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BACKGROUND: Middle meningeal artery embolization (MMAE) has been used as an effective minimally invasive treatment for chronic subdural hematomas (cSDH). The demographics and clinical outcomes after MMAE treatment for cSDH have not yet been studied using the large scale of a national database. METHODS: We queried all MMAE cases up to October 7(th), 2020, from the TriNetX Analytics Network. We identified patients >18 years old who underwent MMAE for the treatment of cSDH. Patient demographics, baseline characteristics, comorbidities, and clinical outcomes were evaluated within 180 days post-MMAE. 180-day mortality and recurrence analyses were performed after propensity score matching to control for baseline characteristics and comorbidities. RESULTS: A total 191 patients were included (mean age: 71.2 ± 13.5, 73.3% male, 69.6% White, 13.6% Black/African American, and 16.8% other). Essential hypertension (71.3%), heart disease (62.8%), type 2 diabetes mellitus (27.2%), nicotine dependence (23.6%), chronic kidney disease (19.4%), and overweight/obesity (19.4%) were among the most prevalent comorbidities. At presentation, 20.4% and 40.3% were on antiplatelet and anticoagulation therapy, respectively. Outcomes within a 180-day follow-up were 6.3% (or 1.0–5.8% when propensity-matched) for mortality (12 patients), 7.3% for craniotomy/craniectomy after MMAE (14 patients), 0.52–5.2% for burr hole procedures (1–10 patients), and no patients with low vision/blindness. CONCLUSION: MMAE is a safe and effective minimally invasive procedure for the treatment of cSDH. This represents the first analysis of patients undergoing MMAE for cSDH using a national database.

Objectives: We set out to evaluate the risk for severe coronavirus disease 2019 (COVID-19) infection and subsequent cerebrovascular disease (CVD) in the population with a prior diagnosis of CVD within the past 10 years. Methods: We utilized the TriNetX Analytics Network to query 369,563 CO­VID-19 cases up to December 30, 2020. We created 8 cohorts of patients with COVID-19 diagnosis based on a previous diagnosis of CVD. We measured the odds ratios, relative risks, risk differences for hospitalizations, ICU/critical care services, intubation, mortality, and CVD recurrence within 90 days of COVID-19 diagnosis, compared to a propensity-matched cohort with no prior history of CVD within 90 days of COVID-19 diagnosis. Results: 369,563 patients had a confirmed diagnosis of COVID-19 with a subset of 22,497 (6.09%) patients with a prior diagnosis of CVD within 10 years. All cohorts with a CVD diagnosis had an increased risk of hospitalization, critical care services, and mortality within 90 days of COVID-19 diagnosis. Additionally, the data demonstrate that any history of CVD is associated with significantly increased odds of subsequent CVD post-COVID-19 compared to a matched control. Conclusions: CVD, a known complication of CO­VID-19, is more frequent in patients with a prior history of CVD. Patients with any previous diagnosis of CVD are at higher risks of morbidity and mortality from COVID-19 infection. In patients admitted to the ED due to COVID-19 symptoms, these risk factors should be promptly identified as delayed or missed risk stratification and could lead to an ineffective and untimely diagnosis of subsequent CVD, which would lead to protracted hospitalization and poor prognosis.

Background Few studies have investigated opioid utilization by geriatric patients after spinal surgery, a population in whom degenerative spine disease (DSD) is highly prevalent. We aimed to quantify rates of chronic, continuous opioid utilization by geriatric patients following spine surgery for DSD-related diagnoses. Materials and methods Utilizing a national 5% Medicare sample database, we investigated individuals aged above 66 years who underwent spinal surgery for a DSD-related diagnosis between the years of 2008 and 2014. The outcomes of interest were the rate of and risk factors for continuous opioid utilization at 1-year following anterior cervical discectomy and fusion, posterior cervical fusion, 360-degree cervical fusion, lumbar microdiscectomy, lumbar laminectomy, posterior lumbar fusion, anterior lumbar fusion, or 360-degree lumbar fusion for a DSD-related diagnosis. Results Of the 14,583 Medicare enrollees who met study criteria, 6.0% continuously utilized opioids 1-year after spinal surgery. When stratified by preoperative opioid utilization (with the prior year divided into 4 quarters), the rates of continuous utilization at 1-year postsurgery were 0.3% of opioid-naive patients and 23.6% of patients with opioid use in all 4 quarters before surgery. Anxiety, benzodiazepine use within the year before surgery, and Medicaid dual-eligibility were associated with prolonged opioid utilization. Conclusions Of opioid-naive geriatric patients who underwent surgery for DSD, 0.3% developed chronic, continuous opioid use. Preoperative opioid use was the strongest predictor of prolonged utilization, which may represent suboptimal use of nonopioid alternatives, pre-existing opioid use disorders, delayed referral for surgical evaluation, or over-prescription of opioids for noncancer pain.

Objective Atypical and anaplastic meningiomas, unlike their benign counterparts, are highly aggressive, locally destructive, and likely to recur after treatment. These diseases are difficult to definitively treat with traditional radiotherapy without injuring adjacent brain parenchyma. The physical properties of ion radiotherapy allows for treatment plans that avoid damaging critical neural structures. The objectives of this systematic review were to evaluate the use and efficacy of ion radiotherapy in the treatment of atypical and anaplastic meningiomas. Methods We performed a systematic review of the literature by querying the PubMed and Ovid databases to identify and examine literature addressing the efficacy of ion radiotherapy in maintaining long-term local tumor control for patients with atypical or anaplastic meningiomas. The outcome of interest was rate of local tumor control at 5 years after ion radiotherapy. Results Across the included studies, proton therapy delivered a mean local control rate of 59.62% after 5 years. Carbon ion radiotherapy studies showed local control rates of 95% and 63% at 2 years for grade II and III meningiomas, respectively. In contrast, carbon ion radiotherapy studies that failed to differentiate between atypical and anaplastic meningiomas produced a local control rate of 33% at 2 years. Conclusions Proton and carbon ion radiotherapy maintain comparable rates of local control to conventional photon therapy and allow for more targeted treatment plans that may limit excess radiation damage. Although additional prospective trials are needed, ion therapy represents a burgeoning field in the treatment of atypical and anaplastic meningiomas.

Background When diagnosed simultaneously, obesity, diabetes, and hypertension form a medical constellation called metabolic syndrome (MetS). The prevalence of MetS in Western cultures has been on a steady increase and MetS has been associated with increased postoperative complications in multiple surgical settings. Objective In this study, we evaluate the relationship between MetS and the outcomes of craniotomy for supratentorial brain tumor. Methods Cases of craniotomy for supratentorial brain tumors were extracted from the American College of Surgeons National Surgical Quality Improvement Program for 2012–2016. The 15,136 patients identified were divided into 2 cohorts based on the presence (4.1%) or absence (95.9%) of MetS. We compared the 2 cohorts for preoperative comorbidities, intraoperative details, and postoperative morbidity and mortality. Results Patients in the MetS+ cohort were significantly older (63.4 vs. 56.1 years) and were more likely to show comorbidities of various organ systems (all P ≤ 0.05). However, operative times were similar (P = 0.573). The number of medical complications was almost double in patients with MetS (15.8% vs. 8.5%; P ≤ 0.001). Unplanned readmissions (14.6% vs. 10.4%; P = 0.004), reoperations (6.9% vs. 4.6%; P = 0.007), and mortality (5.6% vs. 2.9%; P ≤ 0.001) were also more frequent in our MetS+ group. Nevertheless, surgical complications localized to the operative site were not statistically increased (7.4% vs. 5.8%; P = 0.098). Conclusions A diagnosis of MetS does not seem to be associated with increased rates of surgical site events. However, neurosurgeons should be aware that these patients have a significantly higher likelihood of general medical complications, readmissions, reoperations, and death.

Background Middle meningeal artery embolization (MMAE) has been used as an effective minimally invasive treatment for chronic subdural hematomas (cSDH). The demographics and clinical outcomes after MMAE treatment for cSDH have not yet been studied using the large scale of a national database. Methods We queried all MMAE cases up to March 19th, 2021 from the TriNetX Analytics Network. We identified patients >18 years old who underwent MMAE for the treatment of cSDH. Patient demographics, baseline characteristics, comorbidities, and clinical outcomes were evaluated within 1-year post-MMAE. 1-year mortality and recurrence analyses were performed after propensity score matching to control for baseline characteristics and comorbidities. Results A total 292 patients were included (mean age: 70.6 ± 13.9, 27.7% female, 71.6% White, 13.0% Black/African American, and 15.4% other). Essential hypertension (71.9%), heart disease (61.6%), type 2 diabetes mellitus (27.4%), nicotine dependence (26.0%), chronic kidney disease (19.52%), and overweight/obesity (18.2%) were among the most prevalent comorbidities. At presentation, 21.6% and 42.7% were on antiplatelet and anticoagulation therapy, respectively. Outcomes within a one-year follow-up were 6.2% (or 2.74-5.82% when propensity-matched) for mortality (18 patients), 0.34-3.4% for repeat MMAE (1-10 patients), 6.5% for craniotomy/craniectomy after MMAE (19 patients), 5.1% for burr hole procedures (15 patients), and 0.35-3.5% for low vision/blindness (1-10 patients). Conclusion MMAE is a safe and effective minimally invasive procedure for the treatment of cSDH. This represents the first analysis of patients undergoing MMAE for cSDH using a national database. Disclosures A. Nia: None. R. Lall: None. V. Srinivasan: None. P. Kan: None.

Infections of the lumbar spine can have serious sequelae, including neurological deficits, paralysis, and death. Prolonged infection can result in fracture of the vertebrae, local abscesses, and infiltration and compression of local vascular structures. In cases with significant instability or neurological compromise, a common treatment approach is vertebral corpectomy with interbody cage followed by long-term antibiotics. The following case describes a patient with a three-month history of progressively worsening lower back pain, lower extremity radiculopathy, and bilateral lower extremity edema, in the setting of a nontraumatic three-column fracture dislocation of L5 with grade 4 retrolisthesis of L4 on L5. A posterior-only corpectomy with placement of an expandable cage, to be followed by pedicle screw placement from L3-S1/ilium, was performed. The procedure was successful, and the patient was discharged on postoperative day 5 without complication and with resolution of his edema. Histopathological analysis demonstrated acute and chronic inflammation, but extensive tests and cultures failed to identify a causative organism. This case highlights several interesting features, including a technically challenging and seldom-performed procedure, as well as the ability of lumbar spinal infections to present with leg edema due to involvement the inferior vena cava and iliac vessels. For patients with three-column fractures of L5 due to an inflammatory process or trauma, a single-stage posterior corpectomy with placement of an expandable cage may be considered as an appropriate treatment option.

The growing elderly population in Western societies has led to an increasing number of primary brain tumors occurring in patients beyond the age of 65. The purpose of this study was to assess and compare the safety, efficacy, and outcomes of oncological craniotomy procedures between patients above and below 65 years. We performed a retrospective analysis of the ACS-NSQIP database to identify patients undergoing supratentorial and infratentorial tumor excisions by neurosurgeons between 2008 and 2016. We stratified them based on a cutoff age of 65 years and analyzed for minor and major complications, reoperation, the total length of hospital stay, and mortality within a standardized 30-day follow-up. Among the 30,183 analyzed patients, 9,652 (32%) were elderly (age ≥ 65). The bivariate analysis demonstrated significantly increased risk of complications, including major and minor complications and mortality in patients with metabolic syndrome, preoperative steroid use, and ASA classification ≥3. (p-value ≤ 0.001***). After controlling for confounding variables in our logistic regression models, older age, metabolic syndrome, extended operative time beyond 5 h, dependent functional health status, ASA class ≥3, steroid use pre-operatively, and black/African American race were found to be significant predictors of major and minor complication. Our study provides a comprehensive analysis of perioperative risk factors and predictors of adverse outcomes following craniotomy for supratentorial and infratentorial tumors in elderly patients. We identified increased age as an independent risk factor for minor and major adverse events as well as extended hospitalization.

Two unlike metals near one another can break down as they move toward electrochemical equilibrium resulting in galvanic corrosion. We describe a case of electrochemical corrosion resulting in pseudarthrosis, followed by instrumentation failure leading to subarachnoid hemorrhage. A 53-year-old female with a history of cervical instability and two separate prior cervical fusion surgery with sublaminar cables presented with new onset severe neck pain. Restricted range of motion in her neck and bilateral Hoffman's was noted. X-ray of her cervical spine was negative. A noncontrast CT scan of her head and neck showed subarachnoid hemorrhage in the prepontine and cervicomedullary cisterns. Neurosurgical intervention involved removal of prior stainless steel and titanium cables, repair of cerebrospinal fluid leak, and nonsegmental C1–C3 instrumented fusion. She tolerated the surgery well and followed up without complication. Galvanic corrosion of the Brook's fusion secondary to current flow between dissimilar metal alloys resulted in catastrophic instrumentation failure and subarachnoid hemorrhage.

Object Patients with systemic cancer and a single brain metastasis who undergo treatment with resection plus radiotherapy live longer and have a better quality of life than those treated with radiotherapy alone. Historically, whole-brain radiotherapy (WBRT) has been the mainstay of radiation therapy; however, it is associated with significant delayed neurocognitive sequelae. In this study, the authors looked at survival in patients with single and multiple intracranial metastases who had undergone surgery and adjuvant stereotactic radiosurgery (SRS) to the tumor bed and synchronous lesions. Methods The authors retrospectively reviewed the records from an 8-year period at a single institution for consecutive patients with brain metastases treated via complete resection of dominant lesions and adjuvant radiosurgery. The cohort was analyzed for time to local progression, synchronous lesion progression, new intracranial lesion development, systemic progression, and overall survival. The Kaplan-Meier method (stratified by age, sex, tumor histology, and number of intracranial lesions prior to surgery) was used to calculate both progression-free and overall survival. A Cox proportional-hazards regression model was also fitted with the number of intracranial lesions as the predictor and survival as the outcome controlling for disease severity, age, sex, and primary histology. Results The median overall follow-up among the 150-person cohort eligible for analysis was 17 months. Patients had an average age of 46.2 years (range 16–82 years), and 62.7% were female. The mean (± standard deviation) number of intracranial lesions per patient was 2.5 ± 2.3. The mean time between surgery and stereotactic radiosurgery (SRS) was 3.2 ± 4.1 weeks. Primary cancers included lung cancer (43.3%), breast cancer (21.3%), melanoma (10.0%), renal cell carcinoma (6.7%), and colon cancer (6.7%). The average number of isocenters per treated lesion was 7.6 ± 6.6, and the average treatment dose was 17.8 ± 2.8 Gy. One-year survival for patients in this cohort was 52%, and the 1-year local control rate was 77%. The median (±standard error) overall survival was 13.2 ± 1.9 months. There was no difference in survival between patients with a single lesion and those with multiple lesions (p = 0.319) after controlling for age, sex, and histology of primary tumor. Patients with primary breast histology had the greatest overall median survival (22.9 ± 6.2 months); patients with colorectal cancer had the shortest overall median survival (5.3 ± 1.8 months). The most common cause of death in this series was systemic progression (79%). Conclusions These results confirm that 1-year survival for patients with multiple intracranial metastases treated with resection followed by SRS to both the tumor bed and synchronous lesions is similar to established outcomes for patients with a single intracranial metastasis.

Patients with high-grade glioma are at elevated risk of venous thromboembolism (VTE). The relationship between VTE and survival in glioma patients remains unclear, as does the optimal protocol for chemoprophylaxis. The purpose of this study was to assessthe incidence of and risk factors associated with VTE in patients with high-grade glioma, and the correlation between VTE and survival in this population. Furthermore, we sought to define a protocol for perioperative DVT prophylaxis. This was a retrospective review of patients who underwent craniotomy for resection of high-grade glioma (WHO grade III or IV) at Northwestern University between 1999 and 2010. A total of 336 patients met inclusion criteria. 53 patients developed postoperative VTE (15.7 %). Median survival was 12.0 months and was not significantly different between VTE(+) and VTE(-) patients. Demographics and surgical factors were not significantly correlated with VTE development. Prior history of VTE was highly predictive of postoperative VTE (OR 7.1, p < .01), as was seizure (OR 2.4, p = .005). Increased duration of postoperative ICU stay was also a risk factor for VTE (p = .025). 25 patients in our study received prophylactic anticoagulation(pAC) with either heparin or enoxaparin. Early initiation of pAC was associated with decreased incidence of VTE (p = .042). There were no hemorrhagic complications in patients receiving pAC. VTE is a common complication in high-grade glioma patients. Early initiation of anticoagulation is safe and may decrease the risk of VTE. We recommend initiation of chemoprophylaxis on postoperative day 1 in patients without contraindication.

Stereotactic radiosurgery (SRS) is often used as adjuvant treatment for residual or recurrent tumor following microsurgical resection of posterior fossa meningiomas. SRS is associated with excellent rates of local control, however long-term complications remain unclear. Secondary malignancy is an often discussed but rarely described complication of SRS. We present a 56-year-old woman who underwent near total resection of a petroclival meningioma, followed by two episodes of SRS over the ensuing 8 years for local recurrence. She returned 14 years after initial diagnosis with neurologic deterioration and was found to have massive recurrence. Pathology was consistent with high-grade chondrosarcoma. The tumor continued to progress despite debulking and proton-beam therapy and the patient died of medical complications. To our knowledge this is the first report of malignant transformation of a meningioma to high-grade chondrosarcoma, further notable due to the remarkable clinical course and delayed presentation after initial surgery and radiosurgery. Though this may have been a de novo tumor, it is also possible that this represents a case of radiation-induced neoplasm. Although SRS continues to gain favor as a treatment modality, delayed malignant degeneration is a potential complication and physicians should counsel patients of this risk.

Objectives This study aims to report tumor control rates and cranial nerve function after low dose (11.0 Gy) Gamma knife radiosurgery (GKRS) in patients with vestibular schwannomas. Methods A retrospective chart review was performed on 30 consecutive patients with vestibular schwannomas treated from March 2004 to August 2010 with GKRS at the Robert H. Lurie Comprehensive Cancer Center of Northwestern University. The marginal dose for all patients was 11.0 Gy prescribed to the 50% isodose line. Median follow-up time was 42 months. The median treatment volume was 0.53 cm 3 . Hearing data were obtained from audiometry reports before and after radiosurgery. Results The actuarial progression free survival (PFS) based on freedom from surgery was 100% at 5 years. PFS based on freedom from persistent growth was 91% at 5 years. One patient experienced tumor progression requiring resection at 87 months. Serviceable hearing, defined as Gardner–Robertson score of I–II, was preserved in 50% of patients. On univariate and multivariate analyses, only higher mean and maximum dose to the cochlea significantly decreased the proportion of patients with serviceable hearing. Conclusion Vestibular schwannomas can be treated with low doses (11.0 Gy) of GKRS with good tumor control and cranial nerve preservation.

While Vagus Nerve Stimulation (VNS) is proven to be a safe and effective adjunctive therapy in the general population with medically intractable seizures, little is published about its implantation during pregnancy. Here we illustrate the case of a 21year old primigravid woman with medically refractory seizures who underwent safe and successful VNS implantation and immediate activation of the device in her 32nd week of pregnancy, resulting in dramatically improved seizure control and subsequent delivery of a healthy baby.

OBJECTIVEGlioblastoma (GBM) and primary central nervous system lymphoma (PCNSL) are common intracranial pathologies encountered by neurosurgeons. They often may have similar radiological findings, making diagnosis difficult without surgical biopsy; however, management is quite different between these two entities. Recently, predictive analytics, including machine learning (ML), have garnered attention for their potential to aid in the diagnostic assessment of a variety of pathologies. Several ML algorithms have recently been designed to differentiate GBM from PCNSL radiologically with a high sensitivity and specificity. The objective of this systematic review and meta-analysis was to evaluate the implementation of ML algorithms in differentiating GBM and PCNSL.METHODSThe authors performed a systematic review of the literature using PubMed in accordance with PRISMA guidelines to select and evaluate studies that included themes of ML and brain tumors. These studies were further narrowed down to focus on works published between January 2008 and May 2018 addressing the use of ML in training models to distinguish between GBM and PCNSL on radiological imaging. Outcomes assessed were test characteristics such as accuracy, sensitivity, specificity, and area under the receiver operating characteristic curve (AUC).RESULTSEight studies were identified addressing use of ML in training classifiers to distinguish between GBM and PCNSL on radiological imaging. ML performed well with the lowest reported AUC being 0.878. In studies in which ML was directly compared with radiologists, ML performed better than or as well as the radiologists. However, when ML was applied to an external data set, it performed more poorly.CONCLUSIONSFew studies have applied ML to solve the problem of differentiating GBM from PCNSL using imaging alone. Of the currently published studies, ML algorithms have demonstrated promising results and certainly have the potential to aid radiologists with difficult cases, which could expedite the neurosurgical decision-making process. It is likely that ML algorithms will help to optimize neurosurgical patient outcomes as well as the cost-effectiveness of neurosurgical care if the problem of overfitting can be overcome.

Patients who undergo craniotomy for brain neoplasms have a high risk of developing venous thromboembolism (VTE), including deep vein thromboses (DVT) and pulmonary emboli (PE). The reasons for this correlation are not fully understood. This retrospective, single-center review aimed to determine the risk factors for VTE in patients who underwent neurosurgical resection of brain tumors at Northwestern University from 1999 to 2010. Our cohort included 1148 patients, 158 (13.7%) of whom were diagnosed with DVT and 38 (3.3%) of whom were diagnosed with PE. A variety of clinical factors were studied to determine predictors of VTE, including sex, ethnicity, medical co-morbidities, surgical positioning, length of hospital stay, tumor location, and tumor histology. Use of post-operative anticoagulants and hemorrhagic complications were also investigated. A prior history of VTE was found to be highly predictive of post-operative DVT (odds ratio [OR]=7.6, p=0.01), as was the patient's sex (OR=14.2, p

Invasive central nervous system aspergillosis is a rare form of fungal infection that presents most commonly in immunocompromised individuals. There have been multiple previous reports of aspergillus vertebral osteomyelitis and spinal epidural aspergillus abscess; however to our knowledge there are no reports of intramedullary aspergillus infection. We present a 19-year-old woman with active acute lymphoblastic leukemia who presented with several weeks of fevers and bilateral lower extremity weakness. She was found to have an intramedullary aspergillus abscess at T12-L1 resulting from adjacent vertebral osteomyelitis and underwent surgical debridement with ultra-sound guided aspiration and aggressive intravenous voriconazole therapy. To our knowledge this is the first reported case of spinal aspergillosis invading the intramedullary cavity. Though rare, this entity should be included in the differential for immunocompromised patients presenting with fevers and neurologic deficit. Early recognition with aggressive neurosurgical intervention and antifungal therapy may improve outcomes in future cases.