Search

Purpose Flow diverting stents have revolutionized the treatment of intracranial aneurysms through endoluminal reconstruction of the parent vessel. Despite this, certain aneurysms require retreatment. The purpose of this study was to identify clinical and radiologic determinants of aneurysm retreatment following flow diversion. Methods A multicenter flow diversion database was evaluated to identify patients presenting with an unruptured, previously untreated aneurysm with a minimum of 12 months’ clinical and angiographic follow-up. Univariate and multivariate logistic regression modeling was performed to identify determinants of retreatment. Results We identified 189 aneurysms treated in 189 patients with a single flow-diverting stent. Mean age was 54 years, and 89% were female. Complete occlusion was achieved in 70.3% and 83.6% of patients at six and 12 months, respectively. Aneurysm retreatment with additional flow-diverting stents occurred in 5.8% of cases. Univariate analysis revealed that dome diameter [Formula: see text]10 mm ( p = 0.012), pre-clinoid internal carotid artery location ( p = 0.012), distal > proximal parent vessel diameter ( p = 0.042), and later dual antiplatelet therapy (DAPT) discontinuation ( p Conclusions Prolonged DAPT is the most important determinant of aneurysm retreatment following single-device flow diversion. Abbreviating DAPT duration to only six months should be a consideration in this population, especially for patients with a large aneurysm dome diameter.

Background Open surgery has traditionally been preferred for the management of bifurcation middle cerebral artery (MCA) aneurysms. Flow diverting stents present a novel endovascular strategy for aneurysm treatment. Objective To add to the limited literature describing the outcomes and complications in the use of flow diverters for the treatment of these complex aneurysms. Methods This is a multicenter retrospective review of MCA bifurcation aneurysms undergoing flow diversion. We assessed post-treatment radiological outcomes and both thromboembolic and hemorrhagic complications. Results We reviewed the outcomes of 54 aneurysms treated with flow diversion. Four (7.4%) of the aneurysms had a history of rupture (3 remote and 1 acute). Fourteen (25.9%) of the aneurysms already underwent either open surgery or coiling prior to flow diversion. A total of 36 out of the 45 aneurysms (80%) with available follow-up data had adequate aneurysm occlusion with a median follow-up time of 12 mo. There were no hemorrhagic complications but 16.7% (9/54) had thromboembolic complications. Conclusion Flow diverting stents may be a viable option for the endovascular treatment of complex bifurcation MCA aneurysms. However, compared to published series on the open surgical treatment of this subset of aneurysms, flow diversion has inferior outcomes and are associated with a higher rate of complications.

BACKGROUND AND PURPOSE Ischemic diffusion-weighted imaging-fluid-attenuated inversion recovery (DWI-FLAIR) mismatch may be useful in guiding acute stroke treatment decisions given its relationship to onset time and parenchymal viability; however, it relies on subjective grading. Radiomics is an emerging image quantification methodology that may objectively represent continuous image characteristics. We propose a novel radiomics approach to characterize DWI-FLAIR mismatch. METHODS Ischemic lesions were visually graded for FLAIR positivity (absent, subtle, obvious) among consecutive large vessel occlusion stroke patients who underwent hyperacute MRI. Radiomic features were extracted from within the lesions on DWI and FLAIR. The DWI-FLAIR mismatch radiomics signature was built with features systematically selected by a cross-validated ElasticNet linear regression model of mismatch. RESULTS We identified 103 patients with mean age 68 ± 16 years; 63% were female. FLAIR hyperintensity was absent in 25%, subtle in 55%, and obvious in 20%. Inter-rater agreement for visual grading was moderate (Κ = .58). The radiomics signature of DWI-FLAIR mismatch included native FLAIR histogram kurtosis and local binary pattern-filtered FLAIR gray-level cluster shade; both correlated with visual grading (ρ = -.42, p

BackgroundRandomized trials have not demonstrated benefit from intravenous thrombolysis among patients undergoing endovascular thrombectomy (EVT). However, these trials included primarily patients presenting directly to an EVT capable hub center. We sought to study outcomes for EVT candidates who presented to spoke hospitals and were subsequently transferred for EVT consideration, comparing those administered alteplase at spokes (i.e., ‘drip-and-ship’ model) versus those not.MethodsConsecutive EVT candidates presenting to 25 spokes from 2018 to 2020 with pre-transfer CT angiography defined emergent large vessel occlusion and Alberta Stroke Program CT score ≥6 were identified from a prospectively maintained Telestroke database. Outcomes of interest included adequate reperfusion (Thrombolysis in Cerebral Infarction (TICI) 2b–3), intracerebral hemorrhage (ICH), discharge functional independence (modified Rankin Scale (mRS) ≤2), and 90 day functional independence.ResultsAmong 258 patients, median age was 70 years (IQR 60–81), median National Institutes of Health Stroke Scale (NIHSS) score was 13 (6-19), and 50% were women. Ninety-eight (38%) were treated with alteplase at spokes and 113 (44%) underwent EVT at the hub. Spoke alteplase use independently increased the odds of discharge mRS ≤2 (adjusted OR 2.43, 95% CI 1.08 to 5.46, p=0.03) and 90 day mRS ≤2 (adjusted OR 3.45, 95% CI 1.65 to 7.22, p=0.001), even when controlling for last known well, NIHSS, and EVT; it was not associated with an increased risk of ICH (OR 1.04, 95% CI 0.39 to 2.78, p=0.94), and there was a trend toward association with greater TICI 2b–3 (OR 3.59, 95% CI 0.94 to 13.70, p=0.06).ConclusionsIntravenous alteplase at spoke hospitals may improve discharge and 90 day mRS and should not be withheld from EVT eligible patients who first present at alteplase capable spoke hospitals that do not perform EVT. Additional studies are warranted to confirm and further explore these benefits.

Sex-specific differences in ischemic stroke outcomes are prevalent. We sought to investigate sex differences in the determinants of reperfusion and functional outcomes after endovascular thrombectomy (EVT) for emergent large vessel occlusion ischemic stroke (ELVO). Patients presenting to a single referral center with an anterior circulation ELVO that underwent EVT from 2011 to 2019 were included in this retrospective analysis. Sex differences in history, presentation, adequate reperfusion (TICI 2b-3), and 90-day good outcome [delta modified Rankin Scale (mRS) ≤ 2 from pre-stroke] were examined. Multivariable logistic regression analyses were performed to assess sex-specific associations with outcomes. Three hundred and eighty-one consecutive ELVO patients were identified. Women (N = 193) were older (75 vs 64 years, p

The Woven EndoBridge (WEB) can be used to treat wide-necked aneurysms without antiplatelet medications, suggesting it may have advantages in the setting of aneurysmal subarachnoid hemorrhage (aSAH). The goal was assessment of safety and efficacy of WEB in aSAH given the delayed nature of aneurysmal thrombosis. An international retrospective analysis of patients with aSAH treated with WEB was conducted at 7 tertiary centers from 2016 to 2020. Outcomes included rates of rebleeding, retreatment, complications, and complete occlusion. Furthermore, a systematic review and meta-analysis was conducted from 2011 to 2020 assessing the same outcomes. All pooled event rates were calculated using a random effect model. Consecutive patients with aSAH harbored 25 aneurysms that were treated with 29 WEB devices. The mean age was 53 years, and 65% were female. Zero experienced rebleeding, 2 were retreated, 2 experienced complications, 16 were completely occluded at 3 months, and 21 were completed occluded at 9–12 months. Meta-analysis of 309 WEB treatments for aSAH from 7 case series revealed 2.5% (95% CI 1–5%) had rebleeding, 9% (95% CI 4–17%) were retreated, 17% (95% CI 10–30%) had complications, and 61% (95% CI 51–71%) were completely occluded at 3–6 months. WEB embolization in the setting of aSAH provides similar protection against rebleeding with comparable retreatment rates to traditional approaches. However, there is a higher rate of incomplete radiographic occlusion and operative complications compared to WEB embolization of unruptured aneurysms. Long-term prospective studies are needed to fully delineate the role of WEB embolization in aSAH.

Background Transradial access for neurointerventional procedures was adopted and modified from cardiovascular intervention and is increasingly established as a safe and effective alternative to transfemoral catheterization. As social media influences public opinion on medical treatment, this study analyzes Twitter conversations to elucidate social media’s depiction of transradial access as a neurointerventional tool. Materials and methods Twitter hashtags #RadialFirst and #RadialForNeuro were evaluated using a mixed-method analysis of quantitative social media metrics and qualitative thematic analysis. Results Between January 2015 and April 2020, 104,146 tweets from 141 countries employed the hashtag #RadialFirst (2015 (1); 2016 (0); 2017 (22,804); 2018 (33,074); 2019 (38,352); 2020 (9,915 January-April)). These generated 226,909,374 impressions and were retweeted 80,120 times by 13,707 users. Media was present in 62.5% of tweets (e.g. wrist image, angiographic runs) but only 14.5% had a reference article. Physicians authored 70.8% of tweets; interventional cardiologists accounted for 83% of top 100 influencers. #RadialForNeuro is more nascent (6 posts in 2019; 323 posts January–April 2020), with 392,662 impressions, and 254 retweets by 177 users; physicians authored 35.6%. Compared to #RadialFirst, #RadialforNeuro tweets were more likely to include media (76%), less likely to include citations (9.7%), and more likely to discuss complications and troubleshooting techniques. Conclusion Twitter activity regarding transradial access permits information dissemination and discussion on approach benefits and challenges. However, many posts arise from non-physician sources and lack links to peer-reviewed publication. The public should be mindful that tweets may reflect opinions, rather than experience or scientific evidence.

Background Online education has provided an important tool to continue medical education during the COVID-19 pandemic. Our study aimed to evaluate trainee and attending perceptions of online webinars as an educational tool in neurosurgery. Methods We conducted a cross-sectional survey study. A web-based 19-question survey was distributed to the people who attended the webinar series that was carried out by the Saudi Association of Neurological Surgery from March 29, 2020 to May 31, 2020. Candidates were identified through their registration e-mails. The survey was distributed June 5–8, 2020. Results A total of 156 responses were received (survey response rate: 60%). The overall satisfaction rate among residents and attendings (board-certified neurosurgeons) was similar (>80%). However, only 56.4% of attendings reported they were comfortable with online webinars compared with 81.2% of residents (P value Conclusions Online educational webinars provide an educational value that can be considered as an adjunct to traditional (in-person) education methods. Among trainees, the satisfaction of neurosurgery webinars was encouraging to consider as an education method. More objective research and progress are required to adopt and refine existing online didactic and neurosurgical teaching tools while creating more engaging future distant learning models.

الملخص: أهداف البحث: تحقيق ابتسامة طبيعية أثناء استعادة الأسنان الأمامية يمثل تحديا. ويعد اختيار البعد المناسب للأسنان أمرا مهما للحصول على ابتسامة جميلة. الهدف من هذه الدراسة هو قياس وتحليل أبعاد الأسنان الأمامية العلوية، ونسب عرضها النسبي في المجتمع السعودي. طرق البحث: ضم البحث ١٨٠ (ذكور = ١١٢؛ إناث = ٦٨) شخصا لديهم جميع الأسنان الأمامية للفك العلوي (المدى العمري = ٢٠-٣٠) سنة. تم عمل طبعات الفك العلوي باستخدام مادة (فينيل-بولي سيلوكسان) وصبها. وتم استخدام الفرجار الرقمي لحساب طول وعرض الأسنان الأمامية العلوية من قوالب الأسنان بالمليمترات (ملم) وتم تصوير القوالب رقميا لحساب نسب العرض النسبية. النتائج: متوسط عرض القاطعة المركزية كان ٨.٧٤ ملم (ذكر = ٨.٨٩ ملم، أنثى = ٨.٦٠ ملم)، والقواطع الجانبية ٦.٦٤ملم (ذكر = ٦.٧٩ ملم؛ أنثى = ٦.٤٩ ملم) وكان الناب ٧.٨٢ملم (ذكر = ٨.٠١ ملم؛ أنثى = ٧.٦٣ ملم). ومتوسط الطول المسجل لهذه الأسنان كان ٩.٨٤ ملم (ذكر = ١٠.٠٤ملم، أنثى = ٩.٦٤ملم)، ٨.٠٩ ملم (ذكر = ٨.٣٠ ملم، أنثى = ٧.٨٩ملم) و٩.٠٨ ملم (ذكر = ٩.٤٨ ملم، أنثى = ٨.٦٩ ملم)، على التوالي. وكانت القيم المتوسطة لنسبة العرض النسبي التي تم قياسها على صور قوالب الأسنان ٦٣.٦٩ للقواطع الجانبية / القاطعة المركزية و٣٥.٧٨ للقاطع الناب / الجانبي. ولم توجد فروق ذات دلالة إحصائية بين القيم المتوسطة لنسبة العرض النسبي للجانب الأيمن والأيسر وبين الذكور والإناث. الاستنتاجات: لوحظ عدم وجود تماثل بين الأسنان الأمامية اليسرى واليمنى. وكانت نسبة العرض إلى الطول للقواطع المركزية والجانبية مماثلة لكلا الجنسين مع اختلاف طفيف في الأنياب. وتتخذ الأسنان الأمامية للسكان السعوديين شكلا أقرب للمربع مع تشابه في الأبعاد مع السكان الأتراك. Abstract: Objectives: Achieving a natural smile while restoring anterior teeth is challenging. Selecting appropriate dimensions of teeth is important for aesthetics. This study aims to measure and analyse the dimensions of the maxillary anterior teeth and their relative width proportions in a Saudi subpopulation. Methods: One hundred and eighty patients (112 men and 68 women) with intact maxillary anterior teeth (age range = 20–30 years) participated in this research. Maxillary impressions (Vinyl Polysiloxane) were created and poured. A digital caliper was used to record the length and width of maxillary anterior teeth in millimetres (mm) from the dental casts, and the casts were digitally photographed to calculate relative width ratios. Results: The mean width for central incisor was 8.74 mm (men = 8.89 mm, women = 8.60 mm), lateral incisor 6.64 mm (men = 6.79 mm, women = 6.49 mm) and canine 7.82 mm (men = 8.01 mm women = 7.63 mm). The recorded mean lengths for these teeth were 9.84 mm (men = 10.04 mm, women = 9.64 mm), 8.09 mm (men = 8.30 mm, women = 7.89 mm) and 9.08 mm (men = 9.48 mm, women = 8.69 mm). The mean values of apparent width/width ratio measured on the cast photographs were 63.69 mm for the lateral incisor/central incisor and 78.35 mm for canine/lateral incisor. No statistically significant difference was found between the mean values of the apparent width/width ratio of the right and left sides and between men and women. Conclusions: This study showed a minor asymmetry between left and right side anterior teeth among the participants. The width to length ratio of the central and lateral incisors was similar for both genders, with minor differences in the canines. A squarish form of anterior teeth for the Saudi population with dimensional similarities to the Turkish population was found.

Objective: The aim of the study was to assess the failure loads and compressive stresses among bilayered press on Y-TZP (POZ) and press on metal (POM) crowns with different core-veneer thickness. Methods: Thirty metal and Y-TZP copings were fabricated using CAD-CAM technology with specified thickness. All copings were veneered with ceramic materials using hot pressing technique, with 2mm and 2.5mm thickness. The different coping veneer thickness of crowns resulted in six study groups, including, POM: Coping/ veneer thickness of 0.7/2mm (Gp1), 0.7/2.5mm (Gp 2) and 1mm/2mm (Gp 3)- POZ: 0.7/2mm (Gp A), 0.7/2.5mm (Gp B) and 1mm/2mm (Gp C). Crowns were cemented to a standard implant analog and failure loads (FL) and compressive stress (CS) was ascertained by controlled load application in a universal testing machine. Data was analysed using ANOVA and multiple comparisons test. Results: The maximum FL were observed in the POM specimens with a C/V ratio of 1/2 (Group 3-1880.67± 256.78 N), however the lowest FL were exhibited by POZ crowns with 1/2 C/V ratio (Group C-611.89± 72.79 N). Mean FL and CS were significantly higher in POM compared to POZ crowns in respective groups. Increasing the coping-veneer thickness increased FL and CS among POM crowns. Increasing veneer and decreasing coping thickness improved FL and CS among POZ crowns. Conclusions: Press on metal specimen showed higher resistance to fracture than Press on Y-TZP specimens. Improved failure loads were observed in thin coping and thick veneers among Press on Y-TZP crowns. doi: https://doi.org/10.12669/pjms.36.7.2472 How to cite this:Vohra F, Shuwaish MB, Al-Deeb M, Alhamdan R, Alotaibi N, Abduljabbar T. Comparison of failure loads and compressive stress in Press on metal and Press on Y-TZP copings. Pak J Med Sci. 2020;36(7):1645-1650. doi: https://doi.org/10.12669/pjms.36.7.2472 This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Background Aneurysms of the anterior choroidal artery (AChA) have been associated with high treatment-associated morbidity due to ischemic complications. Objective To report a large clinical experience of microsurgically treated AChA aneurysms and describe a systematic approach to reduce ischemic complications. Methods One hundred forty-six patients with AChA aneurysms were retrospectively reviewed from a prospectively maintained database. Clinical characteristics, surgical techniques, clinical outcomes, arterial infarction, and use of intraoperative adjuncts (ie, ultrasonography, indocyanine green videoangiography, and neuromonitoring) were analyzed. Results In total, one hundred forty-three aneurysms (97.9%) were clipped. Temporary clipping was utilized in 47 cases (32.2%) with mean occlusion time of 5.6 min. Arterial infarction occurred in 12 patients (8.2%). In clipped aneurysms, 90.5% were completely obliterated, 8.8% had minimal residual ( 5% of original). Mortality (2.7%) was limited to patients with high-grade subarachnoid hemorrhage. Indocyanine green videoangiography and neuromonitoring altered operative technique in ∼20% of cases. Multivariate logistic regression identified intraoperative rupture as the sole predictor for arterial infarction. Conclusion Open microsurgical clipping remains a safe, effective treatment for AChA aneurysms. Microsurgical technique is paramount in preserving AChA patency and reducing ischemic complications. Despite increasing reliance on qualitative measures of AChA blood flow (videoangiography and ultrasonography) and neurophysiological monitoring, these technologies aid us infrequently. However, these adjuncts provide important safety checks for AChA patency. Temporary clipping must be used judiciously to lower the risk of intraoperative rupture while limiting possible ischemia in the AChA territory.

Computer-assisted navigation (CAN) improves the accuracy of spinal instrumentation in vertebral fractures and degenerative spine disease; however, it is not widely adopted because of lack of training, high capital costs, workflow hindrances, and accuracy concerns. We characterize shifts in the use of spinal CAN over time and across disciplines in a single-payer health system, and assess the impact of intra-operative CAN on trainee proficiency across Canada.A prospectively maintained Ontario database of patients undergoing spinal instrumentation from 2005 to 2014 was reviewed retrospectively. Data were collected on treated pathology, spine region, surgical approach, institution type, and surgeon specialty. Trainee proficiency with CAN was assessed using an electronic questionnaire distributed across 15 Canadian orthopedic surgical and neurosurgical programs.In our provincial cohort, 16.8% of instrumented fusions were CAN-guided. Navigation was used more frequently in academic institutions (15.9% vs. 12.3%, plt;0.001) and by neurosurgeons than orthopedic surgeons (21.0% vs. 12.4%, plt;0.001). Of residents and fellows 34.1% were fully comfortable using spinal CAN, greater for neurosurgical than orthopedic surgical trainees (48.1% vs. 11.8%, p=0.008). The use of CAN increased self-reported proficiency in thoracic instrumentation for all trainees by 11.0% (p=0.036), and in atlantoaxial instrumentation for orthopedic trainees by 18.0% (p=0.014).Spinal CAN is used most frequently by neurosurgeons and in academic centers. Most spine surgical trainees are not fully comfortable with the use of CAN, but report an increase in technical comfort with CAN guidance particularly for thoracic instrumentation. Increased education in spinal CAN for trainees, particularly at the fellowship stage and, specifically, for orthopedic surgery, may improve adoption.La chirurgie assistée par ordinateur (CAO) permet d’améliorer la précision de l’exploration instrumentale employée dans le cas de fractures vertébrales et de maladies dégénératives de la colonne vertébrale. Cela dit, elle n’a pas encore été adoptée à grande échelle en raison d’un manque de formation, de coûts d’immobilisation considérables, d’obstacles liés à l’organisation du travail et de doutes quant à son exactitude. C’est dans cette perspective que nous voulons décrire, parmi divers champs de pratique, les transformations se rapportant au fil du temps à l’utilisation de la CAO de la colonne vertébral dans le cadre d’un régime de santé universel à payeur unique. Qui plus est, nous voulons aussi évaluer l’impact de la CAO en ce qui a trait aux compétences des stagiaires partout au Canada.Pour ce faire, nous avons passé en revue de façon rétrospective une base de données tenue à jour prospectivement au sujet de patients ontariens ayant été soumis de 2005 à 2014 à une exploration instrumentale de la colonne vertébrale. Les données obtenues portaient sur le type de pathologie traitée, sur la région de la colonne vertébrale visée, sur l’approche chirurgicale privilégiée, sur le type d’établissement et sur la spécialité du chirurgien ayant intervenu. Les compétences des stagiaires en matière de CAO ont également été évaluées à l’aide d’un questionnaire en ligne diffusé au sein de 15 programmes canadiens de chirurgie orthopédique et de neurochirurgie.En tout, 16,8 % des fusions instrumentées réalisées au sein de notre cohorte ontarienne l’ont été à l’aide de la technique de la CAO. Cette dernière a été utilisée plus fréquemment dans des établissements d’enseignement universitaire (15,9 % par opposition à 12,3 % pour les autres; p0,001) mais aussi plus souvent par des neurochirurgiens (21,0 % par opposition à 12,4 % par des chirurgiens orthopédiques; p0,001). En outre, 34,1 % des résidents et des médecins suivant une formation complémentaire étaient parfaitement à l’aise dans l’utilisation de la CAO de la colonne vertébrale (48,1 % de ceux se spécialisant en neurochirurgie par opposition à 11,8 % de ceux se spécialisant en chirurgie orthopédique; p = 0,008). L’utilisation de la CAO a par ailleurs entraîné une augmentation, auto-déclarée, de 11,0 % de l’aptitude à faire usage de l’exploration instrumentale thoracique chez tous les stagiaires (p = 0,036); dans le cas de l’exploration instrumentale atlanto-axiale, cette augmentation a été de 18,0 % (p = 0,014) chez les stagiaires en chirurgie orthopédique.La CAO de la colonne vertébrale est employée le plus souvent par les neurochirurgiens dans des établissements d’enseignement universitaire. La plupart des stagiaires en chirurgie de la colonne vertébrale ne sont pas entièrement à l’aise en ce qui concerne l’utilisation de la CAO. Toutefois, ils ont signalé une augmentation de leur aisance à utiliser la CAO et à bénéficier de son assistance, en particulier dans des cas d’exploration instrumentale thoracique. En somme, une plus ample formation en matière de CAO de la colonne vertébrale offerte aux stagiaires, particulièrement à ceux suivant une formation complémentaire et dans le champ de la chirurgie orthopédique, pourrait favoriser son adoption.

Objective Intracranial arterial dissection (IAD) is a rare cerebrovascular disease that is likely underdiagnosed because of the inherent difficulty of visualizing the subtle radiographic signs of the pathologic small intracranial arteries. No widespread consensus exists on the treatment of IAD, and thus it is often managed empirically because of the absence of major randomized controlled trials. In this study, we conducted a systematic review to evaluate the management and treatment options for IAD. Methods We performed a systematic review in accordance with the PRISMA guidelines using the following databases: MEDLINE (PubMed) and Cochrane Library. Included studies were limited to human patients with dissections in intracranial vessels only. Results A total of 82 studies were included in this systematic review. The most common complications of IAD were cerebral infarction and subarachnoid hemorrhage, and thus, patients with IAD can be subdivided into those presenting with either ischemia or hemorrhage, respectively. Those with ischemia were predominantly managed with antiplatelet therapy, whereas patients presenting with hemorrhage often were amenable to treatment with endovascular techniques. Conclusions Given these findings, clinicians should prescribe antiplatelet therapy for patients with IAD presenting with ischemia and consider endovascular treatment for those presenting with hemorrhage. However, further investigation is required given the heterogeneity of methods and reporting outcomes in the investigated studies.

Study design Bibliometric analysis. Objective To identify, and summarize the key findings of, the top 100 most highly cited works published in spinal disorder topic-specific journals. Summary of background data There is an abundance of published articles pertaining to spine surgery and spinal disorders. The number of citations a work receives provides a useful measure of its scientific impact. An understanding of the most cited works in spine surgery can identify literature that surgeons and researchers should be familiar with, point to the most active areas of research, inform the design of educational curricula, and help guide future research efforts. Methods Journals relating to spinal disorders were identified using the Journal Citation Reports database. We then searched the Web of Science database for articles appearing in each of these journals. The top 100 most cited works were selected for analysis. Results The top 100 most cited articles appeared in seven of eight journals dedicated to spinal disorders, with 84 in Spine and seven in the European Spine Journal. The citation count for individual articles ranged from 343 to 1949. Most works (73) were published between 1990 and 2004. The greatest number of articles (22) focused on low back pain, followed by biomechanics (13), degenerative disc disease (12), and lumbar spinal stenosis/lumbar fusion (9). With regard to study design, laboratory investigations were the most common (12), followed by guideline documents (11), reviews (10), and retrospective cohort studies (10). Conclusion The most cited works in spinal disorder journals are guidelines for low back pain, descriptions of quality of life (QOL) metrics, or laboratory investigations into spinal biomechanics. A gap exists for work relating to neck pain or cervical spinal pathology (e.g., cervical myelopathy), representing opportunity for future work. Time of publication, topic of study, study design, and journal are possible determinants of likelihood of citation. Level of evidence N/A.

Introduction: Endovascular thrombectomy (EVT) has revolutionized large vessel occlusion (LVO) stroke care. However, over half remain functionally disabled or die despite treatment. Understanding outcomes may influence EVT selection, novel therapies, and prognostication. We sought to identify associations between outcomes and brain regions involved in ischemic lesions. Methods: For consecutive LVO patients with post-EVT MRI, acute ischemic lesions were manually segmented from DWI and spatially normalized. Individual lesion volumes were automatically parcellated (atlas-defined 94 cortical regions, 14 subcortical nuclei, 20 white matter tracts) and then reduced to ten anatomically plausible lesion patterns using unsupervised dimensionality reduction techniques. Ninety-day modified Rankin Scale (mRS) was modeled via Bayesian regression, taking the ten lesion patterns as inputs and controlling for lesion size, age, sex, acute NIH Stroke Scale, alteplase, and TICI 2b-3 reperfusion. Results: We identified 153 LVO patients with mean age 68±15 years and 51% female. Median NIHSS was 16 (IQR 13-20), 56% received alteplase, and 84% achieved TICI2b-3. The lesion patterns predictive of 90-day mRS involved bilateral subcortical nuclei, pre- and postcentral gyri, insular and opercular cortex, as well as left-sided inferior frontal and angular gyri ( Figure 1A ). Lesions affecting white matter tracts had the highest relevance predicting 90-day mRS ( Figure 1B ). Conclusions: These data describe the significance for outcomes of specific brain regions involved in ischemic lesions on MRI after EVT. Future work in additional datasets is needed to confirm these granular findings.

BACKGROUND: We used a cross-sectional study design (questionnaire) to investigate the use of image-guided navigation (IGN) in Saudi Arabia and explore possible differences in implementing IGN for daily practice. METHODS: An internet-based survey was sent to all spine surgeons who are practicing in Saudi Arabia (orthopedics or neurosurgery). The survey is composed of 12 items that collected demographic and academic data. RESULTS: Ninety-nine answered the questionnaire from 197; 80% were from Riyadh, the capital, and 50% were consultants (attending physicians). Orthopedic surgeons were almost 60% of responders compared to 40% neurosurgeons. The use of navigation in Saudi hospitals was high (76.8%). There was a significant difference between specialties in the preference of using navigation (23.2% for orthopedics versus 81.4% for neurosurgery, P < .001) and routine use in surgical spine cases (88.4% for neurosurgery versus 50.0% orthopedics, P < .001). The majority of responders from neurosurgery learned to use navigation during residency compared to orthopedics responders (51.2% versus 28.6%, P = .001). More than 30% of orthopedics responders expressed they never learned navigation compared to only 4% of neurosurgery responders. The comfort level of > 75% with performing surgery using navigation was significantly different between specialties (25% for orthopedics versus 46.5% for neurosurgery, P < .001). CONCLUSION: Saudi spine surgeons are among the highest users of IGN systems. The strong healthcare infrastructure and the availability of these devices across the country are among the most important factors for its prevalence. Enhancing surgical exposure and education of postgraduate trainees to use these tools, especially within orthopedics, could increase use and comfort level rates.

With the increase in heart disease and frequent heart attacks, the death rate has increased in a terrifying and appalling manner worldwide due to the lack of first aid practices such as cardiopulmonary resuscitation (CPR). Cardiopulmonary resuscitation is a dual process in which the paramedic resuscitates the lung and heart. As for resuscitation of the lung, it is through the delivery of air and oxygen to it through artificial respiration, as for reviving the heart, it is accomplished through manual pressure on the area of the injured heart “in the area between the thoracic bone and the spine” so that blood is pumped to human vital organs of the injured person’s body, especially the brain. This paper involves designing a manikin that interacts with humans to facilitate the application of CPR in a correct and scientific form by measuring the strength and depth of pressure and calculating the number of compression per minute (CPM). The system control architecture is based on IoT concept where data that is read from integrated sensors and sent to IoT hubs such as Amazon Web Services. The purpose of this work is to provide trainees with a training tool on resuscitation approaches.

Ultra-low frequency (ULF) signals in the geomagnetic records are important indicators for many phenomena; therefore identification of such signals is an important issue. Automatic identification of these ULF signals is not an easy target because of their small magnitudes. Through this study in hand, two algorithms are proposed to automatically detect these micro-pulsations. The first algorithm uses the multi-level components (details) of the discrete wavelet transform (DWT) instead of the original geomagnetic record. The vector of the maximum values of the cross-correlation between the record and an arbitrary chosen ULF pattern in the same frequency range is a good indicator for the existence of these micro-pulsations. The second algorithm is based on convolutional neural network (CNN) framework guided with the multi-resolution-analysis (MRA) of the DWT. Preprocessing the geomagnetic records using the MRA of DWT to produce the fifth and the sixth details to be the input to the deep CNN topology, highly improved the accuracy to approach 91.11%. In addition, deep learning based algorithm showed better results than the DWT based algorithm in light of all the performance metrics.

BACKGROUND Digital subtraction angiography (DSA) is still considered the gold standard test to evaluate arteriovenous malformation's (AVM) residual after microsurgical resection. OBJECTIVE To evaluate the safety and reliability of intraoperative computed tomography angiography (iCTA) as an immediate method of evaluating the surgical results of AVM resection. METHODS We performed a retrospective review for all cases of cerebral AVMs at our institute from January 2015 to April 2020 who underwent surgical resection of cerebral AVM and had iCTA. All included patients underwent a postoperative DSA, and the results were compared with iCTA. RESULTS Twenty-eight cases were included. All cases showed complete resection (100%) in the iCTA, and the results were consistent with the postoperative DSA results. The sensitivity of iCTA was 100%. The added operative time ranged from 25 to 30 min. There were no complications related to the use of iCTA. CONCLUSION Intraoperative assessment of AVMs surgical results with an iCTA is safe and reliable. The sensitivity of iCTA following AVM resection merits further investigations.

Background Trans-radial access for neuro-endovascular procedures has gained popularity in recent years, driven in part by social media. The approach was adopted and modified from that used by interventional cardiology. This study analyzes Twitter conversations regarding this topic using the popular hashtag #RadialFirst. Materials and Methods Twitter was evaluated for public content pertaining to all trans-radial access. We conducted a mixed-method analysis that includes a quantitative examination of all social media metrics (no. of tweets, mentions, retweets, locations, word count) and a qualitative evaluation of tweets for thematic analysis. Results Between January 2013 and February 2020, there were 100,531 tweets from 100 countries using the hashtag #RadialFirst. These tweets had an overall impression of 218 million and were retweeted 75,000 times by 13,103 users. More than 60% of tweets carried media materials (e.g. wrist image, angiographic runs) but only 14% of tweets had a link to an article. USA (17%) and the UK (4.2%) had the highest numbers of tweets. Physicians authored 84% of the tweets and interventional cardiologists accounted for 94% of the top 100 influencers for the hashtag. Tweets showed steady increase in numbers over time and coincided later with the appearance of a new hashtag for neuro-intervention, #RadialForNeuro. Five prominent themes emerged from the coded data: sharing cases, providing operative tips, requesting information, highlighting adverse events, and tweets related to commercial endorsements. Conclusion This study is the first to provide insight into Twitter communications regarding trans-radial access. These findings highlight the impact of Twitter in disseminating the technique, and the role of social media in education and refinement of technical approaches. Disclosures N. Alotaibi: None. P. Harker: None. F. Robertson: None. J. Vranic: None. M. Koch: None. C. Stapleton: None. T. Leslie-Mazwi: None. A. Patel: None.

Background Alternative metrics (Altmetrics) are increasingly being used as a new metric of scientific dissemination by most medical journals. The aim of this study is to investigate predictors of higher Altmetric scores within the neuro-interventional surgery scope. Methods We performed a comprehensive search for neuro-interventional related publications using the Altmetric database. Articles were selected based on wide-range search criteria that include terms ‘interventional’, ‘neuroradiology’, ‘neurosurgery’ and ‘neuro-intervention’. We studied all online references for any article mentioned on Facebook, Twitter, blogs, and mainstream media sources. The strength of associations between all metrics was studied using Pearson correlation coefficient. Values close to 1 indicates strong correlation. Results A total of 12,501 articles pertinent to neuro-intervention were obtained from the Altmetric database. These articles had an average of an altimetric score of 8 (95% CI for the mean 7.7 to 9.2). The strongest correlations for Altmetrics were for the following online mentions: general news outlets (Pearson’s r: 0.89), Twitter (0.78), Facebook (0.48) and Reddit (0.45). Interestingly, Wikipedia, peer-reviewed outlets and LinkedIn mentions had the weakest correlations coefficients (0.11, 0.21, and 0.00, respectively). Journals with social media presence had the highest average of total altimetric scores compared to journals without social media accounts. Conclusions Compared to general news outlets and Twitter, professional online networks such as peer-reviewed outlets and LinkedIn did not have a significant association with high altermetric ‘trending’ scores in neuro-interventional surgery. The long-term impact of these metrics on citations or funding requires a prospective analysis. Disclosures N. Alotaibi: None. P. Harker: None. F. Robertson: None. J. Vranic: None. M. Koch: None. C. Stapleton: None. T. Leslie-Mazwi: None. A. Patel: None.

Background Recently, the American Academy of Otolaryngology-Head and Neck Surgery Foundation (AAO-HNSF) published evidence-based recommendations to improve the quality and management variation for patients who suffer from epistaxis, however, there were no clear guidelines on timing and techniques of endovascular management. Methods A systematic review and meta-analysis in accordance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Our primary outcome was the proportion of patients who had immediate bleeding control after endovascular management. Secondary outcomes included percentage of major adverse events following embolization. Sensitivity analysis was conducted according to center protocol (materials used, unilateral vs. bilateral approach, and timing of treatment). Results Fourteen case series (with 719 patients) met our inclusion criteria for primary and secondary outcome. The pooled event rate for immediate control was 86% (95% confidence interval [CI], 82%-89%). Major adverse events (stroke, craniofacial skin necrosis, and retro-peritoneal hemorrhage) had an overall event rate of 2.4% (95% CI 1.4%-4%). Most embolizations were targeting distal portion of the internal maxillary (>95% of cases). Sensitivity analysis revealed that bilateral approaches were associated with less recurrence rates, however, higher rates of major adverse events were notes. Several factors were identified for heterogeneity between studies, including outcomes definitions, follow-up time, angiographic protocol, target vessels and embolization’s materials. Conclusions The best available evidence for endovascular management of epistaxis is based on retrospective observational studies. Deficiency of standardized reporting methods is a significant drawback to understand the exact role of endovascular treatment for epistaxis and whether it is superior to other operative methods. Disclosures N. Alotaibi: None. P. Harker: None. F. Robertson: None. J. Vranic: None. M. Koch: None. C. Stapleton: None. T. Leslie-Mazwi: None. A. Patel: None.

Background Compared to stent-assisted coiling the Woven EndoBridge (WEB) device offers the advantage of treatment of wide-necked aneurysms without antiplatelet medications. However, the safety and efficacy of WEB is yet to be fully defined in the setting of aneurysmal subarachnoid hemorrhage (aSAH), given concerns regarding the delayed nature of aneurysm thrombosis. Methods The search protocol was developed a priori according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. A literature search using the OVID Medline, Embase, Web of Science, and Cochrane Library databases from inception to February 2020 was performed using relevant key words to identify cases of aSAH that were treated with WEB. The primary outcome measure was radiographic complete occlusion rates. Secondary outcomes included rebleeding and complications rates. All pooled event rates were calculated using random effect model. Results Six articles, all of which were observational case series, representing 261 ruptured aneurysms were included for analysis (average follow up time was 4 months). Most of these aneurysms were in the anterior circulation (>60%). The likelihood of a complete radiographic occlusion following WEB for ruptured aneurysms was 66.6% (95% CI 47–74%). Rebleeding rates were 2.8% (95% CI 1–6%). The pooled event rate for complications (procedural aneurysm rupture, thromboembolic, and device protrusion in the parent artery) across five studies was 17.9% (95% CI 9–32%). Overall retreatment rates were 10% (95% CI 4–22%) and the need for early or delayed stent placement was 5% (95% CI 1–12%). There was no significant heterogeneity between studies in rebleeding and stent placement outcomes (I2 Conclusion The WEB device in aSAH appears to provide similar protection against rebleeding and retreatment rates that are comparable to traditional approaches; however, there is a higher rate of incomplete radiographic occlusion and operative complications. Long-term prospective studies are needed to fully delineate the role of WEB embolization in aSAH. Disclosures N. Alotaibi: None. P. Harker: None. F. Robertson: None. J. Vranic: None. M. Koch: None. C. Stapleton: None. T. Leslie-Mazwi: None. A. Patel: None.

Background Social media use continues to gain momentum in academic neurosurgery. To increase journal impact and broaden engagement, many scholarly publications have turned to social media to disseminate research. The Journal of Neurosurgery Publishing Group (JNSPG) established a dedicated, specialized social media team (SMT) in November 2016 to provide targeted improvement in digital outreach. Objective The goal of this study was to examine the impact of the JNSPG SMT as measured by increased engagement. Methods We analyzed various metrics, including impressions, engagements, retweets, likes, profile clicks, and URL clicks, from consecutive social media posts from the JNSPG’s Twitter and Facebook platforms between February 1, 2015 and February 28, 2019. Standard descriptive statistics were utilized. Results Between February 2015 and October 2016, when a specialized SMT was created, 170 tweets (8.1 tweets/month) were posted compared to 3220 tweets (115.0 tweets/month) between November 2016 and February 2019. All metrics significantly increased, including the impressions per tweet (mean 1646.3, SD 934.9 vs mean 4605.6, SD 65,546.5; P=.01), engagements per tweet (mean 35.2, SD 40.6 vs mean 198.2, SD 1037.2; P Conclusions Social media has been established as a crucial tool for the propagation of neurosurgical research and education. Implementation of the JNSPG specialized SMT had a demonstrable impact on increasing the online visibility of social media content.

OBJECTIVEDespite increasing adoption of endoscopic techniques for repair of nonsagittal single-suture craniosynostosis, the efficacy and safety of the procedure relative to established open approaches are unknown. In this systematic review the authors aimed to directly compare open surgical and endoscope-assisted techniques for the treatment of metopic, unilateral coronal, and lambdoid craniosynostosis, with an emphasis on quantitative reported outcomes.METHODSA literature search was performed in compliance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Relevant articles were identified from 3 electronic databases (MEDLINE, EMBASE, and CENTRAL [Cochrane Central Register of Controlled Trials]) from their inception to August 2017. The quality of methodology and bias risk were assessed using the Effective Public Health Practice Project (EPHPP) Quality Assessment Tool for Quantitative Studies.RESULTSOf 316 screened records, 7 studies were included in a qualitative synthesis of the evidence, of which none were eligible for meta-analysis. These reported on 111 unique patients with metopic, 65 with unilateral coronal, and 12 with lambdoid craniosynostosis. For all suture types, 100 (53%) children underwent endoscope-assisted craniosynostosis surgery and 32 (47%) patients underwent open repair. These studies all suggest that blood loss, transfusion rate, operating time, and length of hospital stay were superior for endoscopically treated children. Although potentially comparable or better cosmetic outcomes are reported, the paucity of evidence and considerable variability in outcomes preclude meaningful conclusions.CONCLUSIONSLimited data comparing open and endoscopic treatments for metopic, unilateral coronal, and lambdoid synostosis suggest a benefit for endoscopic techniques with respect to blood loss, transfusion, length of stay, and operating time. This report highlights shortcomings in evidence and gaps in knowledge regarding endoscopic repair of nonsagittal single-suture craniosynostosis, emphasizing the need for further matched-control studies.

Background and Purpose— Anemia after aneurysmal subarachnoid hemorrhage is common and potentially modifiable. Here, we first evaluate the effect of anemia on neurological outcome and death and second, study the effects of packed red blood cell transfusion on outcome. Methods— A secondary analysis on 413 subjects in the CONSCIOUS-1 study (Clazosentan to Overcome Neurological Ischemia and Infarction Occurring After Subarachnoid Hemorrhage). Multivariable logistic regression identified independent risk factors for anemia and determined the effect of anemia on neurological outcome and death, while adjusting for selected covariates. Optimal predictive thresholds for hemoglobin levels were determined using receiver operating characteristic curve analysis. Finally, patients were pseudorandomized to transfusion using propensity score matching to study the effect of transfusions on outcome. Results— Anemia, defined as hemoglobin 10 g/dL was associated with improved neurological outcomes (odds ratio, 0.09; 95% confidence interval, 0.002–0.72; P=0.015), with no differences in mortality. Conclusions— Anemia after aneurysmal subarachnoid hemorrhage is associated with poor long-term neurological outcome and death. Transfusion of packed red blood cells is beneficial for patients who are not considerably anemic beforehand, suggesting further work needs to define the threshold but also the time period of anemia that is sufficient and necessary to contribute to poor outcomes. Clinical Trial Registration— URL: https://www.clinicaltrials.gov . Unique identifier: NCT00111085.

OBJECTIVEIntracranial electroencephalography (iEEG) monitoring is an important method of identifying the seizure focus in patients with medically refractory epilepsy. While previous studies have demonstrated low rates of surgical complications, reported rates of surgical site infection (SSI) are highly variable. To date, no studies have specifically evaluated the patient or operative risk factors contributing to SSI. The goals of this study were to examine the rate of SSI after iEEG monitoring for epilepsy workup in pediatric patients and to determine the variables that might contribute to the development of SSI.METHODSA retrospective analysis of hospital charts at the Hospital for Sick Children was performed for all patients who had undergone iEEG monitoring between 2000 and 2016. Univariate and multivariate analyses were performed to look for statistically significant variables in relation to SSI.RESULTSAmong 199 patients eligible for analysis, 8 (4.0%) developed SSIs within a period ranging from 21 to 51 days postoperatively. Univariate analysis yielded 4 factors related to SSI: number of people present in the operating room on electrode insertion (p = 0.02), length of insertion surgery (p = 0.04), previous operation at the same surgical site (p = 0.04), and number of depth electrodes inserted (p = 0.01). Multivariate analysis revealed that both the number of people present during the implant operation (OR 0.08, 95% CI 0.01–0.70) and the number of depth electrodes inserted (OR 3.52, 95% CI 1.44–8.59) independently contributed to SSI.CONCLUSIONSThis is the largest case series and the first comprehensive review of both patient and operative risk factors in the development of SSI from iEEG monitoring in a pediatric population. The authors’ institution had a lower rate of infection than those in most other studies, which could be explained by their protocol of administering intravenous antibiotics perioperatively and post–implant removal antibiotics for 14 days. The authors found a correlation between SSI and the number of people present during the implant operation, as well as the number of depth electrodes; both may contribute to breaks in sterility.

Objective Despite the increasing prominence of stereotactic radiosurgery (SRS) in treating intracranial and spinal pathologies, there is currently a dearth of exposure to this modality in the neurosurgical residency. To address this gap, the aim of this study is to assess neurosurgery educators' views regarding the current state of SRS exposure, and to identify potential approaches to improve residency education in this domain. Methods Qualitative thematic analysis and constructivist grounded theory methodology were employed. Semistructured telephone-based interviews were conducted with current or past residency program directors, as well as current departmental chairs across neurosurgical departments in Canada. Interviews were transcribed and subjected to thematic analysis using open and axial coding. Results Of the 34 eligible participants, the overall response rate was 41.1% (14/34), with a 35.3% participation rate (12/34). Participants represented 9 of the 12 Canadian institutions surveyed. The majority of participants were current program directors (n = 8), followed by past program directors (n = 2), and departmental chairs (n = 2). Most respondents 75% (9/12) view an increasing role for SRS in neurosurgery. Unanimously, respondents endorse greater exposure to SRS during residency through formal residency rotations and engagement in interdisciplinary tumor boards to facilitate involvement in clinical decision-making. Conclusions This is the first study to systematically collate neurosurgery educators' views on SRS in residency in Canada and demonstrates recognition of the discordance between SRS in practice and residency training. Neurosurgery educators broadly endorse increased exposure to this modality. Future work is needed to delineate the requirements necessary to achieve adequate competency in SRS.

Summary Objective To perform a systematic review and meta‐analysis of real‐world evidence for the use of low‐frequency repetitive transcranial magnetic stimulation (rTMS) in the treatment of drug‐resistant epilepsy. Methods We systematically searched PubMed, Scopus, Medline, and clinicaltrials.gov for all relevant articles. Relevant patient and stimulation predictors as well as seizure outcomes were assessed. For studies with and without individual participant data (IPD), the primary outcomes were the rate of “favorable response” (reduction in seizure frequency ≥50%) and pooled event rate of mean reduction in seizure frequency, respectively. Outcomes were assessed with comparative statistics and random‐effects meta‐analysis models. Results Of 3,477 identified articles, 12 met eligibility and were included in this review. We were able to obtain IPD for 5 articles constituting 34 participants. Univariate analysis on IPD identified greater favorable response event rates between participants with temporal seizure focus versus extratemporal (50% vs. 14%, p = 0.045) and between participants who were stimulated with a figure‐8 coil versus other types (47% vs. 0%, p = 0.01). We also performed study‐level meta‐analysis on the remaining 7 studies without IPD, which included 212 participants. The pooled mean event rate of 50% seizure reduction using low‐frequency rTMS was 30% (95% confidence interval [CI] 12–57%). Sensitivity analysis revealed that studies with a mean age ≤21 years and studies using targeted stimulation had the highest seizure reduction rates compared to studies with a mean age >21 years (69% vs. 18%) and not using a targeted stimulation (47% vs. 14–20%). Moreover, we identified high interstudy heterogeneity, moderate study bias, and high publication bias. Significance Real‐world evidence suggests that low‐frequency rTMS using a figure‐8 coil may be an effective therapy for the treatment of drug‐resistant epilepsy in pediatric patients. This meta‐analysis can inform the design and expedite recruitment of a subsequent randomized clinical trial.

Background Context Spinal intraoperative computer-assisted navigation (CAN) may guide pedicle screw placement. Computer-assisted navigation techniques have been reported to reduce pedicle screw breach rates across all spinal levels. However, definitions of screw breach vary widely across studies, if reported at all. The absolute quantitative error of spinal navigation systems is theoretically a more precise and generalizable metric of navigation accuracy. It has also been computed variably and reported in less than a quarter of clinical studies of CAN-guided pedicle screw accuracy. Purpose This study aimed to characterize the correlation between clinical pedicle screw accuracy, based on postoperative imaging, and absolute quantitative navigation accuracy. Design/Setting This is a retrospective review of a prospectively collected cohort. Patient Sample We recruited 30 patients undergoing first-time posterior cervical-thoracic-lumbar-sacral instrumented fusion±decompression, guided by intraoperative three-dimensional CAN. Outcome Measures Clinical or radiographic screw accuracy (Heary and 2 mm classifications) and absolute quantitative navigation accuracy (translational and angular error in axial and sagittal planes). Methods We reviewed a prospectively collected series of 209 pedicle screws placed with CAN guidance. Each screw was graded clinically by multiple independent raters using the Heary and 2 mm classifications. Clinical grades were dichotomized per convention. The absolute accuracy of each screw was quantified by the translational and angular error in each of the axial and sagittal planes. Results Acceptable screw accuracy was achieved for significantly fewer screws based on 2 mm grade versus Heary grade (92.6% vs. 95.1%, p=.036), particularly in the lumbar spine. Inter-rater agreement was good for the Heary classification and moderate for the 2 mm grade, significantly greater among radiologists than surgeon raters. Mean absolute translational-angular accuracies were 1.75 mm-3.13° and 1.20 mm-3.64° in the axial and sagittal planes, respectively. There was no correlation between clinical and absolute navigation accuracy. Conclusions Radiographic classifications of pedicle screw accuracy vary in sensitivity across spinal levels, as well as in inter-rater reliability. Correlation between clinical screw grade and absolute navigation accuracy is poor, as surgeons appear to compensate for navigation registration error. Future studies of navigation accuracy should report absolute translational and angular errors. Clinical screw grades based on postoperative imaging may be more reliable if performed in multiple by radiologist raters.

Background and Purpose— Cerebral infarction after aneurysmal subarachnoid hemorrhage is a significant cause of substantial morbidity and mortality. Because early and delayed cerebral infarction after aneurysmal subarachnoid hemorrhage may be mediated by different processes, we evaluated whether aneurysm-securing methods contributed to infarcts and whether long-term outcomes differ between early and delayed infarcts. Methods— A post hoc analysis of the CONSCIOUS-1 study (Clazosentan to Overcome Neurological Ischemia and Infarction Occurring After Subarachnoid Hemorrhage) was performed. Using multivariate logistic regression analysis and propensity matching, independent clinical risk factors associated with infarctions were identified, and the contribution of cerebral infarcts to long-term outcomes was evaluated. Results— Within the cohort of 413 subjects, early infarcts were present in 76 subjects (18%), whereas delayed infarcts occurred in 79 subjects (19%), and 36 subjects (9%) had new infarctions that were present on both early and delayed imaging. Propensity score matching revealed a significantly higher proportion of early infarcts after clipping (odds ratio, 4.62; 95% confidence interval, 1.99–11.57; P =0.00012). Multivariate logistic regressions identified clipping as an independent risk factor for early cerebral infarction (odds ratio, 0.26; 95% confidence interval, 0.15–0.48; P P =0.039). Early infarcts were a significant independent risk factor for poor long-term outcomes at 3 months (odds ratio, 2.34; 95% confidence interval, 1.18–4.67; P =0.015). Conclusions— Clipping is an independent risk factor for the development of early cerebral infarcts, whereas delayed cerebral infarcts are associated with angiographic vasospasm. Early cerebral infarcts are stronger predictors of worse outcome than delayed infarction. Clinical Trial Registration— URL: http://www.clinicaltrials.gov . Unique identifier: NCT00111085.

Selective dorsal rhizotomy (SDR) is a surgical treatment for spasticity, primarily in cerebral palsy (CP). There is a growing trend for patients to seek medical information from their peers on social media platforms. This study qualitatively and quantitatively assessed the use of social media as an information-sharing and support-seeking tool by patients and caregivers. A search was performed on Facebook, Twitter, and YouTube. Public information was quantitatively assessed by category, users, year of creation, and country of origin. Representative samples of comments and posts were then qualitatively assessed by thematic analysis. One hundred eighty-five Facebook groups and pages, 97 YouTube videos, and 14 Twitter accounts were identified, based in 13 countries. SDR and CP groups had a mean membership of 3063 and 2339, respectively; SDR and CP pages had a mean number of “likes” of 1650 and 10,711, respectively. Total YouTube video views were 593,135 (mean 6115). Total Twitter followers were 62,609 (mean 2160). Qualitative analysis identified seven categories of comments: emotional support and forming connections (22.34%), sharing information and advice (15.96%), appreciation and successes (31.91%), challenges and difficulties (8.51%), advertising/offering services (4.79%), inequities and access (4.79%), and social media as a second opinion (11.7%). This study outlines the use of social media platforms in the distribution of information regarding SDR. We highlight the importance placed by patients and caregivers on the advice of their peers. The current report should inform healthcare providers’ interactions with patients with respect to information seeking and provision of support.

Of background data Computer-assisted 3-dimensional navigation may guide spinal instrumentation. Optical topographic imaging (OTI) is a novel navigation technique offering comparable accuracy and significantly faster registration workflow relative to current navigation systems. It has previously been validated in open posterior thoracolumbar exposures. Objective To validate the utility and accuracy of OTI in the cervical spine. Study design This is a prospective preclinical cadaveric and clinical cohort study. Methods Standard midline open posterior cervical exposures were performed, with segmental OTI registration at each vertebral level. In cadaveric testing, OTI navigation guidance was used to track a drill guide for cannulating screw tracts in the lateral mass at C1, pars at C2, lateral mass at C3-6, and pedicle at C7. In clinical testing, translaminar screws at C2 were also analyzed in addition. Planned navigation trajectories were compared with screw positions on postoperative computed tomographic imaging, and quantitative navigation accuracies, in the form of absolute translational and angular deviations, were computed. Results In cadaveric testing (mean±SD) axial and sagittal translational navigation errors were (1.66±1.18 mm) and (2.08±2.21 mm), whereas axial and sagittal angular errors were (4.11±3.79 degrees) and (6.96±5.40 degrees), respectively.In clinical validation (mean±SD) axial and sagittal translational errors were (1.92±1.37 mm) and (1.27±0.97 mm), whereas axial and sagittal angular errors were (3.68±2.59 degrees) and (3.47±2.93 degrees), respectively. These results are comparable to those achieved with OTI in open thoracolumbar approaches, as well as using current spinal neuronavigation systems in similar applications. There was no radiographic facet, canal or foraminal violations, nor any neurovascular complications. Conclusions OTI is a novel navigation technique allowing efficient initial and repeat registration. Accuracy even in the more mobile cervical spine is comparable to current spinal neuronavigation systems.

OBJECTIVEAlthough deep brain stimulation (DBS) is an accepted treatment for childhood dystonia, there is significant heterogeneity in treatment response and few data are available to identify ideal surgical candidates.METHODSData were derived from a systematic review and individual patient data meta-analysis of DBS for dystonia in children that was previously published. Outcomes were assessed using the Burke-Fahn-Marsden Dystonia Rating Scale for movement (BFMDRS-M) and for disability (BFMDRS-D). The authors used partial least squares, bootstrapping, and permutation statistics to extract patterns of contributions of specific preoperative characteristics to relationship with distinct outcomes, in all patients and in patients with primary and secondary dystonia separately.RESULTSOf 301 children undergoing DBS for dystonia, 167 had primary dystonia, 125 secondary dystonia, and 9 myoclonus dystonia. Three dissociable preoperative phenotypes (latent variables) were identified and associated with the following: 1) BFMDRS-M at last follow-up; 2) relative change in BFMDRS-M score; and 3) relative change in BFMDRS-D score. The phenotype of patients with secondary dystonia, with a high BFMDRS-M score and truncal involvement, undergoing DBS at a younger age, was associated with a worse postoperative BFMDRS-M score. Children with primary dystonia involving the trunk had greater improvement in BFMDRS-M and -D scores. Those with primary dystonia of shorter duration and proportion of life with disease, undergoing globus pallidus DBS, had greater improvements in BFMDRS-D scores at long-term follow-up.CONCLUSIONSIn a comprehensive, data-driven, multivariate analysis of DBS for childhood dystonia, the authors identified novel and dissociable patient phenotypes associated with distinct outcomes. The findings of this report may inform surgical candidacy for DBS.

During the current COVID-19 pandemic, timing and preparedness for healthcare facilities are fundamental. This descriptive article narrates the Department of Internal Medicine at the College of Medicine and King Saud University Medical City (KSUMC) response before and during the COVID-19 outbreak by focusing on the preparedness and mitigation plans the department implemented for its clinical services. A COVID-19 taskforce was created to implement the pathways for healthcare workers' workflow organization, plan the effective use of isolation facilities and personal protective equipment, and enhance liaisons between departments in the medical city. Telehealth was utilized for outpatient services, and medications were delivered to patients via courier. Aerosol-generating procedures were conducted after thoroughly reviewing the clinical indications and time-related risks. Medical day unit services followed a strict multistep screening protocol and rescheduled nonurgent investigations and therapeutics when possible. The Department of Internal Medicine prepandemic preparedness helped significantly mitigate the pandemic impact on KSUMC. Prioritizing in-hospital clinical care according to the patients' conditions, full adherence to infection control measures, clear and efficient communication between departments, and utilizing telehealth were the key elements in maintaining state-of-the-art clinical care during the pandemic.

Endoscopic third ventriculostomy/choroid plexus cauterization (ETV/CPC) has gained popularity in its treatment of infantile hydrocephalus over the past decade. In this manuscript, we perform a systematic review and meta-analysis to determine the efficacy and safety of ETV/CPC, and to compare the procedural outcomes between North American and sub-Saharan African cohorts. Systematic review was performed using four electronic databases and bibliographies of relevant articles, with no language or date restrictions. Cohort studies of participants undergoing ETV/CPC that reported outcome were included using MOOSE guidelines. The outcome was time to repeat CSF diversion or death. Forest plots were created for pooled mean and its 95 % CI of outcome and morbidity. Of 78 citations, 11 retrospective reviews (with 524 total participants) were eligible. Efficacy was achieved in 63 % participants at follow-up periods between 6 months and 8 years. Adverse events and mortality was reported in 3.7 and 0.4 % of participants, respectively. Publication bias was detected with respect to efficacy and morbidity of the procedure. A large discrepancy in success was identified between ETV/CPC in six studies from sub-Saharan Africa (71 %), compared to three studies from North America (49 %). The reported success of ETV/CPC for infantile hydrocephalus is higher in sub-Saharan Africa than developed nations. Large long-term prospective multi-center observational studies addressing patient-important outcomes are required to further evaluate the efficacy and safety of this re-emerging procedure.

Background: Complications of nonunited Type II odontoid fractures can range from neck pain to progressive neurological deficit from cervical myelopathy. Rarely, the hypertrophic nonunion requires both anterior transoral decompression and posterior decompression with instrumented fusion. We present a case and review literature around this entity. Case Description: A 68-year-old female presented with rapidly progressive cervical myelopathy (from normal to moderate myelopathy modified Japanese Orthopedic Association [mJOA] 13) over 3 months. Her history was positive for a Type II odontoid fracture managed conservatively and lost to follow-up for 25 years. Spinal imaging studies revealed hypertrophic nonunion and craniocervical kyphotic deformity with significant subaxial stenosis and segmental kyphosis. The patient underwent anterior transoral decompression, followed by posterior occipitothoracic decompression and instrumented fusion. At follow-up, the cervical myelopathy has improved to near normalcy (mJOA 17) with no evidence or implant-related complication. Conclusion: Rarely, nonunion of Type II odontoid fractures may be hypertrophic where both instability and compression cause neurological morbidity. Such cases require anterior transoral decompression, posterior cervical decompression, and instrumented fusions.

Aim We performed a meta-analysis with individual participant data of deep brain stimulation (DBS) for dystonia in children and young people. Method Three databases (PubMed, Embase, and Web of Science) were queried from January 1999 to August 2017 with no language restrictions to identify case studies and cohort studies reporting on pediatric patients (age ≤21y) with dystonia. The primary outcomes were changes in Burke-Fahn-Marsden (BFM) or Barry-Albright Dystonia Scale scores. A mixed-effects regression was used to identify associations between clinical covariates and outcomes. Results Of 2509 citations reviewed, 72 articles (321 children) were eligible. At last follow-up (median 12mo, 25th centile=9.0; 75th centile=32.2), 277 (86.3%) patients showed improvement in dystonia, while 66.1 percent showed clinically significant (>20%) BFM Dystonia Rating Scale-motor improvement. On multivariable hierarchical regression, older age at dystonia onset, inherited dystonia without nervous system pathology and idiopathic dystonia (vs inherited with nervous system pathology or acquired dystonia), and truncal involvement indicated a better outcome (p Interpretation The data suggest that DBS is effective and should be considered in selected children with inherited or idiopathic dystonia. What this paper adds Deep brain stimulation is effective in selected children with inherited or idiopathic dystonia.

OBJECTIVEIn this systematic review and meta-analysis the authors aimed to directly compare open surgical and endoscope-assisted techniques for the treatment of sagittal craniosynostosis, focusing on the outcomes of blood loss, transfusion rate, length of stay, operating time, complication rate, cost, and cosmetic outcome.METHODSA literature search was performed in compliance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Relevant articles were identified from 3 electronic databases (MEDLINE, EMBASE, and CENTRAL [Cochrane Central Register of Controlled Trials]) from their inception to August 2017. The quality of methodology and bias risk were assessed using the Effective Public Health Practice Project Quality Assessment Tool for Quantitative Studies. Effect estimates between groups were calculated as standardized mean differences with 95% CIs. Random and fixed effects models were used to estimate the overall effect.RESULTSOf 316 screened records, 10 met the inclusion criteria, of which 3 were included in the meta-analysis. These studies reported on 303 patients treated endoscopically and 385 patients treated with open surgery. Endoscopic surgery was associated with lower estimated blood loss (p < 0.001), shorter length of stay (p < 0.001), and shorter operating time (p < 0.001). From the literature review of the 10 studies, transfusion rates for endoscopic procedures were consistently lower, with significant differences in 4 of 6 studies; the cost was lower, with differences ranging from $11,603 to $31,744 in 3 of 3 studies; and the cosmetic outcomes were equivocal (p > 0.05) in 3 of 3 studies. Finally, endoscopic techniques demonstrated complication rates similar to or lower than those of open surgery in 8 of 8 studies.CONCLUSIONSEndoscopic procedures are associated with lower estimated blood loss, operating time, and days in hospital. Future long-term prospective registries may establish advantages with respect to complications and cost, with equivalent cosmetic outcomes. Larger studies evaluating patient- or parent-reported satisfaction and optimal timing of intervention as well as heterogeneity in outcomes are indicated.

OBJECTIVEThe aim of this study was to describe the current state of epilepsy surgery and establish estimates of seizure outcomes following surgery for medically intractable epilepsy (MIE) in low- and middle-income countries (LMICs).METHODSThe MEDLINE and Embase databases were searched without publication date restriction. This search was supplemented by a manual screen of key epilepsy and neurosurgical journals (January 2005 to December 2016). Studies that reported outcomes for at least 10 patients of any age undergoing surgery for MIE in LMICs over a defined follow-up period were included. A meta-analysis with a random-effects model was performed in accordance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) statement and MOOSE (Meta-analysis of Observational Studies in Epidemiology) guidelines. Pooled estimates of seizure freedom and favorable seizure outcomes following anterior temporal lobectomy with or without amygdalohippocampectomy (ATL ± AH) were reported.RESULTSTwenty studies were selected, of which 16 were from Asian centers. The average age at surgery in all studies was less than 30 years, and the average preoperative duration of epilepsy ranged from 3 to 16.1 years. Mesial temporal sclerosis accounted for 437 of 951 described pathologies, and 1294 of the 1773 procedures were ATL ± AH. Based on 7 studies (646 patients) the pooled seizure freedom estimate following ATL ± AH was 68% (95% CI 55%–82%). Based on 8 studies (1096 patients), the pooled estimate for favorable seizure outcomes was 79% (95% CI 74%–85%).CONCLUSIONSSurgery for MIE in LMICs shows a high percentage of seizure freedom and favorable outcomes. These findings call for a concerted global effort to improve timely access to surgery for MIE patients in these regions, including investments aimed at refining existing and establishing additional centers.

A 61-year-old man underwent a left cervical internal carotid artery stenting following a recent ischemic stroke. Postoperative angiography was satisfactory and did not reveal any in-stent filling defect (figure 1A). Optical coherence tomography (OCT) probe was used to visualize the endoluminal area following stenting. OCT confirmed optimum placement of the stent and reveled a small plaque protrusion from the stent struts following deployment (figure 1B).

Objectives Wikipedia is the largest online encyclopedia with over 40 million articles, and generating 500 million visits per month. The aim of this study is to assess the readability and quality of Wikipedia pages on neurosurgical related topics. Patients and Methods We selected the neurosurgical related Wikipedia pages based on the series of online patient information articles that are published by the American Association of Neurological Surgeons (AANS). We assessed readability of Wikipedia pages using five different readability scales (Flesch Reading Ease, Flesch Kincaid Grade Level, Gunning Fog Index, SMOG) Grade level, and Coleman-Liau Index). We used the Center for Disease Control (CDC) Clear Communication Index as well as the DISCERN Instrument to evaluate the quality of each Wikipedia article. Results We identified a total of fifty-five Wikipedia articles that corresponded with patient information articles published by the AANS. This constitutes 77.46% of the AANS topics. The mean Flesch Kincaid reading ease score for all of the Wikipedia articles we analyzed is 31.10, which indicates that a college-level education is necessary to understand them. In comparison to the readability analysis for the AANS articles, the Wikipedia articles were more difficult to read across every scale. None of the Wikipedia articles meet the CDC criterion for clear communications. Conclusion Our analyses demonstrated that Wikipedia articles related to neurosurgical topics are associated with higher grade levels for reading and also below the expected levels of clear communications for patients. Collaborative efforts from the neurosurgical community are needed to enhance the readability and quality of Wikipedia pages related to neurosurgery.

OBJECTIVE The Neurosurgical Atlas is a popular world-wide multimedia website in neurosurgery with informative chapters and videos to promote excellence and safety in neurosurgical techniques. Here, we present our analysis of the viewing data of this website. This is intended to describe how online neurosurgical resources are being utilized by today's neurosurgical community. We hope this will be a useful guide for neurosurgeons interested in online multimedia education. DESIGN/SETTING/PARTICIPANTS We analyzed Google Analytics and Vimeo data collected from The Neurosurgical Atlas between June 2016 and August 2017, which tracked user demographics, geographical location, and the videos watched. Views were also analyzed categorically by dividing videos into 6 neurosurgical topics and into basic and advanced levels as per their surgical complexity. RESULTS During the study period, there were 246,259 website visits and 143,868 video plays. The most frequent age group seen was 25 to 34 (44%), followed by 35 to 44 (24%), and 71% of visitors were male. Most website visits were from the United States (29.52%) followed by Brazil (6.43%). There was a steady increase in website visits and video plays over time, with multiple peaks corresponding to promotional email updates. The 6 neurosurgical topics were all similarly popular in video plays, with the general neurosurgical topics being slightly preferred. Similarly, basic and advanced topics were both viewed frequently, with a slight preference for the basic topics. CONCLUSIONS Our study presents the first piece of evidence demonstrating the feasibility and popularity of a free online resource in neurosurgical education. Our experience highlights the growing demand for free-access online chapters, anatomical illustrations, and operative videos. This initiative should not stop with The Neurosurgical Atlas; other surgeons should feel encouraged to employ similar methods to disseminate and advance surgical education.