaters in the right visual field, and pulsatile tinnitus. Imaging revealed an avidly enhancing mass abutting the right Foramen of Monro, causing obstructive hydrocephalus. Following resection, histopathological analysis identified the lesion as a SEGA. However, on further workup, the patient was found to have no genetic or clinical findings of TSC, which exemplifies a rare case of SEGA in the absence of a TSC diagnosis., Lessons: It is essential for physicians to be aware of the possibility of SEGA in the absence of other characteristics of TSC, which has many implications for a patient's clinical course. The authors present the seventh case of SEGA without genetic or clinical features of TSC described in the literature.

Meningiomas are the most common primary intracranial tumor in adults and can be associated with significant morbidity and mortality. Radiologists, neurosurgeons, neuro-oncologists, and radiation oncologists rely on multiparametric MRI (mpMRI) for diagnosis, treatment planning, and longitudinal treatment monitoring; yet automated, objective, and quantitative tools for non-invasive assessment of meningiomas on mpMRI are lacking. The BraTS meningioma 2023 challenge will provide a community standard and benchmark for state-of-the-art automated intracranial meningioma segmentation models based on the largest expert annotated multilabel meningioma mpMRI dataset to date. Challenge competitors will develop automated segmentation models to predict three distinct meningioma sub-regions on MRI including enhancing tumor, non-enhancing tumor core, and surrounding nonenhancing T2/FLAIR hyperintensity. Models will be evaluated on separate validation and held-out test datasets using standardized metrics utilized across the BraTS 2023 series of challenges including the Dice similarity coefficient and Hausdorff distance. The models developed during the course of this challenge will aid in incorporation of automated meningioma MRI segmentation into clinical practice, which will ultimately improve care of patients with meningioma.

Background: Anaplastic meningioma are rare, cancerous tumors of the central nervous system that often require multimodal therapy for tumor control. Both laser interstitial thermal therapy (LITT) and brachytherapy with implanted cesium-131 metallic seeds have demonstrated efficacy in the treatment of recurrent and resistant anaplastic meningioma; however, their safety as a dual therapy has never been reported., Observations: In this report, the authors present a case of a 53-year-old female who received LITT in combination with brachytherapy after surgical and radiation treatment options had been exhausted. The authors discuss the unique safety concern of thermal injury with this treatment combination and demonstrate their method for the safe administration of these treatments together. Furthermore, the authors provide a review of the literature on LITT as an emerging therapy for anaplastic meningioma., Lessons: The use of LITT in combination with brachytherapy remains an option for salvage therapy in patients with recurrent meningioma that provides durable local control of tumor.

Iatrogenic chyle leak (CL) following lymphatic vessel damage is an uncommon but serious complication of neck dissections. In the setting of anterior cervical discectomy and fusion (ACDF), left-sided CL are an exceedingly rare complication, with an incidence of only 0.02 %. Only three cases of right-sided CL during an ACDF have been reported. The case presented is the first right-sided CL to be successfully identified intraoperatively and treated. Intraoperative and postoperative management are discussed. This case will hopefully bring clinical and surgical awareness to providers caring for patients undergoing an ACDF., Competing Interests: Competing Interests 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 © 2022 Elsevier B.V. All rights reserved.)

We report the case of a 62-year-old man who presented with a progressive myelopathy secondary to spinal cord compression from an odontoid process fracture and subaxial central canal stenosis. The patient underwent a C1-T2 posterior decompression and instrumented fusion (PCDF) and did well immediately postoperatively. However, on POD1, he developed a right hypoglossal nerve (HN) palsy attributed to direct mechanical compression or injury from the C1 lateral mass screw (LMS), which improved following a revision and screw replacement. While HN injury is a known complication of high anterior and anterolateral cervical spine approaches as well as transcondylar screw fixation, this case aims to expand on the limited reports available regarding hypoglossal nerve injury following placement of bicortical C1 LMS. Furthermore, the use of fluoroscopic guidance in addition to anatomic landmarks and triggered electromyography of the tongue are offered as potential solutions to prevent HN injury intraoperatively., (© 2022 Published by Elsevier Inc. on behalf of University of Washington.)

Introduction The American Association of Neurological Surgeons (AANS) and the Congress of Neurological Surgeons (CNS) 2014 lumbar fusion guidelines for stenosis with degenerative spondylolisthesis (DS) support surgical decompression and fusion as an effective treatment option for symptomatic stenosis associated with DS. The association between the number of levels decompressed in patients with single-level fusion and clinical outcomes has never been published. Methods A retrospective analysis of a single-center, prospectively collected database was performed on 77 patients to compare the effect of the number of decompression levels in patients that received single-level fusion surgery. A total of 77 patients met the criteria. Group one had one level decompressed, group two had two levels decompressed, and group three had three or four levels decompressed. All patients received lumbar fusion surgery at a single spinal level. Outcomes at six months included: Substantial Clinical Benefit (SCB) (ΔODI ≥ 10 points); Minimal Clinically Important Difference (MCID) (ΔODI ≥ 5); no MCID (ΔODI <5 points). Student's t-tests, one-way analysis of variance (ANOVA), and post hoc comparison using unpaired two-tailed student's t-test with Holm-Bonferroni correction were performed. p -values were ranked from smallest to largest, and alpha level adjustments were made.  Results A sub-analysis of each group's clinical outcomes showed that patients with two levels decompressed reached greater clinical outcomes. SCB was obtained by approximately 60% (group one: 12.5% vs. group three: 40%) of the patients. A total of 77.6% (38/49) achieved MCID (group one: 62.5% vs. group three: 55%). Single-level fused patients with two levels of decompression showed an improvement of 48% from baseline ODI, as opposed to group one: 17.85% and group three: 21.1%. Patients belonging to group two showed the lowest rate of no improvement. Baseline ODI scores were similar upon presentation ( p =0.46), and the difference was found among groups after six months of follow-up ( p =0.009). Post hoc comparison showed statistical significance in the comparison between group two and group three ( p =0.009, alpha value: 0.017). Conclusion The addition of more than two levels of decompression to single-level fused patients might be associated with poor clinical outcomes and spinal instability., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2022, Gonzalez et al.)

Objective: Posterior cervical decompression and fusion (PCDF) is a commonly performed procedure to address cervical myelopathy. A significant number of these patients require revision surgery for adjacent-segment disease (ASD) or pseudarthrosis. Currently, there is no consensus among spine surgeons on the inclusion of proximal thoracic spine instrumentation. This study investigates the benefits of thoracic extension in long-segment cervical fusions and the potential drawbacks. The authors compare outcomes in long-segment subaxial cervical fusion for degenerative cervical myelopathy with caudal vertebral levels of C6, C7, and T1., Methods: A retrospective analysis identified 369 patients who underwent PCDF. Patients were grouped by caudal fusion level. Reoperation rates for ASD and pseudarthrosis, infection, and blood loss were examined. Data were analyzed with chi-square, 1-way ANOVA, and logistic regression., Results: The total reoperation rate for symptomatic pseudarthrosis or ASD was 4.8%. Reoperation rates, although not significant, were lower in the C3-6 group (2.6%, vs 8.3% for C3-7 and 3.8% for C3-T1; p = 0.129). Similarly, rates of infection were lower in the shorter-segment fusion without achieving statistical significance (2.6% for C3-6, vs 5.6% for C3-7 and 5.5% for C3-T1; p = 0.573). The mean blood loss was documented as 104, 125, and 224 mL for groups 1, 2, and 3, respectively (p < 0.001)., Conclusions: Given the lack of statistical difference in reoperation rates for long-segment cervical fusions ending at C6, C7, or T1, shorter fusions in high-risk surgical candidates or elderly patients may be performed without higher rates of reoperation.

This is a case of a 54-year-old man presenting with complex regional pain syndrome (CRPS) type 1 of the right lower extremity, which was most debilitating in the plantar aspect of the right foot. The patient had prior treatment with thoracic spinal cord stimulation; however, the foot pain remained intractable. Given that his pain was predominantly in his foot and remained debilitating despite thoracic spinal cord stimulation, it was recommended that the patient undergo a trial of dorsal root ganglion (DRG) stimulation. The surgical technique for placement of dorsal root ganglion stimulators is demonstrated in this operative video. The video can be found here: https://youtu.be/&#95;1xMxFZa6tU., Competing Interests: Disclosures Dr. Sharan reports being an owner of Cerebral Therapeutics, Mudjala, and Tigerlabs; being a consultant for Neuspera and Boston Biomedical Association; receiving fellowship support from Medtronic and Abbott; and receiving grants from DARPA and Groff Foundation. Dr. Wu reports being a consultant for Medtronic, Boston Scientific, Abbott, Nevro, and Neuropace; and being on the advisory board of Micro Systems Engineering., (© 2020 The Authors.)

Background and Importance: Carotid-cavernous fistulas (CCF) are pathological connections between carotid artery branches and the cavernous sinus. They can lead to a variety of symptoms, such as chemosis and double vision, or more insidious events, such as vision loss and intracranial hemorrhage. Although these patients are often treated by endovascular means, we describe a case in which the patient's CCF was not able to be accessed by usual methods and required an open surgical approach., Clinical Presentation: The patient had progressive chemosis, double vision, and periorbital pain. Angiogram showed an indirect type D CCF with cortical venous drainage with a large sylvian vein that was directly draining the fistula. The patient did not have a dilated superior ophthalmic vein, and the petrosal sinuses could not be catheterized. Therefore, because of the patient's increased risk for intracranial hemorrhage, she was taken to the operating room for an image guided burr hole for direct catheterization of the sylvian vein. From this point, the fistulous point could be catheterized, and the CCF was embolized using onyx. Follow-up angiogram showed complete occlusion., Conclusion: This is the first report in literature of an indirect CCF being treated through a transsylvian approach with onyx. This combined open-surgical-and-endovascular approach was necessary to get full resolution of the lesion, and patient had rapid improvement of symptoms., (Copyright © 2020 by the Congress of Neurological Surgeons.)

Background: Cholesterol granulomas (GC) of the petrous apex are benign cystic lesions that occur due to a foreign body reaction to blood by-products and cholesterol crystals. They cause erosion and expansion of the petrous apex and lead to cranial nerve deficits., Case Description: We present an operative video of a 28-year-old male whose work-up for horizontal diplopia revealed a right petrous apex GC. He originally underwent a subtemporal and later a transmastoid approach at outside institutions before he presented to us with diplopia due to recurrence. An endoscopic transsphenoidal transclival approach was done for drainage and resection of the GC. The patient did well and his diplopia resolved. A follow-up MRI showed no recurrence of the granuloma., Conclusion: This case illustrates an endoscopic transsphenoidal transclival approach for a recurrent petrous apex CG, which may lead to symptom resolution if done in a timely fashion., Competing Interests: There are no conflicts of interest., (Copyright: © 2020 Surgical Neurology International.)