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OBJECTIVE The "presigmoid corridor" covers a spectrum of approaches using the petrous temporal bone either as a target in treating intracanalicular lesions or as a route to access the internal auditory canal (IAC), jugular foramen, or brainstem. Complex presigmoid approaches have been continuously developed and refined over the years, leading to great heterogeneity in their definitions and descriptions. Owing to the common use of the presigmoid corridor in lateral skull base surgery, a simple anatomy-based and self-explanatory classification is needed to delineate the operative perspective of the different variants of the presigmoid route. Herein, the authors conducted a scoping review of the literature with the aim of proposing a classification system for presigmoid approaches. METHODS The PubMed, EMBASE, Scopus, and Web of Science databases were searched from inception to December 9, 2022, following the PRISMA Extension for Scoping Reviews guidelines to include clinical studies reporting the use of "stand-alone" presigmoid approaches. Findings were summarized based on the anatomical corridor, trajectory, and target lesions to classify the different variants of the presigmoid approach. RESULTS Ninety-nine clinical studies were included for analysis, and the most common target lesions were vestibular schwannomas (60/99, 60.6%) and petroclival meningiomas (12/99, 12.1%). All approaches had a common entry pathway (i.e., mastoidectomy) but were differentiated into two main categories based on their relationship to the labyrinth: translabyrinthine or anterior corridor (80/99, 80.8%) and retrolabyrinthine or posterior corridor (20/99, 20.2%). The anterior corridor comprised 5 variations based on the extent of bone resection: 1) partial translabyrinthine (5/99, 5.1%), 2) transcrusal (2/99, 2.0%), 3) translabyrinthine proper (61/99, 61.6%), 4) transotic (5/99, 5.1%), and 5) transcochlear (17/99, 17.2%). The posterior corridor consisted of 4 variations based on the target area and trajectory in relation to the IAC: 6) retrolabyrinthine inframeatal (6/99, 6.1%), 7) retrolabyrinthine transmeatal (19/99, 19.2%), 8) retrolabyrinthine suprameatal (1/99, 1.0%), and 9) retrolabyrinthine trans-Trautman’s triangle (2/99, 2.0%). CONCLUSIONS Presigmoid approaches are becoming increasingly complex with the expansion of minimally invasive techniques. Descriptions of these approaches using the existing nomenclature can be imprecise or confusing. Therefore, the authors propose a comprehensive classification based on the operative anatomy that unequivocally describes presigmoid approaches simply, precisely, and efficiently.

Color-labeling injections of cadaveric heads have revolutionized education and teaching of neurovascular anatomy. Silicone-based and latex-based coloring techniques are currently used, but limitations exist because of the viscosity of solutions used.To describe a novel "triple-injection method" for cadaveric cranial vasculature and perform qualitative and semiquantitative evaluations of colored solution penetration into the vasculature.After catheter preparation, vessel cannulation, and water irrigation of embalmed cadaveric heads, food coloring, gelatin, and silicone solutions were injected in sequential order into bilateral internal carotid and vertebral arteries (red-colored) and internal jugular veins (blue-colored). In total, 6 triple-injected embalmed cadaveric heads and 4 silicone-based "control" embalmed cadaveric heads were prepared. A qualitative analysis was performed to compare the vessel coloring of 6 triple-injected heads with that of 4 "control" heads. A semiquantitative evaluation was completed to appraise sizes of the smallest color-filled vessels.Naked-eye and microscope evaluations of embalmed experimental and control cadaveric heads revealed higher intensity and more distal color-labeling following the "triple-injection method" compared with the silicone-based method in both the intracranial and extracranial vasculature. Microscope assessment of 1-mm-thick coronal slices of triple-injected brains demonstrated color-filling of distal vessels with minimum diameters of 119 μm for triple-injected heads and 773 μm for silicone-based injected heads.Our "triple-injection method" showed superior color-filling of small-sized vessels as compared with the silicone-based injection method, resulting in more distal penetration of smaller caliber vessels.

OBJECTIVE The present systematic review and pooled analysis aims to assess the incidence and risk factors for the development of retrograde ejaculation (RE) following first-time open anterior lumbar surgery. METHODS A systematic MEDLINE review via PubMed was performed, identifying 130 clinical papers relating to the topic. Eighteen publications were selected according to predetermined inclusion and exclusion criteria and were used to determine the incidence of RE. Only the publications that provided data on surgical risk factors present specifically in the men in the study were included in the analysis of risk factors. RESULTS Of the 2503 men included, there were 57 reported events of RE (2.3%). Of the cases for which long-term data were provided, 45.8% had resolved by final follow-up. There was a statistically significant increased risk associated with a transperitoneal as opposed to a retroperitoneal approach (8.6% vs 3.2%), as well as with the use of recombinant human bone morphogenetic protein–2 (rhBMP-2) in anterior lumbar interbody fusion (ALIF) as opposed to ALIF with bone graft or arthroplasty in controls (5.0% vs 1.8%). However, when excluding from analysis the patients operated on prior to the FDA’s 2008 warning that commented on the drug’s neuroinflammatory properties, there was no significant difference in rates of RE in patients receiving rhBMP-2 versus the control group (2.4% vs 2.5%). There was no significant difference in risk based on single- versus multilevel procedure or on ALIF versus arthroplasty. CONCLUSIONS In a pooled analysis of currently published data on men undergoing first-time open anterior lumbar surgery, this study found an overall incidence of RE of 2.3%. Nearly half of these patients recovered, reporting resolution of symptoms anywhere between 3 months and 48 months. Analysis of risk factors was limited by a paucity of published literature segregating data by sex. However, there was an increased risk associated with rhBMP-2 only when including data collected prior to the FDA warning on its detrimental properties. The authors therefore posit that the risk of RE is probably overestimated in the literature, given that the vast majority of the data available were collected prior to this warning and given the subsequent implementation of precautions when handling rhBMP-2.

Odontoidectomy may pose some risks for O-C1 and/or C1-C2 instability, with previous authors reporting techniques for endonasal C1-C2 fusion. However, no technique for endonasal O-C1 fusion currently exists. We sought to describe the feasibility of endonasal anterior C1 (AC1) screw placement for endonasal O-C1 fusion.Seven adult cadaveric heads were studied for endonasal placement of 14 C1 screws. Using thin-cut computed tomography (CT)-based "snapshot" neuronavigation assistance, 4 mm x 22 mm screws were placed in the C1 lateral mass using a 0° driver. Post-placement CT scans were obtained to determine site-of-entry measured from C1 anterior tubercle, screw angulation in axial and sagittal planes, and screw proximity to the central canal and foramen transversarium.Average site-of-entry was 16.57 mm lateral, 2.23 mm rostral, and 5.53 mm deep to the anterior-most portion of the C1 ring. Average axial angulation was 19.49° lateral to midline, measured at the C1 level. Average sagittal angulation was 13.22° inferior to the palatal line, measured from the hard palate to the opisthion. Bicortical purchase was achieved in 11 screws (78.6%). Partial breach of the foramen transversarium was observed in 2 screws (14.3%), violation of the O-C1 joint space in 1 (7.1%), and violation of the central canal in 0 (0%). Average minimum screw distances from the unviolated foramen transversaria and central canal were 1.97 mm and 4.04 mm.Navigation-assisted endonasal placement of AC1 screws is feasible. Additional studies should investigate the biomechanical stability of anterior C1 screw-plating systems, with anterior condylar screws as superior fixation point, compared to traditional posterior O-C1 fusion.

Background This case series describes the use of the Medtronic Micro Vascular Plug (MVP) system in the treatment of acute massive orofacial hemorrhages in patients with cancer and trauma, resulting in successful hemostasis in these emergent cases. Case Description The first case describes a patient who presented with life-threatening oropharyngeal hemorrhage after a motor vehicle accident. In the second case, a patient with oropharyngeal cancer presented with life-threatening bleeding from an ulcerated tumor. Patients were successfully treated with a combination of MVP and coils. Immediate postprocedural imaging confirmed that homeostasis was achieved. Conclusions These cases demonstrate that the MVP as an embolic device is a valuable transarterial embolic treatment option in cases of acute orofacial bleeding where rapid, effective hemostasis is required.

The benefit of antibiotic irrigation for prophylaxis against wound infections, not only for traumatic cranial injuries but also in elective neurosurgical care, has recently been called into question. Several articles have cast doubt on the utility of topical antibiotics, and recently, bacitracin irrigation was made unavailable in some US markets. The pervasive nature of antibiotic irrigation, considering the lack of evidence supporting its use, led the authors to question when and how neurosurgeons started using antibiotic irrigation in cranial neurosurgery. Through a review of historical literature, they highlight the adoption of antibiotic irrigation as it began in battlefield surgical practice, gradually leading to the modern concept of antibiotic prophylaxis in civilian and military care.

Odontoidectomy for ventral compressive pathology may result in O-C1 and/or C1-2 instability. Same-stage endonasal C1-2 spinal fusion has been advocated to eliminate risks associated with separate-stage posterior approaches. While endonasal methods for C1 instrumentation and C1-2 trans-articular stabilization exist, no hypothetical construct for endonasal occipital instrumentation has been validated. We provide an anatomic description of anterior occipital condyle (AOC) screw endonasal placement as proof-of-concept for endonasal craniocervical stabilization.Eight adult, injected cadaveric heads were studied for placing 16 AOC screws endonasally. Thin-cut CT was used for registration. After turning a standard inferior U-shaped nasopharyngeal flap endonasally, 4 mm × 22 mm AOC screws were placed with a 0° driver using neuronavigation. Post-placement CT scans were obtained to determine: site-of-entry, measured from the endonasal projection of the medial O-C1 joint; screw angulation in sagittal and axial planes, proximity to critical structures.Average site-of-entry was 6.88 mm lateral and 9.74 mm rostral to the medial O-C1 joint. Average angulation in the sagittal plane was 0.16° inferior to the palatal line. Average angulation in the axial plane was 23.97° lateral to midline. Average minimum screw distances from the jugular bulb and hypoglossal canal were 4.80 mm and 1.55 mm.Endonasal placement of AOC screws is feasible using a 0° driver. Our measurements provide useful parameters to guide optimal placement. Given proximity of hypoglossal canal and jugular bulb, neuronavigation is recommended. Biomechanical studies will ultimately be necessary to evaluate the strength of AOC screws with plate-screw constructs utilizing endonasal C1 lateral mass or C1-2 trans-articular screws as inferior fixation points.

OBJECTIVE Although the role of inflammation in the development of aneurysms is established, less is known about the development of intracranial aneurysms in the setting of underlying autoimmune disease. The underlying systemic inflammatory characteristics of disorders such as systemic lupus erythematosus, rheumatoid arthritis, and Sjögren’s syndrome may influence the development of intracranial aneurysms through common inflammatory pathways. The authors hypothesized that there is an association between underlying autoimmune disease and aneurysm growth and rupture. METHODS Medical records of patients who underwent cerebral angiography between August 2018 and August 2021 were manually reviewed. Autoimmune diseases as defined for this study are those known to have systemic inflammatory effects on the central nervous system or multiple other organ systems. Statistical analysis, including construction of multivariable linear and logistic regression models, was performed using R version 4.1.0. RESULTS Chart review identified 190 patients with 469 ruptured and unruptured saccular intracranial aneurysms. There were 31 patients with 44 aneurysms identified as having an autoimmune disease. The mean size of a ruptured aneurysm was significantly smaller among patients with autoimmune disease compared with patients without autoimmune disease (4.14 mm vs 5.34 mm, p = 0.03). The multivariate logistic regression model did not identify any significant association between rupture and autoimmune disease when controlling for other variables (p = 0.49). In the multivariate linear regression model, autoimmune disease was still significantly associated with a smaller size at rupture (p = 0.04), and smoking was associated with a larger size at rupture (p = 0.03) when controlling for other variables. A second multivariate logistic regression model found autoimmune disease to be independently associated with rupture at a size smaller than 7 mm (p = 0.02), while smoking was independently associated with rupture at a size larger than 7 mm (p = 0.01). CONCLUSIONS Autoimmune disease is associated with a smaller aneurysm size at rupture, although it is not associated with rupture itself. This association may be due to inflammatory pathways that are common to autoimmune diseases as well as aneurysm wall development. Although the authors were unable to identify any association between rupture status and the presence of autoimmune disease, the association between smaller size at rupture and autoimmune disease warrants further studies, as autoimmune disease may influence the trajectory of aneurysm development and the decision to treat.

BackgroundThe purpose of this review is to summarize the data available for the role of angiography and embolization in the comprehensive multidisciplinary management of brain arteriovenous malformations (AVMsMethodsWe performed a structured literature review for studies examining the indications, efficacy, and outcomes for patients undergoing endovascular therapy in the context of brain AVM management. We graded the quality of the evidence. Recommendations were arrived at through a consensus conference of the authors, then with additional input from the full Society of NeuroInterventional Surgery (SNIS) Standards and Guidelines Committee and the SNIS Board of Directors.ResultsThe multidisciplinary evaluation and treatment of brain AVMs continues to evolve. Recommendations include: (1) Digital subtraction catheter cerebral angiography (DSA)—including 2D, 3D, and reformatted cross-sectional views when appropriate—is recommended in the pre-treatment assessment of cerebral AVMs.(I, B-NR). (2) It is recommended that endovascular embolization of cerebral arteriovenous malformations be performed in the context of a complete multidisciplinary treatment plan aiming for obliteration of the AVM and cure.(I, B-NR). (3) Embolization of brain AVMs before surgical resection can be useful to reduce intraoperative blood loss, morbidity, and surgical complexity.(IIa, B-NR). (4) The role of primary curative embolization of cerebral arteriovenous malformations is uncertain, particularly as compared with microsurgery and radiosurgery with or without adjunctive embolization. Further research is needed, particularly with regard to risk for AVM recurrence.(III equivocal, C-LD). (5) Targeted embolization of high-risk features of ruptured brain AVMs may be considered to reduce the risk for recurrent hemorrhage.(IIb, C-LD). (6) Palliative embolization may be useful to treat symptomatic AVMs in which curative therapy is otherwise not possible.(IIb, B-NR). (7) The role of AVM embolization as an adjunct to radiosurgery is not well-established. Further research is needed.(III equivocal, C-LD). (8) Imaging follow-up after apparent cure of brain AVMs is recommended to assess for recurrence. Although non-invasive imaging may be used for longitudinal follow-up, DSA remains the gold standard for residual or recurrent AVM detection in patients with concerning imaging and/or clinical findings.(I, C-LD). (9) Improved national and international reporting of patients of all ages with brain AVMs, their treatments, side effects from treatment, and their long-term outcomes would enhance the ability to perform clinical trials and improve the rigor of research into this rare condition.(I, C-EO).ConclusionsAlthough the quality of evidence is lower than for more common conditions subjected to multiple randomized controlled trials, endovascular therapy has an important role in the management of brain AVMs. Prospective studies are needed to strengthen the data supporting these recommendations.

BACKGROUND Inferior petrosal sinus sampling (IPSS) is a useful technique in the diagnosis of Cushing’s disease (CD) when the imaging finding is negative or equivocal. Different authors have reported considerable variability in the ability to determine tumor laterality with IPSS. Here the authors present a retrospective case series of 7 patients who underwent IPSS using a systematic algorithm to improve lateralization accuracy by identifying optimal sampling sites on the basis of individual cavernous sinus drainage patterns in each patient. OBSERVATIONS Of the 7 patients identified, 6 were determined to have CD and subsequently underwent surgery. IPSS was accurate in all patients from whom laterality was predicted. Arterial and venous angiography were used to define cavernous sinus drainage patterns and determine optimal sampling sites. All patients who underwent surgery achieved hormonal cure. LESSONS All IPSS predictions of lateralization were correct when available, and all patients who underwent surgery achieved hormonal cure. Advances in angiographic techniques for identification of the site of primary drainage from the cavernous sinus and subsequent optimization of microcatheter placement may improve the ability to predict tumor laterality.

As the Journal of Neurosurgery (JNS) enters its 76th year of publication, its role as a principal repository of the neurosurgical body of knowledge continues to rise. Following in the steps of earlier journals in other disciplines, the JNS was founded to help provide experts in the field of neurological surgery a forum to present and interpret the important data that have shaped the way the field is practiced around the world. Though not exclusive in its mission, the “White Journal” innovated the management as well as the delivery of information and has served as an example for neurosurgical journals born thereafter.As with all events, the foundational elements of the JNS are centered on the needs of the times. An understanding of the precipitating events and the individuals instrumental in its genesis and subsequent maturation brings to light the JNS’s main focus: to be the principal journal for the field.

Treatment of acute ischemic stroke (AIS) has evolved significantly in the past few years. Endovascular treatment (EVT) is now proved to be efficacious up to 24 hours from onset in properly selected patients. The recently updated 2018 American Heart Association-American Stroke Association guidelines reflect the important role of imaging in triage and patient selection for EVT of AIS. Pretreatment imaging in patients with acute stroke should (a) allow assessment for intracranial hemorrhage and demonstrate (b) the extent of early ischemic changes, (c) the presence of large arterial occlusion, and (d) in some cases potential salvageable tissue before the decision to proceed with EVT. The authors review how multimodality imaging can be used for EVT selection in the context of the recent guidelines. They highlight the importance of having streamlined imaging workflows that are integrated with clinical decision making to maximize treatment efficiency. Knowledge of the various imaging criteria including perfusion imaging used for EVT selection is highlighted. The authors discuss variable imaging paradigms used for selection of patients in the early and late windows (who present before vs after 6 hours from onset of symptoms), as reflected in the latest guidelines and in relation to their level of evidence. Finally, they focus on challenges in the subgroups of patients who were excluded from recent EVT trials and with limited evidence to prove the efficacy of EVT, such as patients with low NIHSS (National Institutes of Health Stroke Scale) score, distal occlusion, or large ischemic core. ©RSNA, 2019 See discussion on this article by Leslie-Mazwi.

Background: The University of Cincinnati Stroke Team provides acute stroke care to the southwest Ohio, northern Kentucky, and southeast Indiana catchment area of ~2 million people and 30 healthcare facilities. We previously published a significant decline in stroke activations and reperfusion treatment (IV thrombolysis and EVT) rates following state announcements of COVID-19 mitigation measures. Here, we update these trends after state reopening guidelines. Methods: We compared Stroke Team activations and reperfusion treatments logged in a prospectively collected database, comparing the same period in 2020 versus 2019. Kentucky and Ohio announced school and restaurant closures on March 12 and 13, respectively, followed by Indiana. A stepwise reopening of our tristate area started on May 1, 2020. We also compared trends in activations and treatment rates before (Weeks 1-10), during (Weeks 11-17), and after (Weeks 18-26) the lifting of COVID-19 mitigation efforts using the Poisson test, and graphically with segmented regression analysis. Results: Compared to 2019, stroke team activations declined by 12% in 2020 (95% CI 7 - 16%; p Conclusion: The initial decline in stroke team activations during COVID-19 mitigation efforts was followed by an increase in activations after reopening. Hospital capacity and 911 services remained fully intact, suggesting that the reduction in activations were related to reduced presentation by patients for emergent stroke care.

The purpose of this publication is to provide a review of social media usage by neurointerventionalists. Using published literature and available local, regional, and national guidelines or laws, we reviewed data on social media usage as it pertains to neurointerventional surgery. Recommendations are provided based on the quality of information and conformity of medico-legal precedent and law. Social media is a growing entity as it is used both promotionally and educationally. Neurointerventionalists may post de-identified radiographic images with discussions, but should be conscientious and adhere to applicable laws and regulations, strict ethical codes, and institutional policies.

Background The ability to prognosticate rupture for cerebral aneurysms is paramount to prevent the risks inherent to open clipping or endovascular coiling. The goal of this study was to create a mathematical model to predict the probability of rupture incorporating the salient biomorphometric characteristics of the aneurysm. Methods Posterior communicating artery aneurysms confirmed by computed tomography angiography were subjected to three-dimensional reconstruction to ascertain the following biomorphometric parameters: height, width, neck size, aspect ratio, bottle neck factor, aneurysm angle, deflection angle, neck angle, and proximal internal carotid artery- distal internal carotid artery angle. Significant factors related to rupture were determined and a forward stepwise binary logistic regression was performed to establish the log-odds of rupture. Results A total of 101 aneurysms (80 ruptured and 21 unruptured) were included. Of the six statistically significant biomorphometric parameters measured, aneurysm deflection angle and aspect ratio both were considerably larger (p=0.001) in ruptured cases compared to unruptured ones. Binary logistic regression applied to the dataset demonstrated a 96% sensitivity and 89% overall accuracy. Conclusions This updated binary logistic regression model was able to identify aneurysm rupture more robustly when compared to previous models. Future studies combining patient specific characteristics, along with previously determined biomorphometric parameters may further enhance this model. Disclosures N. Damodara: None. K. Thomas: None. J. Quinn: None. C. Gandhi: None. C. Prestigiacomo: None.

Anterior and lateral approaches to the lumbar spine are commonly used today for a variety of indications. These approaches can ultimately be traced back to early attempts to treat Pott’s disease. Evidence of Mycobacterium tuberculosis infection of the spine dates as far back as 2400 BCE, with ancient Egyptian mummies exhibiting lesions consistent with Pott’s disease. For many centuries, Pott’s disease was treated conservatively, and surgery came to be used when conservative therapy was ineffective, as medical therapy had yet to become available. In 1779, Percivall Pott recommended that peripheral paraspinal tuberculous abscesses be drained after noticing that patients’ lower limb function improved after the formation of spontaneous draining sinuses. Building on Pott’s ideas, Menard described the first lateral approach to the spine via a costotransversectomy approximately 1 century after Pott’s theory. Most importantly, the surge in understanding anatomy with respect to developing safe corridors to the deeper structures of the human body brought together advances in technology, instrumentation, and visualization. Surgeons were thus emboldened to explore more complex anterior approaches to the spine. In 1906, Muller reported the first successful anterior approach to the spine in a patient with Pott’s disease. Over the next several decades, the efforts of surgeons such as Ito, Capener, Burns, and Mercer would lead to the development of the anterior lumbar interbody fusion. The costotransversectomy later evolved into the lateral rhachotomy and lateral extracavitary approach, which along with advances in the anterior lumbar interbody fusion paved the way for the oblique lumbar interbody fusion and lateral lumbar interbody fusion.

Supplemental Digital Content is available in the text., Background and Purpose: Anecdotal evidence suggests that the coronavirus disease 2019 (COVID-19) pandemic mitigation efforts may inadvertently discourage patients from seeking treatment for stroke with resultant increased morbidity and mortality. Analysis of regional data, while hospital capacities for acute stroke care remained fully available, offers an opportunity to assess this. We report regional Stroke Team acute activations and reperfusion treatments during COVID-19 mitigation activities. Methods: Using case log data prospectively collected by a Stroke Team exclusively serving ≈2 million inhabitants and 30 healthcare facilities, we retrospectively reviewed volumes of consultations and reperfusion treatments for acute ischemic stroke. We compared volumes before and after announcements of COVID-19 mitigation measures and the prior calendar year. Results: Compared with the 10 weeks prior, stroke consultations declined by 39% (95% CI, 32%–46%) in the 5 weeks after announcement of statewide school and restaurant closures in Ohio, Kentucky, and Indiana. Results compared with the prior year and time trend analyses were consistent. Reperfusion treatments also appeared to decline by 31% (95% CI, 3%–51%), and specifically thrombolysis by 33% (95% CI, 4%–55%), but this finding had less precision. Conclusions: Upon the announcement of measures to mitigate COVID-19, regional acute stroke consultations declined significantly. Reperfusion treatment rates, particularly thrombolysis, also appeared to decline qualitatively, and this finding requires further study. Urgent public education is necessary to mitigate a possible crisis of avoiding essential emergency care due to COVID-19.

Admiral Lord Horatio Nelson is perhaps the most renowned naval commander, who allowed Britain to have dominion over the sea for 100 years after his victory at the Battle of Trafalgar. He was able to do so despite suffering from a multitude of communicable diseases and traumatic injuries, including the functional loss of his right eye, amputation of his right arm, scalp laceration, head injury, and finally a spinal injury. These injuries had permanent consequences but did not stop him from leading the charge and allowing the British to defeat the French and Spanish fleets in the decisive Battle of Trafalgar.

Motor vehicle collisions (MVCs) are a significant cause of head injuries today, but efforts to manage and prevent these injuries extend as far back as the beginning of modern neurosurgery itself. Head trauma in MVCs occurred as far back as 1899, and the surgical literature of the time mentions several cases of children being struck by passing automobiles. By the 1930s, Dr. Claire L. Straith, a Detroit plastic surgeon, recommended changes to automobile design after seeing facial injuries and depressed skull fractures that resulted from automobile accidents. During World War II, Sir Hugh Cairns, a British neurosurgeon, demonstrated the efficacy of motorcycle helmets in preventing serious head injury. In the 1950s, Dr. Frank H. Mayfield, a Cincinnati neurosurgeon on the trauma committee of the American College of Surgeons, made several recommendations, such as adding padded dashboards and seatbelts, to make automobiles safer. Ford implemented the recommendations from Dr. Mayfield and others into a safety package for the 1956 models. Significant work has also been done to prevent head injury in motorsports. Efforts by surgeons, especially neurosurgeons, to prevent head injury in MVCs have saved countless lives, although it is a less frequently celebrated achievement.

Background Relative residence time (RRT) is a marker of disturbed blood flow, marked by low magnitude and high oscillatory wall shear stress (WSS). The relation between solute residence time in proximity to the vascular endothelium and the atherosclerotic process is well appreciated in the literature. Objective To assess the influence of RRT on side-wall aneurysm inception to better understand the role of atherosclerosis in aneurysm formation. Methods Fourteen side-wall internal carotid artery aneurysms from the Aneurisk repository which met criteria for parent vessel reconstruction were reconstructed with Vascular Modeling Toolkit. Computational fluid dynamics analysis was carried out in Fluent. RRT was calculated in MATLAB (The MathWorks Inc, Natick, Massachusetts). We analyzed the results for correlations, defined as presence or absence of local elevations in RRT in specific regions of vasculature. Results RRT was concluded to be negatively correlated with aneurysm inception in this study of side-wall internal carotid artery aneurysms, with 12/14 cases yielding the absence of local RRT elevations within or in close proximity of the removed ostium. Subsequent analysis of WSS showed that 11 of 14 aneurysms were formed in an atheroprotective environment, with only 1 of 14 formed in an atherogenic environment. Two models were found to be of indeterminate environment. Conclusion Atherogenesis and atherosclerosis have long been thought to be a major inciting factor responsible for the formation of aneurysms in the cerebral vasculature. We propose that inception of side-wall aneurysms occurs in hemodynamic environments that promote an atheroprotective endothelial phenotype and that the atheroprotective phenotype is therefore aneurysmogenic.

Bilateral carotid cavernous fistulas are rare entities that can cause debilitating symptoms and can lead to more severe consequences if left untreated. Therefore, the recognition and adequate treatment of these pathologies is very important. We present 2 cases of bilateral carotid cavernous fistulas that arose as a result of cavernous sinus thrombosis. We review the literature and discuss the pathophysiology, symptomatology, management, and treatment of bilateral carotid cavernous fistulas. Within our own cases, treatment of the patients was varied. The patient in case 1 was successfully treated with endovascular therapy after a failed trial of anticoagulation. The patient in case 2 demonstrated resolution of bilateral carotid cavernous fistulas after anticoagulation therapy. Case 2 highlights the fact that certain cases of bilateral carotid cavernous fistulas due to cavernous sinus thrombosis may benefit from extensive anticoagulation therapy. If anticoagulation therapy is unsuccessful, endovascular therapy may prove beneficial in resolving the fistulous shunt.

The debate over the influence approach sidedness has on the risk of recurrent laryngeal nerve palsy (RLNP) following anterior cervical discectomy and fusion (ACDF) has its origins with the introduction of the procedure for radicular pain in the 1950s. The recurrent laryngeal nerves follow disparate courses in the lower neck secondary to differences in embryogenesis. Because of these differences, some authors believe a right-sided approach increases the risk of RLNP. However, modern surgical series have not shown a clear risk of RLNP with a right- versus left-sided approach. By looking at the historical context surrounding the introduction of ACDF, we propose the dogmatic view of an increased risk of RLNP with a right-sided approach likely arose from a combination of theoretical anatomic risk and the early surgical experience of a pioneer of the procedure.

Wall shear stress, the frictional force of blood flow tangential to an artery lumen, has been demonstrated in multiple studies to influence aneurysm formation and risk of rupture. In this article, the authors review the ways in which shear stress may influence aneurysm growth and rupture through changes in the vessel wall endothelial cells, smooth-muscle cells, and surrounding adventitia, and they discuss shear stress–induced pathways through which these changes occur.

BackgroundThe aim of this publication is to provide a detailed update on the diagnosis, treatment, and endovascular techniques for posterior circulation emergent large vessel occlusion (pc-ELVO).MethodsWe performed a review of the literature to specifically evaluate this disease and its treatments.ResultsData were analyzed, and recommendations were reported based on the strength of the published evidence and expert consensus.ConclusionWhile many questions about pc-ELVO remain to be studied, there is evidence to support particular practices in its evaluation and treatment.

Carotid artery stenosis is implicated in up to 40% of all ischemic strokes. Accordingly, symptomatic, high-grade carotid artery stenosis portends an especially high risk of future stroke. Intervention via open or endovascular approaches drastically reduces this risk. Under the appropriate conditions, carotid artery stenting serves as a safe and effective alternative to carotid endarterectomy. We present the case of a 57-yr-old male with symptomatic, high-grade stenosis of his right internal carotid artery, for whom a history of radiation to the head and neck represented a relative contraindication to carotid endarterectomy, and thus endovascular treatment with angioplasty and stenting was performed. Informed consent was obtained prior to the procedure. Intraprocedurally, stent delivery past the area of stenosis proved somewhat challenging. However, by employing several nuanced maneuvers, we utilized our guiding catheter in a nonconventional manner in order to successfully perform the procedure. As the field of neuroendovascular surgery evolves, each case provides us unique lessons, which in turn expands our interventional capabilities and adds to the armamentarium of neuroendovascular techniques. We present this surgical video both as a means to provide a general overview of carotid artery stenting, and to share a lesson learned through the implementation of an interesting technical nuance.

Cushing disease (CD), or hypercortisolemia secondary to an adrenocorticotropic hormone-secreting (ACTH-secreting) pituitary adenoma, is the most common etiology of noniatrogenic Cushing syndrome. 1 The diagnostic algorithm employed in the patient with suspected CD is complex and includes consideration for inferior petrosal sinus sampling (IPSS). 2 , 3 When workup is consistent with CD, extracapsular resection of the ACTH-secreting pituitary adenoma through the endonasal corridor is the preferred operative strategy. 4 In this publication, we discuss the case of a 26-year-old woman who presented with 9 months of weight gain ( Video 1 ). Initial labs, including low- and high-dose dexamethasone suppression tests, were consistent with CD. Findings on dynamic magnetic resonance imaging were suggestive of a left 2-mm microadenoma. IPSS confirmed central origin of hypercortisolemia and was indicative of a left-sided focus. The patient was taken to the operating room for endoscopic endonasal approach for extracapsular resection of left-sided, ACTH-secreting microadenoma. Following surgery, the patient required glucocorticoid supplementation after her cortisol levels decreased to 2 ug/dL the evening of surgery. Subsequent laboratory analysis has been consistent with hormonal cure. 5 , 6 The accompanying video manuscript describes 1) preoperative diagnostic evaluation of the patient with suspected CD, 2) indications for and techniques of IPSS, 3) nuances of endoscopic transsphenoidal surgical management, and 4) relevant considerations in postoperative care. Of note, full patient consent for photography and/or recording of other forms of video/imaging was obtained in the preoperative period. 7 , 8 , 9 , 10

Background: Traumatic extracranial internal carotid artery (ICA) dissections are uncommon and can be difficult to treat. Thinning of adventitia and dilatation may occur following arterial dissection, thus resulting in a fusiform pseudoaneurysm, which can subsequently cause bleeding, expanding, or pulsatile hematoma. Currently, medical management with anticoagulation remains the first line of treatment and yields good outcomes in 75% of cases with a mortality rate of 3-4%. Endovascular intervention is indicated with failure of medical therapy, progressive enlargement of a traumatic pseudoaneurysm, acute flow-related infarcts due to vessel occlusion, or when anticoagulation is contraindicated due to risk of pseudoaneurysm rupture and hemorrhage. Recognized interventional treatments include parent artery occlusion with or without revascularization, endovascular coil embolization, and covered stenting. Summary: A wide variety of endovascular stents are available that are capable of opening a stenosed vessel while obliterating the associated false lumen and providing a scaffold for embolization of the pseudoaneurysm. The use of the Pipeline Embolization Device (PED) in the management of traumatic intracranial pseudoaneurysms has been described. However, there are few reports on the usage of the PED for treating traumatic extracranial ICA dissection and/or pseudoaneurysms. However, a potential complication of the use of PED in the extracranial ICA is a hypothetical tendency to migrate in a mobile vessel. Thus, the risk of migration of the PED has encouraged practitioners to adopt strategies to limit this risk. Key Messages: We describe different techniques employed to anchor the flow-diverting construct within tortuous, mobile vessels.

Treatment of complex aneurysms using microsurgical and other conventional neuroendovascular techniques remains challenging. As a result, stent- and balloon-assisted coiling are instead performed to treat morphologically complex aneurysms, which include giant, wide-necked, and fusiform aneurysms. While these techniques have had success in treating these complex aneurysms, recanalization rates associated with these techniques are still problematic. In the constant effort to improve the outcome of complex aneurysm treatment, flow-diverting stents (FDSs) have emerged in recent years as the preferred treatment. Instead of directly obstructing the flow of blood into the aneurysmal sac, as is the case for stent- and balloon-assisted coiling, FDSs are placed in the parent blood vessel to divert blood flow away from the aneurysm itself. Subsequent to the diverting away of blood from the aneurysm, a thrombotic cascade ensues that ultimately results in the closure of the aneurysm while the parent vessel's perforators are preserved. Current known risks for this procedure include vessel rupture or perforation, in-stent thrombosis, perforator occlusion, procedural or delayed hemorrhages, and perianeurysmal edema. In this review, we will evaluate the mechanisms of actions, clinical applications, complications, and ongoing studies for FDSs.

OBJECTIVE The utility of routine repeat head CT (HCT) scans in the management of minimal head injury (MHI) patients with an intracranial hemorrhage (ICH) has been questioned in multiple studies. All these studies analyzed this by obtaining a repeat HCT study, and none examined the effects of eliminating these routine HCT studies in neurologically intact patients. The authors' institution implemented a new “Neurologic Observation without Repeat HCT” (NORH) protocol with no repeat HCT scanning for patients admitted for MHI and ICH whose neurological status was maintained or improved to a Glasgow Coma Scale score of 15 at 24 hours after admission. This purpose of this study was to assess the outcomes and safety of this novel protocol. METHODS Records of patients who sustained blunt trauma MHI and an ICH and/or skull fracture on initial HCT between January 1, 2009, and December 31, 2012, were retrieved from the trauma registry of a Level I trauma center. The authors analyzed 95 patients in whom the NORH protocol was followed. Outcome measures included death, emergency department readmission, neurosurgical intervention, delayed repeat HCT, and length of stay. RESULTS The NORH protocol was followed for 95 patients; 83% of the patients were male, the average age was 38 ± 16.0 years old, and the most common cause of trauma was assault (35%). Of the 95 patients in whom the NORH protocol was followed, 8 (8%) had a delayed repeat HCT study (> 24 hours) after admission, but none resulted in neurosurgical intervention because of progression of ICH. The average length of stay was 4 ± 7.2 days. None of the patients were readmitted to the hospital. CONCLUSIONS Implementation of the NORH protocol (eliminating routine follow-up HCT) resulted in very low rates of delayed neurological deterioration, no late neurosurgical interventions resulting from ICH progression, very few emergency department revisits, and no readmissions. For a select group of MHI patients with ICH, the NORH protocol is safe and effective, and can reduce radiation exposure and costs.

BACKGROUND AND PURPOSE: Comparing outcomes between endovascular aneurysm coiling trials can be difficult because of heterogeneity in patients and end points. We sought to understand the impact of geography on aneurysm retreatment in patients enrolled in the Matrix and Platinum Science Trial. MATERIALS AND METHODS: Post hoc analysis was performed on data from the Matrix and Platinum Science trial. Patients were stratified as either North American or international. Baseline patient demographics, comorbidities, aneurysm characteristics, procedural complications, and clinical and angiographic outcomes were compared. RESULTS: We evaluated 407 patients from 28 North American sites and 219 patients from 15 international sites. Patient demographics differed significantly between North American and international sites. Aneurysms were well occluded postprocedure more often at international than North American sites ( P < .001). Stents were used significantly more often at North American sites (32.7% [133 of 407]) compared with international sites (10.0% [22 of 219]; P < .001). At 455 days, there was no difference in the proportion of patients alive and free of disability ( P = .56) or with residual aneurysm filling ( P = .10). Ruptured aneurysms were significantly more likely to have been retreated at North American sites within the first year ( P < .001) and at 2 years ( P < .001). Among all patients for whom the treating physician believed there to be Raymond 3 aneurysm filling at follow-up, absolute rates of retreatment at international and North American sites were similar by 2-year follow-up. CONCLUSIONS: Data from the Matrix and Platinum Science Trial demonstrate that aneurysm retreatment occurs with different frequency and at different times in different regions of the world. This trend has critical value when interpreting trials reporting short-term outcomes, especially when judgment-based metrics such as retreatment are primary end points that may or may not take place within the defined study follow-up period. Though these variations can be controlled for and balanced within a given randomized trial, such differences in practice patterns must be accounted for in any attempt to compare outcomes between different trials. Despite these differences, endovascular-treated intracranial aneurysms around the world have similar clinical outcomes.