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The "weekend effect" is the negative effect on disease course and treatment resulting from being admitted to the hospital during a weekend. Whether the weekend effect is associated with worse outcomes for patients treated for aneurysmal subarachnoid hemorrhage (aSAH) is unknown. We assessed neurologic outcomes of patients with aSAH admitted during the weekend versus during the week.A retrospective database was reviewed to identify all patients with aSAH who received open or endovascular treatment from August 1, 2007, to July 31, 2019, at a quaternary center. The primary outcome was a poor neurologic outcome (modified Rankin Scale score2). Propensity adjustment included age, sex, treatment type, Hunt and Hess grade, and Charlson Comorbidity Index.A total of 1014 patients (women, 703 [69.3%]; men, 311 [30.7%]; mean age, 56 [standard deviation, 14]) met inclusion criteria; 726 (71.6%) had weekday admissions, and 288 (28.4%) had weekend admissions. There was no significant difference between patients with a weekday versus a weekend admission in mean (standard deviation) time to treatment (0.85 [1.29] vs. 0.93 [1.30] days, P = 0.10) or length of stay (19 [9] vs. 19 [9] days, P = 0.04). Total cost and rates of delayed cerebral ischemia and vasospasm were similar between the admission groups, both overall and within the open and endovascular treatment cohorts. After propensity adjustment, weekend admission was not a significant predictor of a modified Rankin Scale score greater than 2 (odds ratio [95% confidence interval]; 1.12 [0.85-1.49]; P = 0.4).No difference in neurologic outcomes was associated with weekend admission among this cohort of patients with aSAH.

The additional hospital costs associated with delayed cerebral ischemia (DCI) have not been well investigated in prior literature. In this study, the total hospital cost of DCI in aneurysmal subarachnoid hemmorhage (aSAH) patients treated at a single quaternary center was analyzed.All patients in the Post-Barrow Ruptured Aneurysm Trial treated for an aSAH between January 1, 2014, and July 31, 2019, were retrospectively analyzed. DCI was defined as cerebral infarction identified on computed tomography, magnetic resonance imaging, or autopsy after exclusion of procedure-related infarctions. The primary outcome was the difference in total cost (including hospital, discharge facility, and all follow-up) using a propensity-adjusted analysis. Propensity score covariate-adjusted linear regression analysis included age, sex, open versus endovascular treatment, Hunt and Hess score, and Charlson Comorbidity Index score.Of the 391 patients included, 144 (37%) had DCI. Patients with DCI had a significantly greater cost compared to patients without DCI (mean standard deviation $112,081 [$54,022] vs. $86,159 [$38,817]; P 0.001) and a significantly greater length of stay (21 days [11] vs. 18 days [8], P = 0.003, respectively). In propensity-adjusted linear regression analysis, both DCI (odds ratio, $13,871; 95% confidence interval, $7558-$20,185; P 0.001) and length of stay (odds ratio, $3815 per day; 95% confidence interval, $3480-$4149 per day; P 0.001) were found to significantly increase the cost.The significantly higher costs associated with DCI further support the evidence that adverse effects associated with DCI in aSAH pose a significant burden to the health care system.

Liver cirrhosis is associated with an increased risk of aneurysmal subarachnoid hemorrhage (aSAH). However, large studies analyzing the prognosis of cirrhotic patients after aSAH treatment are lacking. This study explores factors associated with inpatient mortality among aSAH patients with cirrhosis.All patients who underwent open or endovascular treatment for an aSAH at a large quaternary center between January 1, 2003, and July 31, 2019, were retrospectively reviewed. Patients were grouped into cirrhosis versus noncirrhosis groups. Univariate analysis determined variables associated with inpatient mortality. Variables with P0.20 were included in a propensity-adjusted multivariable logistic regression analysis to predict inpatient mortality.A total of 1419 patients were treated for aSAH; 17 (1.2%) had confirmed cirrhosis. Inpatient mortality was significantly higher among cirrhotic patients than noncirrhotic patients (35.3% vs. 6.8%; P0.001). In the univariate analysis for inpatient mortality, the variables cirrhosis, age65 years, Charlson Comorbidity Index4, aneurysm size ≥10 mm, Hunt and Hess grade3, Fisher grade 4, delayed cerebral ischemia (DCI), and posterior circulation aneurysm had P0.20 and were included in the multivariable analysis. The propensity-adjusted stepwise multivariable logistic regression analysis showed that cirrhosis (odds ratio [OR]: 12.7, 95% confidence interval [CI]: 3.3-48.7), Hunt and Hess grade3 (OR: 3.9, 95% CI: 2.3-6.4), Fisher grade 4 (OR: 3.7, 95% CI: 1.3-10.7), and DCI (OR: 2.4, 95% CI: 1.5-3.9) were associated with inpatient mortality (P ≤ 0.01).Cirrhosis was a predictor of inpatient mortality among aSAH patients and was a stronger predictor than DCI or a poor Hunt and Hess grade among patients in this study.

Intraoperative neuromonitoring (IONM) is useful during spinal cord operations, but whether IONM is necessary for posterior cervical surgeries for degenerative conditions is unknown. We evaluated the utility of somatosensory evoked potential (SSEP) and motor evoked potential (MEP) monitoring as a tool for predicting new postoperative neurologic deficits during posterior decompression and fusion for degenerative cervical spine conditions.We retrospectively reviewed posterior cervical operations performed at our institute over a 4-year period. Patients with postoperative neurologic deficits were identified, and a detailed analysis performed to ascertain whether SSEP or MEP monitoring accurately predicted the onset of new postoperative deficits.Overall, 498 patients were included in the analysis (median age 66 years; range: 22-93 years). SSEP monitoring was performed in all patients, and both SSEP and MEP monitoring were performed in 121 patients (24%). Twenty-one patients (4.2%) had new postoperative neurologic deficits. SSEP had significantly higher specificity (90%) but lower sensitivity (33%) than MEP (74% specificity [P = 0.008], 50% sensitivity [P = 0.01]) for detecting neurologic compromise intraoperatively. For SSEP, the positive predictive value (PPV) and negative predictive value (NPV) in detecting intraoperative changes that translated to new postoperative neurological deficits were 12% and 97%, respectively, whereas for MEP, the PPV and NPV were 6% (P = 0.009) and 98% (P = 0.20), respectively.IONM during posterior cervical operations for degenerative conditions of the spine is not reliable at predicting new postoperative neurologic deficits in patients treated for degenerative conditions, but may provide peace of mind to the surgeon intraoperatively when no abnormalities are detected.

Despite advances in endovascular techniques, microsurgery continues to play an important role in the treatment of cerebral aneurysms. This article reviews the history of surgical treatment of intracranial aneurysms and the evolving role of microsurgery in the endovascular era. Although endovascular tools and techniques have changed significantly since the placement of the first Guglielmi coils in 1990, with the development of endoluminal flow-diverting stents and now endosaccular flow-diverting devices, microsurgical treatment of aneurysms has also continued to evolve. Since the first treatment with Hunterian ligation by Horsley in the 1800s, surgical treatment of intracranial aneurysms has advanced significantly beginning with the introduction of the microscope and microsurgical techniques in the 1950s. More recent advances in microsurgical treatment of aneurysms include microsurgical adjuncts, such as indocyanine green angiography, adenosine, and the exoscope, as well as tailored craniotomies, retractorless surgery, and novel bypass constructs for complex aneurysms. Microsurgery continues to play an important role in the endovascular era.

Background Operating microscopes and adjunctive technologies are continually refined to advance microneurosurgical care. How frequently these advances are used is unknown. In the present study, we assessed the international adoption of microneurosurgical technologies and discussed their value. Methods A 27-question electronic survey was distributed to cerebrovascular neurosurgeon members of U.S., European, and North American neurosurgical societies and social media networks of cerebrovascular and skull base neurosurgeons. The survey encompassed the surgeons' training background, surgical preferences, and standard microneurosurgical practices. Results Of the respondents, 56% (53 of 95) were attendings, 74% (70 of 95) were in their first 10 years of practice, and 67% (63 of 94) practiced at an academic teaching hospital. Vascular, endovascular, and skull base fellowships had been completed by 38% (36 of 95), 27% (26 of 95), and 32% (30 of 95) of the respondents, respectively. Most respondents did not use an exoscope (78%; 73 of 94), a mouthpiece (61%; 58 of 95), or foot pedals (56%; 55 of 94). All 95 respondents used a microscope, and 71 (75%) used Zeiss microscopes. Overall, 57 neurosurgeons (60%) used indocyanine green for aneurysms (n = 54), arteriovenous malformations (n = 43), and dural arteriovenous fistulas (n = 42). Most (80%; 75 of 94) did not use fluorescence. The respondents with a vascular-focused practice more commonly used indocyanine green, Yellow 560 fluorescence, and intraoperative 2-dimensional digital subtraction angiography. The respondents with a skull base–focused practice more commonly used foot pedals and an endoscope-assist device. Conclusions The results from the present survey have characterized the current adoption of operative microscopes and adjunctive technologies in microneurosurgery. Despite numerous innovations to improve the symbiosis between neurosurgeon and microscope, their adoption has been underwhelming. Future advances are essential to improve surgical outcomes.

Background Owing to prolonged hospitalization and the complexity of care required for patients with aneurysmal subarachnoid hemorrhage (aSAH), these patients have a high risk of complications. The risk for wound infection after microsurgical treatment for aSAH was analyzed. Methods All patients who underwent microsurgical treatment for aSAH between August 1, 2007, and July 31, 2019, and were recorded in the Post–Barrow Ruptured Aneurysm Trial database were retrospectively reviewed. The patients were analyzed for risk factors for wound infection after treatment. Results Of 594 patients who underwent microsurgical treatment for aSAH, 23 (3.9%) had wound infections. There was no significant difference in age between patients with wound infection and patients without infection (mean, 52.6 ± 12.2 years vs. 54.2 ± 4.0 years; P = 0.45). The presence of multiple comorbidities (including diabetes, tobacco use, and obesity), external ventricular drain, ventriculoperitoneal shunt, pneumonia, or urinary tract infection was not associated with an increased risk for wound infection. Furthermore, there was no significant difference in mean operative time between patients with wound infection and those without infection (280 ± 112 minutes vs. 260 ± 92 minutes; P = 0.38). Patients who required decompressive craniectomy (DC) were at increased risk of wound infection (odds ratio, 5.0; 95% confidence interval, 1.8–14.1; P = 0.002). Among the 23 total infections, 9 were diagnosed following cranioplasty after DC. Conclusions Microsurgical treatment for aSAH is associated with a relatively low risk of wound infection. However, patients undergoing DC may be at an increased risk for infection. Additional attention and comprehensive wound care are warranted for these patients.

BACKGROUND: The COVID-19 pandemic has significantly affected patient care across specialties. Ramifications for neurosurgery include substantial disruptions to surgical training and changes in nonurgent patient presentations to the emergency department. This study quantifies the effects of the COVID-19 pandemic on the number of emergency department patients who were referred to the neurosurgery department for further consultation and treatment and identifies and describes trends in the characteristics of these visits. METHODS: A retrospective review was performed of neurosurgical consultations at a single high-volume institution for 28 call-day periods before and after the official announcement of the pandemic. Primary outcomes included consultations per call-day, patient presentation category, and patient admission. RESULTS: The neurosurgical service was consulted regarding 629 patients (367 male patients) during the study period, with 471 (75%) and 158 (25%) patients presenting before and after the announcement of the COVID-19 pandemic, respectively. The mean number of neurosurgical consultations per call-day was significantly lower in the COVID-19 period (5.6 consultations) compared with the pre-COVID-19 period (16.8 consultations) (P < 0.001). After adjusting for patient demographics, the rate of presentation for general nonurgent concerns, such as back pain, headaches, and other general weaknesses, significantly decreased (odds ratio [95% confidence interval], 0.60 [0.47-0.77], P < 0.001). CONCLUSIONS: Neurosurgical consultations significantly decreased after the onset of the COVID-19 pandemic, with a substantially lower overall number of consultations necessitating operative interventions. Furthermore, the relative number of patients with nonemergent neurological conditions significantly decreased during the pandemic.

Aneurysmal subarachnoid hemorrhage (aSAH) is debilitating in elderly patients, but literature regarding this population is scarce, and clinical decision-making remains debated. Outcomes of elderly patients with aSAH stratified by age and clinical presentation were analyzed.Patients treated for aSAH were retrospectively analyzed. Patients were trichotomized into a young cohort (aged60 years [n = 268]) and 2 elderly cohorts (aged 60-65 years [n = 60] and ≥65 years [n = 77]). The elderly cohorts were analyzed by poor or good scores at presentation (Hunt and Hess [HH] score3 vs. ≤3, respectively) and poor functional outcome (modified Rankin Scale score2).Of 137 elderly patients, 121 had a 6-year follow-up. The65-year-olds (75% [52/69]) were more likely to have poor functional outcomes than the 60 to 65-year-olds (48% [25/52]) (odds ratio, 3.3; 95% confidence interval, 1.5-7.1; P = 0.002). Among those with an HH score ≤3 at presentation (n = 90), the65-year-old cohort had poorer outcomes than the 60 to 65-year-old cohort at 6-year follow-up (69% [35/51] vs. 36% [14/39], respectively; odds ratio, 3.9; 95% confidence interval, 1.6-9.4; P = 0.003). Among patients with an HH score3, no statistically significant differences in functional outcome were observed between the65-year-old (n = 18) and 60 to 65-year-old (n = 13) cohorts.Elderly patients with aSAH are at high risk for poor functional outcomes. However, among those presenting with good HH scores, younger-elderly patients (aged 60-65 years) tend to fare better than older-elderly patients (aged65 years). Elderly patients presenting with high-grade aSAH fare poorly regardless of age, which can inform clinical decision-making and prognostication.

Objective Epilepsy with periventricular nodular heterotopia (PVNH) lacks a conclusive surgical treatment strategy as eloquent cortex and important white matter tracts frequently overlay the deep periventricular nodules. Our goal was to evaluate the safety and efficacy of laser interstitial thermal therapy (LITT) for the treatment of epilepsy in PVNH. Methods Data on demographic characteristics, complications, visual outcomes, Engel classification at last follow-up, antiepileptic drug use, morbidity, and mortality among patients who underwent this procedure were retrospectively reviewed. Results Between May 2015 and January 2019, 5 patients underwent 6 LITT procedures for epilepsy with PVNH. One patient had residual nodules after their first procedure and underwent a second ablation. The average follow-up time was 12 months. Three patients were Engel class Ia, 1 patient was Engel class II, and 1 patient was Engel class III at last follow-up. Two patients were able to reduce their antiepileptic drugs postoperatively. Three patients had no changes in vision, 1 patient experienced a quadrantanopsia, and 1 patient had subjective blurry vision after their procedures. No patients experienced motor deficits, dysphasia, infection, or mortality. Conclusions LITT appears to be a safe and promising option to provide seizure relief for patients with refractory epilepsy and PVNH that otherwise may not be surgical candidates. Some appropriately determined patients with refractory epilepsy may benefit from LITT before proceeding with an invasive intracranial evaluation. A larger sample size and long-term follow-up is necessary to further elucidate safety and efficacy.

Objective In ventriculoperitoneal shunt (VPS) placement, distal placement of the peritoneal catheter will typically be performed by a neurosurgeon. More recently, laparoscopic-assisted (LA) placement of the distal peritoneal catheter by general surgeons has become common. The present study examined whether LA placement of a VPS (LAVPS) is associated with a reduced operative time, lower hospital costs, and fewer distal revisions. Methods A retrospective review was performed of the data from all patients who had received a new VPS at our institution from 2013 to 2016. Age, sex, diagnosis, previous abdominal surgery, operative time, anesthesia grade, incidence of 30-day shunt failure, and total hospital charges were analyzed. Results A total of 680 patients had undergone first-time VPS placement, including 199 with LAVPS and 481 with non–LAVPS placement (non-LAVPS). The mean age of the LAVPS patients was significantly older than that of the non-LAVPS patients (64.1 vs. 59.3 years; P = 0.002). The mean operative time was shorter in the LAVPS group than in the non-LAVPS group (55 vs. 75 minutes; P Conclusions Compared with non-LAVPS, LAVPS was associated with significantly shorter operative times and fewer distal shunt revisions within 30 days. The findings from a subset analysis supported a decrease in total hospital charges. Additional studies are needed; however, these data suggest that LAVPS is a safer, less-expensive alternative to non-LAVPS.

Background Stereoelectroencephalography (SEEG) is a commonly used technique for mapping the epileptogenic zone before epilepsy surgery. Many SEEG depth electrode implantation techniques involve the use of extensive technological equipment and shaving of the patient's entire head before electrode implantation. Our goal was to evaluate an SEEG depth electrode implantation technique that used readily available cost-effective neurosurgical equipment, was minimally invasive in nature, and required negligible hair shaving. Methods Data on demographic characteristics, operative time, hemorrhagic complications, implantation complications, infection, morbidity, and mortality among patients who underwent this procedure were reviewed retrospectively. Results Between April 2016 and March 2018, 23 patients underwent implantation of 213 depth electrodes with use of this technique. Mean (SD) operative time was 123 (32) minutes (range, 66–181 minutes). A mean (SD) of 9.3 (1.4) electrodes were placed for each patient (range, 8–13 electrodes). Two of the 213 electrodes (0.9%) were associated with postimplantation asymptomatic hemorrhage. One of the 213 electrodes (0.5%) was placed extradurally or incorrectly. None of the 213 electrodes was associated with symptomatic complications. No patients experienced infectious complications at any point in the preoperative, perioperative, or postoperative stages. Conclusions This minimally invasive, cost-effective technique for SEEG depth electrode implantation is a safe, efficient method that uses readily available basic neurosurgical equipment. This technique may be useful in neurosurgery centers with more limited resources. This study suggests that leaving the patient's hair largely intact throughout the procedure does not pose an additional infection risk.

Background Optimal management of patients with extracranial blunt cerebrovascular injury (BCVI) remains controversial, with both anticoagulation and antiplatelet therapy being recommended. The purpose of this study was to evaluate the efficacy and safety of using acetylsalicylic acid (ASA) in the management of BCVI. Methods Patients with BCVI were identified from the registry of a Level 1 trauma center between 2010 and 2017. Digital imaging and electronic medical records were reviewed for patient information including demographic characteristics, injury type, therapy, outcomes, and follow-up. Results Over the study period, 13,578 patients were admitted following blunt trauma, with 94 (0.7%) having confirmed BCVI (mean age, 42 years; 72% male). Mean Injury Severity Score and Glasgow Coma Score were 27 and 10, respectively. BCVI was identified in 130 vessels with Biffl grade I (38%) and grade II injury (29%) being most common. Twelve (13%) patients experienced an ischemic event, but only 3 events occurred after diagnosis. ASA was primary treatment for 56 (60%) patients. Thirty patients (32%) received no treatment; 21 patients died within 24 hours of primary injury. Only 4 patients had ASA contraindications. Four patients (7%) had ASA-related complications; there were 2 cases of intracranial hemorrhage progression and 2 cases of gastrointestinal bleeding. Follow-up vascular imaging at a mean of 36 days demonstrated stable or improved levels of BCVI in 94% of patients. Conclusions An ASA-based management strategy for BCVI was efficacious and relatively safe in this study. This approach may be the preferred treatment for BCVI, but confirmation is needed.

Objective Postoperative peri-lead edema (PLE) is a poorly understood complication of deep brain stimulation (DBS), which has been described sporadically in patients presenting with profound and often delayed symptoms. We performed a prospective evaluation of patients undergoing DBS to determine the frequency of and identify risk factors for PLE. Methods Patients underwent DBS electrode placement by a single physician. Postoperative magnetic resonance imaging (MRI) was performed approximately 6 weeks after the operation in asymptomatic subjects and analyzed for presence of PLE. All symptomatic subjects underwent MRI at the time of presentation. Data regarding index disease, preoperative medical issues, operative technique, and intraoperative variables were collected and statistically analyzed. Results A total of 191 leads were placed in 102 subjects; 15 patients (14.7%) demonstrated PLE. Seven patients (6.9%) presented with symptoms related to PLE, most often altered mental status or neurologic deficit. Many of the MRI findings were profound, with PLE sometimes several centimeters in diameter. No statistically significant difference was found between PLE-positive and normal subjects when analyzing multiple variables, including presence of vascular disease, hypertension, anticoagulant/antiplatelet use, electrode target, index disease, unilateral versus bilateral lead placement, number of brain penetrations, and presence or absence of microelectrode recording. Conclusions Patients with postoperative PLE can present with severe symptoms or can be asymptomatic and go undiagnosed. Because of the delayed-onset potential, PLE may be more common than previously reported. No clear risk factors have been identified; therefore, further studies and increased clinical vigilance are paramount for improving comprehension and possible prevention of PLE.

Modern cerebrovascular bypass surgery uses either extracranial-intracranial (EC-IC) or intracranial-intracranial (IC-IC) approaches. Compared with EC-IC bypasses, IC-IC bypasses allow neurosurgeons to safely address tumors, aneurysms, and other lesions using shorter grafts that are well matched to the size of recipient vessels. Fewer than 100 articles have been published on IC-IC bypasses compared with more than 1000 on EC-IC bypasses. This study examined the increase of interest and innovation in IC-IC bypass.PubMed and Web of Science were searched using keywords specific to IC-IC bypass, yielding 717 articles supplemented with 36 reports from other databases and gray literature. The articles were reviewed, and 98 articles were selected for further evaluation. Final articles were categorized as innovations or retrospective studies. Publication metrics were passed through an analytic program to assess statistical measures of growth.The number of publications describing innovations (n = 52) and retrospective studies (n = 46) in IC-IC surgical techniques increased exponentially (RAs more work is undertaken on IC-IC bypasses, it is critical for knowledge to be shared through research, collaboration, publication, and early teaching within residency training programs. This field has increased exponentially in the past 2 decades and has yet to reach an inflection point, indicating possible additional interest and growth over time.

Cerebral cavernous malformations are abnormal clusters of thin-walled sinusoidal vascular channels without intervening brain parenchyma. The most common presenting symptom is seizure, which results from hemosiderin deposition in surrounding tissues. Early surgical resection of these malformations confers the greatest likelihood of long-term seizure freedom. This operative video demonstrates the resection of a posterior medio-basal temporal cavernous malformation through a contralateral supracerebellar-transtentorial (cSCTT) approach. The patient, a 65-year-old woman, presented with a complex partial seizure with secondary generalization. On preoperative evaluation, she was neurologically intact. The risks and benefits of treatment alternatives, including observation, were explained to her. She consented to proceed with surgery to remove the cavernous malformation.

The use of 5 or more medications is defined as polypharmacy (PPM). The clinical impact of PPM on the isolated severe traumatic brain injury (TBI) patient has not been defined.A retrospective cohort study was performed at our academic level 1 trauma center examining patients with isolated TBI. Pre-injury medications were reviewed, and inhospital mortality was the primary measured outcome.There were 698 patients with an isolated TBI over the 5-year study period; 177 (25.4%) patients reported pre-injury PPM. There were 18 (10.2%) deaths in the PPM cohort and 24 (4.6%) deaths in the non-PPM cohort (P.0001). Stepwise logistic regression analysis revealed a 2.3 times greater risk of mortality in the PPM patients (P = .019).Pre-injury PPM increases mortality in patients with isolated severe TBI. This knowledge may provide opportunities for intervention in this population.