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The prevalence of intracranial aneurysms (IAs) is higher in patients with internal carotid artery (ICA) stenosis, likely due to alterations in intracranial hemodynamics. Severe stenosis or occlusion of one ICA may result in increased demand and altered hemodynamics in the contralateral ICA, thus increasing the risk of contralateral IA formation. In this article, we discuss a relevant case and a comprehensive literature review as it pertains to the association of ICA stenosis and IA. Our patient was a 50-year-old female with a chronic asymptomatic right ICA occlusion who presented with diffuse subarachnoid hemorrhage. Emergent angiography revealed left-sided A1-A2 junction, paraclinoid, left middle cerebral artery (MCA) bifurcation, and left anterior temporal artery aneurysms. Brisk filling of the right anterior circulation through the anterior communicating artery was also identified, signifying increased demand on the left ICA circulation. Complete obliteration of all aneurysms was achieved with coil embolization and clipping. For our literature review, we searched the PubMed and EMBASE databases for case reports and case series, as well as references in previously published review articles that described patients with concurrent aneurysms and ICA stenosis. We selected articles that provided adequate information about the case presentations to compare aneurysm and patient characteristics. Our review revealed a higher number of patients with multiple aneurysms contralateral (25%) to rather than ipsilateral to (6%), the ICA stenosis. We discuss the pathogenesis and management of multiple flow-related IA in the context of the existing literature related to concurrent ICA stenosis and IA., Competing Interests: There are no conflicts of interest., (Copyright: © 2020 Brain Circulation.)

Background: Xanthomatous hypophysitis (XH) is the rarest histologic type of primary hypophysitis. It is nonlymphocytic and characterized by an infiltration of the pituitary gland by lipid-laden histiocytes and macrophages. The clinical and radiologic features overlap heavily with pituitary adenomas and are prone to misdiagnosis. We describe a rare case of XH recurrence at 1 year, treated surgically. Moreover, we provide an updated review of the literature to further elucidate useful management and detection strategies., Case Description: A 45-year-old woman presented with a history of menstrual irregularity for 9 months, amenorrhea, galactorrhea, and headache for 2 months duration. Preoperative endocrinologic studies showed increased prolactin levels. Magnetic resonance imaging of the sella showed a cystic lesion with suprasellar extension suggestive of a pituitary adenoma. The patient underwent transsphenoidal resection, showing a thick yellowish colloidal material. Histopathology showed necrotic tissue with no definitive diagnosis and no identified microorganisms. At 2 months after surgery, prolactin levels and menstrual cycle normalized. At 1 year after surgery, her menstrual cycle again became irregular. Repeat magnetic resonance imaging showed a recurrent mass and a second transsphenoidal resection was undertaken. Repeat histopathology was consistent with XH. The patient is 9 years postoperative and is doing well without evidence of recurrence., Conclusions: XH presents similarly to nonfunctional adenomas and diagnosis remains difficult without surgical pathology, requiring meticulous immunohistochemistry to prevent misdiagnosis. Thus, XH should be considered as a rare cause in the differential of disease of the sellar region. Management can parallel that of pituitary neoplasm, with a focus on radiosurgery, re-resection, and high-dose steroids., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background: Chiari I malformation (CIM) is a disorder characterized by caudal displacement of the cerebellar tonsils below the foramen magnum. It is often associated with syringomyelia and occasionally with hydrocephalus. CIM is commonly treated by posterior fossa decompression with or without removal of the posterior arch of C1 and duraplasty, but the treatment for infants with symptomatic CIM is not well established. We present a case of symptomatic CIM in an infant that was successfully treated with a ventriculoperitoneal shunt (VPS) and discuss the importance of the pathophysiology in management decisions., Case Description: A 6-month-old male with a CIM and a cervicothoracic syrinx presented with stridor, lower cranial nerve dysfunction, and increased tone that worsened with crying. Magnetic resonance imaging studies revealed cerebellar tonsillar displacement extending to the level of C3-C4 with a syrinx extending from C4 to T4. In addition, there was compression of the cervicomedullary junction, fourth ventricular outflow obstruction, and obstructive hydrocephalus. The decision was made to place a ventriculoperitoneal shunt (VPS) instead of performing decompressive surgery as the initial treatment intervention. The infant had significant symptomatic relief at 6-, 9-, and 12-month follow-ups. Postoperative magnetic resonance imaging at 6-month follow-up revealed resolution of the syrinx and ventriculomegaly and ascent of the cerebellar tonsils., Conclusions: Ventriculoperitoneal shunting alone was successfully used to treat an infant with concurrent CIM, syrinx, and hydrocephalus. This case underscores not only the importance of hydrocephalus as the pathogenesis of CIM in some cases but also the possibility of avoiding the morbidity of decompressive surgery in infants., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background: Little attention has been given to the retroverted dens within the existing medical literature. However, this finding can have a clinical impact, especially in patients with Chiari malformation type I (CM1), as it can have consequences for further treatment., Methods: Using standard search engines, we performed a literature review of anatomical, radiologic, and clinical studies as well as pathologic and surgical considerations related to the retroverted dens. Key words for our search included retroverted dens; retroflexed dens; odontoid retroflexion; posterior inclination; and tilted dens., Results: A retroverted dens is most commonly found in the pediatric population in relation to CM1. Research has demonstrated that high degree of dens angulation can result in significant anterior brain stem compression with the need for both anterior and posterior decompression in patients with symptomatic CM1., Conclusions: A greater degree of dens angulation can lead to neurologic symptoms secondary to spinomedullary compression. Therefore, correct measurements are essential as such findings can influence presurgical planning., (Copyright © 2020 Elsevier Inc. All rights reserved.)

The thalamus is a deep cerebral structure that is crucial for proper neurological functioning as it transmits signals from nearly all pathways in the body. Insult to the thalamus can, therefore, result in complex syndromes involving sensation, cognition, executive function, fine motor control, emotion, and arousal, to name a few. Specific territories in the thalamus that are supplied by deep cerebral arteries have been shown to correlate with clinical symptoms. The aim of this review is to enhance our understanding of the arterial anatomy of the thalamus and the complications that can arise from lesions to it by considering the functions of known thalamic nuclei supplied by each vascular territory., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background: "White cord syndrome" or reperfusion injury of chronically ischemic areas of the spinal cord is a relatively newly defined etiology in spinal surgery. This rare syndrome is characterized as unexplained new neurological deficits after an anterior or posterior decompressive cervical procedure. The radiographic hallmark is the presence of hyperintense T2 intramedullary signal change after a decompressive procedure without other pathologic changes. We present an additional case of this complication and review the literature., Case Presentation: A 79-year-old man presented in consultation for advanced cervical myelopathy. He had experienced 2-3 months of worsening gait instability and issues with hand dexterity. Three days prior to presentation his lower extremity weakness had worsened to the point he was no longer able to ambulate. Magnetic resonance imaging (MRI) of the cervical spine demonstrated severe central canal stenosis secondary to spondylosis with T2 hyperintensity correlating to myelomalacia. He underwent an uncomplicated posterior cervical decompression and fusion and awoke with worsened right hemiparesis from neurologic baseline. Brain MRI was negative for stroke and MRI of the cervical spine showed successful decompression but worsening T2 signal changes. The patient's weakness improved with maintaining mean arterial pressure (MAP) goal, steroids, and physical therapy. He was eventually discharged to an acute rehabilitation facility., Conclusions: White cord syndrome is rare and has only been reported in 5 other patients upon review of the literature. Our case is the 7th general and the 5th after posterior cervical decompression. The pathophysiology is thought to be due to a reperfusion type injury of chronically ischemic areas of the spinal cord. All but one patient to date have improved after MAP goal, steroid administration therapy, and acute rehabilitation, including our patients. Spine surgeons should be aware of this potentially devastating complication and how to properly manage these patients' postoperative care., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background: Cauda equina syndrome (CES) results from the dysfunction of the lumbar, sacral, and coccygeal rootlets composing the cauda equina. The underlying etiology is most commonly compression secondary to a large herniated lumbosacral disk; however, any pathology affecting the rootlets can result in the syndrome., Methods: We present a rare case of CES secondary to neoplastic polyradiculitis in a patient with acute myelogenous leukemia (AML) and review the pertinent literature. A 72-year-old male with a medical history of AML presented with 2 weeks of difficulty ambulating, followed by acute-onset low back pain radiating to the buttocks bilaterally., Results: Imaging of the lumbar spine demonstrated diffuse enhancement and thickening of the cauda equina rootlets. Lumbar puncture showed numerous blasts with monocytoid features consistent with AML, and the patient was diagnosed with polyradiculopathy of the cauda equina secondary to diffuse metastatic infiltration., Conclusions: Central nervous system involvement of leukemia is poorly understood, even though such lesions are not uncommon in advanced disease. As treatment has improved, many types of leukemia, such as AML, are believed to be curable, and patients with the disease are living longer. With improved survival, it is reasonable to suspect that such involvement by AML may become more common. Our patient is a classic presentation of CES secondary to diffuse infiltration by AML and serves as an example of this rare manifestation of hematologic malignancy., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Cervical spondylotic myelopathy (CSM) can predispose to acute spinal cord injury and post-operative quadriparesis during non-spine procedures, although few accounts of this phenomenon exist within the literature. To the best of our knowledge, there are only 18 cases reported in the literature including ours with spinal cord injury following elective non-spine surgery with undiagnosed CSM. Due to multifactorial pathophysiology, the maintenance of cervical cord neutrality is not sufficient to ensure that these patients will not sustain cord injury intraoperatively as this solely addresses the role of static factors. Vigilance to factors affecting cord perfusion and vascular compromise, such as the mean arterial pressure (MAP), is imperative. Additionally, further studies should evaluate the role of positioning in the myelopathic patient and whether the steep Trendelenburg position, commonly used in robotic surgeries, contributes to spinal cord venous congestion and resultant cord ischemia in these patients given their baseline stenotic canal. This review illustrates the importance of having a heightened awareness of this common degenerative condition in our aging patient population, often a forgotten underlying medical comorbidity., (Copyright © 2019 Elsevier B.V. All rights reserved.)

Background: Intracranial extension of frontal or ethmoid sinusitis carries a high morbidity and mortality if not treated aggressively. With the emergence of endoscopic sinus surgery (ESS), we questioned whether these approaches have supplanted traditional transcranial procedures for intracranial extension of sinus disease, and whether ESS approaches had a difference in patient outcomes., Methods: Studies reporting surgical management and outcomes of frontal sinus disease with intracranial extension were queried using the United States National Library of Medicine at the National Institutes of Health PubMed database. We also queried common internet search engines. We included studies regarding sinogenic intracranial suppurative infections treated surgically with ESS and neurosurgical approaches. Studies with insufficient data regarding specific treatment methods and studies that included populations of medically treated infections were excluded., Results: A total of 108 cases were identified in which patients with intracranial sinogenic disease were treated via ESS alone (morbidity: 43.5%, mortality: 0.9%), 47 cases via transcranial intervention alone (morbidity: 33.2%, mortality: 7.8%), and 43 cases via simultaneous neurosurgical and ESS approaches (morbidity: 16.3%, mortality: 6.4%). Complex sinus disease with posterior table compromise in the absence of intracranial extension treated via ESS alone was reported in 164 cases with a morbidity and mortality of 3.8% and 0%, respectively., Conclusions: Combined ESS and transcranial approaches achieve definitive control of sinogenic and intracranial disease, whereas either modality alone carries a potential risk for higher morbidity and mortality. The use of ESS alone may have use in the treatment of sinusitis with posterior table erosion prior to intracranial extension., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Objectives: Deep brain stimulation (DBS) is the surgical treatment of choice for moderate to severe Parkinson's Disease (PD). However, few studies have assessed its efficacy in severe PD as defined by the modified Hoehn and Yahr scale (HY). This study evaluates long-term and medication outcomes of DBS in severe PD., Patients and Methods: We retrospectively collected the data of 15 patients from 2008 to 2014 with severe PD treated with DBS. Retrospective assessment with the modified Hoehn and Yahr scale and motor subset of the Unified Parkinson's Disease Rating Scale (UPDRS III) were used to objectively track severity and motor function improvement, respectively. Levodopa equivalence daily doses (LEDD), number of anti-PD medications and number of daily medication doses were used to measure improvements in medication burden. Data was evaluated using univariate analyses, one sample paired t-test, two sample paired t-test, and Wilcoxon signed-rank test., Results: The mean post-operative follow-up was 44.63 months, average age at diagnosis and the average age at time of DBS was 51.3 years and 61.5 years, respectively, and the time from diagnosis to treatment was 13.2 years. Significant decreases were seen in UPDRS III scores (pre-op = 44.533; post-op = 26.13; p = 0.0094), LEDD (pre-op = 1679.34 mg; post-op = 837.48 mg; p = 0.0049), and number of daily doses (pre-op = 21.266; post-op 12.2; p = 0.0046). No significant decrease was seen in the number of anti-PD medications (pre-op = 3.8; post-op = 3.2; p = 0.16)., Conclusion: Following DBS, severe PD patients demonstrated significant improvements in motor function and medication burden during long-term follow-up. We believe our results prove that DBS is efficacious in the management of severe PD, and that further research should follow to expand DBS criteria to include severe disease., (Copyright © 2019. Published by Elsevier B.V.)

Objective: Deep brain stimulation (DBS) is the procedure of choice for Parkinson's disease (PD). It has been used in PD patients younger than 70 years because of better perceived intra- and postoperative outcomes than in patients 70 years or older. However, previous studies with limited follow-up have demonstrated benefits associated with the treatment of elderly patients. This study aims to evaluate the long-term outcomes in elderly PD patients treated with DBS in comparison with a younger population., Methods: PD patients treated with DBS at the authors' institution from 2008 to 2014 were divided into 2 groups: 1) elderly patients, defined as having an age at surgery ≥ 70 years, and 2) young patients, defined as those < 70 years at surgery. Functional and medical treatment outcomes were evaluated using the Unified Parkinson's Disease Rating Scale part III (UPDRS III), levodopa-equivalent daily dose (LEDD), number of daily doses, and number of anti-PD medications. Study outcomes were compared using univariate analyses, 1-sample paired t-tests, and 2-sample t-tests., Results: A total of 151 patients were studied, of whom 24.5% were ≥ 70 years. The most common preoperative Hoehn and Yahr stages for both groups were 2 and 3. On average, elderly patients had more comorbidities at the time of surgery than their younger counterparts (1 vs 0, p = 0.0001) as well as a higher average LEDD (891 mg vs 665 mg, p = 0.008). Both groups experienced significant decreases in LEDD following surgery (elderly 331.38 mg, p = 0.0001; and young 108.6 mg, p = 0.0439), with a more significant decrease seen in elderly patients (young 108.6 mg vs elderly 331.38 mg, p = 0.0153). Elderly patients also experienced more significant reductions in daily doses (young 0.65 vs elderly 3.567, p = 0.0344). Both groups experienced significant improvements in motor function determined by reductions in UPDRS III scores (elderly 16.29 vs young 12.85, p < 0.0001); however, reductions in motor score between groups were not significant. Improvement in motor function was present for a mean follow-up of 3.383 years postsurgery for the young group and 3.51 years for the elderly group. The average follow-up was 40.6 months in the young group and 42.2 months in the elderly group., Conclusions: This study found long-term improvements in motor function and medication requirements in both elderly and young PD patients treated with DBS. These outcomes suggest that DBS can be successfully used in PD patients ≥ 70 years. Further studies will expand on these findings.

Background: Standard open surgical management of thoracolumbar infection, trauma, and tumor is associated with significant morbidity. We compared perioperative and immediate postoperative morbidity of open and mini-open thoracolumbar corpectomy techniques including direct hospital costs., Methods: We retrospectively reviewed medical records of all patients who underwent open or mini-open corpectomy. Demographics (age, sex, body mass index, primary diagnosis), operative data (length of surgery, estimated blood loss, blood transfusion), surgical level, preoperative and postoperative neurologic status (using American Spinal Injury Association Impairment Scale), immediate perioperative complications (within 30 days postoperatively), overall length of stay from admission, length of stay from surgery, and total direct hospital costs were tabulated and analyzed., Results: The study included 43 patients, 20 (46.51%) undergoing open corpectomy and 23 (53.48%) undergoing mini-open corpectomy. Clinical and statistically significant findings in favor of mini-open corpectomy included lower estimated blood loss (1305 mL vs. 560 mL, P = 0.0072), less blood transfusion (241 mL vs. 667 mL, P = 0.029), shorter overall length of stay (7.2 days vs. 12.2 days, P = 0.047), and shorter surgery time (376 minutes vs. 295 minutes, P = 0.035) as well as lower total direct hospital cost ($34,373 vs. $45,376, P = 0.044). There was no statistically significant difference in postoperative complications between the 2 groups (medical complications 5% vs. 4.3%, P = 0.891; surgical complications 5% vs. 8.69%, P = 0.534)., Conclusions: Mini-open TL corpectomy is a safe, cost-effective, clinically effective, and less morbid alternative to standard open thoracotomy surgical techniques., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Background: Parkinson disease (PD) is a common neurodegenerative disease in elderly patients that may be treated with deep brain stimulation (DBS). DBS is an accepted surgical treatment in PD patients <70 years that demonstrates marked improvement in disease symptomology. Patients ≥70 years historically have been excluded from DBS therapy. Our objective is to evaluate the short- and long-term outcomes in patients with PD ≥70 years who underwent DBS at our center., Methods: In our single-center study, we retrospectively assessed a prospective registry of patients with PD treated with DBS who were ≥70 years old at the time of their procedure. Univariate analyses and 1-sample paired t test were used to evaluate data. Motor scores were evaluated with the Unified Parkinson's Disease Rating Scale III, and the effects on medication requirements were evaluated with levodopa equivalence daily doses (LEDD)., Results: Thirty-seven patients were followed for an average of 42.2 months post-DBS. The average ages at diagnosis and at the time of DBS surgery were 63.05 years and 72.45 years, respectively. Significant reductions in the average Unified Parkinson's Disease Rating Scale III score were observed (preoperative 31.8; postoperative 15.6; P < 0.0001). Significant reductions in the average LEDD (preoperative 891.94 mg; postoperative 559.6 mg; P = 0.0008) and medication doses per day (preoperative 11.54; postoperative 7.97; P = 0.0112) also were present., Conclusion: DBS is effective in treating elderly patients with PD. Patients experienced improvement in motor function, LEDD, and medication doses per day after DBS. Our results suggest that DBS is an effective treatment modality in elderly patients with PD., (Copyright © 2016 Elsevier Inc. All rights reserved.)