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Background Carotid artery stenosis, both symptomatic and asymptomatic, has been well studied with several multicenter randomized trials. The superiority of carotid endarterectomy (CEA) to medical therapy alone in both symptomatic and asymptomatic carotid artery stenosis has been well established in previous trials in the 1990s. The consequent era of endovascular carotid artery stenting (CAS) has offered another option for treating carotid artery stenosis. A series of randomized trials have now been conducted to compare CEA and CAS in the treatment of carotid artery disease. The large number of similar trials has created some confusion due to inconsistent results. Here, the authors review the trials that compare CEA and CAS in the management of carotid artery stenosis. Methods The PubMed database was searched systematically for randomized controlled trials published in English that compared CEA and CAS. Only human studies on adult patients were assessed. The references of identified articles were reviewed for additional manuscripts to be included if inclusion criteria were met. The following terms were used during search: carotid stenosis, endarterectomy, stenting. Retrospective or single-center studies were excluded from the review. Results Thirteen reports of seven large-scale prospective multicenter studies, comparing both interventions for symptomatic or asymptomatic extracranial carotid artery stenosis, were identified. Conclusions While the superiority of intervention to medical management for symptomatic patients has been well established in the literatures, careful selection of asymptomatic patients for intervention should be undertaken and only be pursued after institution of appropriate medical therapy until further reports on trials comparing medical therapy to intervention in this patient group are available.

Vertebral compression fractures (VCFs) are a major cause of pain and disability. Here, we reviewed six randomized control trials (RCTs) focusing on the efficacy vs. placebo effect of vertebroplasty (VP) for symptomatic VCF. Four RCTs involved a nonsurgically treated control group. Two RCTs compared the use of VP vs. a sham surgery control group. Notably, RCTs comparing nonsurgically treated patients as a control group vs. those undergoing VP uniformly reported that VP contributed to improved pain relief. In contrast, RCTs comparing sham surgery vs. VP uniformly reported no significant differences between the two groups.

The efficacy of glucocorticoid for treatment of acute spinal cord injuries remains a controversial topic. Differing medical societies have issued conflicting recommendations in this regard. Here we review the available randomized, controlled trial (RCT) data on this subject and offer a synthesis of these data sets.

BACKGROUND: Surgical resection and stereotactic radiosurgery (SRS) are well-established treatment methods for patients with brain metastases, yet their respective roles in the management of brain metastases remain incompletely defined. METHODS: To report on the role of SRS in the treatment of patients with brain metastases from malignant melanoma, a retrospective analysis of 381 intracranial melanoma metastases in 103 consecutive patients who underwent SRS between 2005 and 2011 at Beth Israel Deaconess Medical Center was conducted. The Cyberknife(®) SRS system was used to treat all patients. Clinical, technical, and radiographic data were recorded at presentation and on follow-up. RESULTS: The patient cohort consisted of 40 female (39%) and 63 male (61%) patients with a median age of 57 years. The median overall survival from the time of radiosurgery for the entire patient cohort was 7.6 months. The local control rate at 1-year was 72% for the patients who received surgery followed by SRS and 55% for the entire patient population. Surgery followed by SRS was associated with significantly improved overall survival compared with SRS alone or whole-brain radiation therapy followed by salvage SRS (P < 0.0057). CONCLUSIONS: Both surgery plus SRS and SRS provide comparable local control. Despite the difference in lesion size in the subgroups who received surgery plus SRS and radiosurgery alone, similar outcomes were achieved in both groups, suggesting that surgical treatment of larger lesions can yield results that are not significantly different from small lesions treated by SRS alone.

More and more, the clinical practice of neurosurgery is molded by the results of randomized controlled trials (RCTs).[1] This trend is largely driven by the intense desire of neurosurgeons to understand the impacts of our clinical practices and the application of sophisticated statistical designs toward this end. The growing emphasis on high quality data as the basis of clinical decision making over clinical anecdotes or retrospective series is also demanded by our patient advocacy groups, government, and reimbursement agencies.[2] Accordingly, the number of RCTs that examined the efficacy of various neurosurgical practices has increased dramatically over the past decade.[3] Thoughtful interpretation of the published RCTs result is now an integral part of the neurosurgical practice and an essential responsibility of any modern neurosurgeon. Only through awareness and careful scrutiny of the available and emerging RCTs data can we contribute meaningfully to the evolution of neurosurgical practices and participate in the ongoing conversation of healthcare reform.[4,5] The purpose of the series of articles published under the title “resolving controversies in neurosurgery through randomized controlled trials” is to provide a foundation for discourse directed toward these ends. These articles are intended to provide concise summaries of the available RCTs data pertaining to fundamental questions in the clinical practice of neurosurgery. Each article will select a pertinent topic and begin with a concise description of the issue in question, followed by succinct summaries of the available RCTs data. We will invite commentary from experts in the pertinent fields. Finally, we will solicit input from our readers and publish selective responses from our readership in subsequent issues. We hope that this collection of articles will be of value to the field of Neurosurgery. For the residents, these articles may serve as a foundation for future learning and lend an appreciation of the spectrum of views in our field. The articles may also be of value to early stage neurosurgeons preparing for the oral board examination, by providing a collection of concise synopses of the landmark RCTs studies pertinent to neurosurgical practice. Finally, the articles should be of value to active clinical practitioners by providing summaries of the current RCT literature and a forum for their discussion. We would also like to use these articles as a forum for surveying the views of the SNI readers. As such, each article will be accompanied by a single questionnaire to assess whether the RCTs data strongly, weakly, or fail to support changes in surgical practice. The first hundred responses will be recorded, and the results of these surveys will be reported in future issues. Along with this questionnaire, the reader will have an opportunity to voice his/her thoughts on the subject matter. Select inputs may also be published. The questionnaire and solicitation for opinion can be found at: http://neurosurgery.ucsd.edu/survey/ The inaugural article for this series addresses the clinical value of extended resection in glioblastoma patients. We hope that the SNI readership enjoy this article and look forward to reader comments on the subject matter.

Background: Stereotactic brain biopsies are widely used for establishing the diagnosis of intracranial lesions. Here we examine whether stereotactic biopsy of smaller brain lesions, defined for this study as being less than 1 cubic centimeter (1 cc) in volume, are associated with lowered diagnostic yield. Methods: We conducted a retrospective analysis of 267 consecutive patients who underwent stereotactic brain biopsy between 2007 and 2011. Lesion volumes were calculated and were stratified by 1 cc. Results: A total of 13 of 246 (5.2%) biopsies for lesions >1 cc resulted in nondiagnostic tissue or an incorrect diagnosis. In contrast, 5 of 21 (23.8%) biopsies for 1 cc biopsies (0% and 1%, respectively). Conclusion: This study demonstrates that stereotactic cerebral biopsy of lesions less than a cubic centimeter in volume results in a lower diagnostic yield versus larger lesions (76.2% versus 94.8%). While auxiliary measures may be taken to improve diagnostic yield, these patients may be best managed in a specialized center with experienced stereotactic neurosurgeons and neuropathologists.

Background: Endoscopic third ventriculostomy (ETV) is increasingly used in the treatment of obstructive hydrocephalus. The literature supporting its use in the setting of metastatic disease, however, remains limited. Methods: Between 2005 and 2010, 16 patients underwent ETV for treatment of obstructive hydrocephalus secondary to cerebral metastasis. Efficacy of symptomatic palliation and associated complications were reviewed. The results were compared to reported data for ventriculoperitoneal shunt placement in adult brain tumor patients. Patient selection criteria for ETV are reviewed. Results: Eleven of the 16 patients experienced symptomatic improvement after ETV (69%). Patients who presented with headache associated with nausea, vomiting, or lethargy were more likely to respond to treatment relative to patients presenting with headache alone. Of the 16 ETV patients, one suffered a wound infection and another underwent external ventricular drainage for assessment of intracranial pressure, yielding an overall complication rate of 12.5%. Conclusions: In select patients with obstructive hydrocephalus related to cerebral metastasis, ETV constitutes a minimally invasive palliative option. The efficacy of ETV in this population is comparable to those reported for obstructive hydrocephalus secondary to primary cerebral neoplasm or other non-neoplastic causes. Patients receiving chemotherapy close to the time of ETV may be at increased risk for infection.

Background: Leukoencephalopathy, Calcification, and Cyst (LCC) is a syndrome describing the rare concurrence of these three unusual radiographic findings. Here, we describe the neurosurgical management in a patient afflicted with LCC and review the existing literature on surgical indications and outcomes. Case Description: A 24-year-old man presented with symptoms of progressive headache, gait imbalance and horizontal diplopia. Magnetic resonance imaging (MRI) showed radiographic findings typically associated with LCC, including a large pontine cyst with significant mass effect. The patient's symptoms resolved after open surgical cyst drainage. However, he suffered cyst re-accumulation 3 months after the initial procedure and ultimately underwent placement of a ventriculo-cysto-peritoneal shunt. At the 3-year follow-up, the patient remained symptom free with continued cyst decompression. Conclusion: Our case report suggests that ventriculo-cysto-peritoneal shunting appeared an effective strategy in LCC patients in whom the cyst fenestration failed. We present this case report in the context of the first systematic review of literature on neurosurgical management strategies for patients afflicted with LCC.

BACKGROUND: Penetrating brain injuries caused by explosions are survived in extremely rare cases only. However, potential casualties of such cases may be encountered by regular physicians even outside a war zone, e.g., due to an assault or terror blast. There is very limited literature to this end; therefore, we report the successful neurosurgical management of a penetrating head injury due to a pipe bomb explosion. CASE DESCRIPTION: A 19-year-old man was brought to the ER with a swollen, bleeding right orbit, and a severely injured left hand after having sustained an unwitnessed explosion from a self-made pipe bomb. He presented with a GCS (Glasgow Coma Scale) of 15 at time of admission, work-up revealed an intracranial retained metal fragment measuring 5 × 1 × 0.2 cm lodged retro-orbitally and in the skull base. The patient underwent emergent right temporal craniotomy and temporal lobectomy and simultaneous right enucleation before the petrous bone and sphenoid wing lodged metal fragment was successfully removed. CONCLUSION: This case underscores the importance of having a high suspicion for the presence of an intracranial injury and a retained foreign body in the setting of a penetrating head injury. Aggressive and timely workup as well as expeditious surgical management are crucial in these settings and can generate exceptionally good outcomes despite a major trauma. Language: en