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OBJECTIVE This was a retrospective, cohort study investigating the efficacy and safety of continuous low-dose postoperative tranexamic acid (PTXA) on drain output and transfusion requirements following adult spinal deformity surgery. METHODS One hundred forty-seven patients undergoing posterior instrumented thoracolumbar fusion of ≥ 3 vertebral levels at a single institution who received low-dose PTXA infusion (0.5-1 mg/kg/hr) for 24 hours were compared to 292 control patients who did not receive PTXA. The cohorts were propensity matched based on age, sex, American Society of Anesthesiologist physical status classification, body mass index, number of surgical levels, revision surgery, operative duration, and total intraoperative TXA dose (n = 106 in each group). Primary outcome was 72-hour postoperative drain output. Secondary outcomes were number of allogeneic blood transfusions. RESULTS There was no significant difference in postoperative drain output in the PTXA group compared to control (660 ± 420 mL vs. 710 ± 490 mL, p = 0.46). The PTXA group received significantly more crystalloid (6,100 ± 3,100 mL vs. 4,600 ± 2,400 mL, p < 0.001) and red blood cell transfusions postoperatively (median [interquartile range]: 1 [0-2] units vs. 0 [0-1] units; incidence rate ratio [95% confidence interval], 1.6 [1.2-2.2]; p = 0.001). Rates of adverse events were comparable between groups. CONCLUSION Continuous low-dose PTXA infusion was not associated with reduced drain output after spinal deformity surgery. No difference in thromboembolic incidence was observed. A prospective dose escalation study is warranted to investigate the efficacy of higher dose PTXA.

Background Blood loss during adult spinal deformity surgery is multifactorial. Anesthetic-related factors, such as mode of mechanical ventilation, may contribute to intraoperative blood loss. The aim of this study was to determine the influence of ventilator mode and ventilator parameters on intraoperative blood loss and transfusion requirements in patients undergoing prone position spine surgery. Methods This single-center retrospective study examined electronic medical records of patients ≥18 years of age who underwent elective prone position spine surgery between May 2015 and June 2016. Associations between ventilator mode and ventilator parameters with intraoperative estimated blood loss (EBL), packed red blood cells (PRBCs), fresh-frozen plasma (FFP), cryoprecipitate and platelet transfusions, and subfascial drain output were examined using multiple linear regression models controlling for age, sex, American Society of Anesthesiologist (ASA) physical status score, body mass index (BMI), preoperative blood coagulation parameters and laboratory values, operative levels, cage constructs, osteotomies, transforaminal lumbar interbody fusions, laminectomies, reoperation, spine surgery invasiveness index, and operative time. In a secondary analysis, EBL, blood product transfusions, and postoperative drain output were compared between pressure-controlled ventilation (PCV) and volume-controlled ventilation (VCV) propensity score-matched cohorts. Results Nine hundred forty-six records were reviewed, and 822 were included in the analysis. After adjusting for confounding, no statistically significant associations were observed between mode of ventilation and intraoperative EBL (estimate, -2; 95% confidence interval [CI], -248 to 245; P = .99) or blood product transfusions (PRBC: estimate, -9; 95% CI, -154 to 135; P = .90; FFP: estimate, -3; 95% CI, -59 to 54; P = .93; cryoprecipitate: estimate, -14; 95% CI, -70 to 43; P = .63; platelets: -7; 95% CI, -39 to 24; P = .64). After propensity score matching (n = 27 per group), no significant differences were observed in EBL (mean difference, 525 mL; 95% CI, -15 to 1065; P = .056) or blood transfusions (PRBC: mean difference, 208 mL; 95% CI, -23 to 439; P = .077; FFP (mean difference, 34 mL; 95% CI, -17 to 84; P = .19); cryoprecipitate (mean difference, 55 mL; 95% CI, -24 to 133; P = .17); or platelets (mean difference, 26 mL; 95% CI, -12 to 64; P = .18) between PCV and VCV groups. Conclusions In prone position spine surgery, neither mode of mechanical ventilation nor airway pressure is associated with intraoperative blood loss or need for allogeneic transfusion. Use of modern ventilation strategies using lung protective techniques may mitigate differences in blood loss previously observed between PCV and VCV modes.

Predicting future hemorrhage risk may allow better selection of patients with cerebral cavernous malformations (CCMs) who will likely benefit from treatment. In this study, we sought to identify predictors of CCM hemorrhage, and to compare subsequent symptomatic hemorrhage risks between patients with and without previous hemorrhage.We performed a retrospective review of consecutive CCM patients at our institution between 1982 and 2017. Patients with diffuse or familial CCM syndromes, and those without follow-up data were excluded. The primary endpoint was acute symptomatic hemorrhage causing transient or permanent neurological symptoms. Primary endpoint incidences were compared between patients with and without previous hemorrhage.The study cohort comprised 84 patients with 90 CCMs. Previous hemorrhage was the only significant predictor for the primary endpoint (P = 0.003). CCMs with previous hemorrhage had a higher risk of symptomatic hemorrhage in follow-up than those without previous hemorrhage (26.9 vs. 1.5 symptomatic hemorrhages per 1000 CCM-months, P0.001). CCMs with and without previous hemorrhage had annual hemorrhage rates of 2.7% and 0.15%, respectively. Symptomatic hemorrhage-free survival rates were significantly lower in CCMs with previous hemorrhage (log-rank test, P0.001). Actuarial hemorrhage-free survival rates for CCMs with previous hemorrhage were 75%, 60%, 60%, and 60% at 1, 2, 3, and 4 years, respectively, compared with rates of 95%, 95%, 95%, and 84% for CCMs without previous hemorrhage.Previous hemorrhage is a predictor of subsequent symptomatic hemorrhage in CCMs. Compared with CCMs without previous hemorrhage, those with prior hemorrhage have a significantly higher risk of future symptomatic hemorrhage.

OBJECTIVERecent literature describing complications associated with spinopelvic fixation with iliac screws in adult patients has been limited but has suggested high complication rates. The authors’ objective was to report their experience with iliac screw fixation in a large series of patients with a 2-year minimum follow-up.METHODSOf 327 adult patients undergoing spinopelvic fixation with iliac screws at the authors’ institution between 2010 and 2015, 260 met the study inclusion criteria (age ≥ 18 years, first-time iliac screw placement, and 2-year minimum follow-up). Patients with active spinal infection were excluded. All iliac screws were placed via a posterior midline approach using fluoroscopic guidance. Iliac screw heads were deeply recessed into the posterior superior iliac spine. Clinical and radiographic data were obtained and analyzed.RESULTSTwenty patients (7.7%) had iliac screw–related complication, which included fracture (12, 4.6%) and/or screw loosening (9, 3.5%). No patients had iliac screw head prominence that required revision surgery or resulted in pain, wound dehiscence, or poor cosmesis. Eleven patients (4.2%) had rod or connector fracture below S1. Overall, 23 patients (8.8%) had L5–S1 pseudarthrosis. Four patients (1.5%) had fracture of the S1 screw. Seven patients (2.7%) had wound dehiscence (unrelated to the iliac screw head) or infection. The rate of reoperation (excluding proximal junctional kyphosis) was 17.7%. On univariate analysis, an iliac screw–related complication rate was significantly associated with revision fusion (70.0% vs 41.2%, p = 0.013), a greater number of instrumented vertebrae (mean 12.6 vs 10.3, p = 0.014), and greater postoperative pelvic tilt (mean 27.7° vs 23.2°, p = 0.04). Lumbosacral junction–related complications were associated with a greater mean number of instrumented vertebrae (12.6 vs 10.3, p = 0.014). Reoperation was associated with a younger mean age at surgery (61.8 vs 65.8 years, p = 0.014), a greater mean number of instrumented vertebrae (12.2 vs 10.2, p = 0.001), and longer clinical and radiological mean follow-up duration (55.8 vs 44.5 months, p < 0.001; 55.8 vs 44.6 months, p < 0.001, respectively). On multivariate analysis, reoperation was associated with longer clinical follow-up (p < 0.001).CONCLUSIONSPrevious studies on iliac screw fixation have reported very high rates of complications and reoperation (as high as 53.6%). In this large, single-center series of adult patients, iliac screws were an effective method of spinopelvic fixation that had high rates of lumbosacral fusion and far lower complication rates than previously reported. Collectively, these findings argue that iliac screw fixation should remain a favored technique for spinopelvic fixation.

Nonthrombotic intracranial venous occlusive disease (NIVOD) has been implicated in the pathophysiology of idiopathic intracranial hypertension (IIH) and various non-IIH headache syndromes. Endovascular stenting of stenotic, dominant transverse sinuses (TSs) may reduce trans-stenosis pressure gradients, decrease intracranial pressure, and alleviate symptoms in a subset of NIVOD patients. We present a case in which concurrent stenting of the occipito-marginal sinus obliterated the residual trans-stenosis pressure gradient across an initially stented dominant TS. We hypothesize that this observation may be explained using an electric-hydraulic analogy, and that this patient’s dominant TS and occipito-marginal sinus may be modeled as a parallel hemodynamic circuit. Neurointerventionalists should be aware of parallel hemodynamic drainage patterns and consider manometry and possibly additional stenting of stenotic, parallel venous outflow pathways if TS stenting alone fails to obliterate the trans-stenosis pressure gradient.

The SMART coil (Penumbra Inc., Alameda, CA, USA) is a new microcoil designed to enhance deliverability. Although prior studies have described its perioperative safety and efficacy, the follow-up outcomes after embolization of intracranial aneurysms using SMART coils have not been reported. Therefore, the aim of this retrospective cohort study is to assess the angiographic outcomes at interim follow-up after aneurysm embolization with SMART coils. We reviewed data from consecutive patients with intracranial aneurysms who underwent endovascular treatment using SMART coils between June 2016 and August 2017. Baseline data and follow-up angiographic outcomes using the modified Raymond-Roy classification (MRRC) were recorded. The study cohort comprised 33 patients with 34 aneurysms who underwent SMART coil embolization and had sufficient follow-up data. The mean age was 57 years, and 82% were female. The mean aneurysm maximum diameter and neck width were 6.1 ± 2.2 mm and 3.2 ± 1.2 mm, respectively, and 14.7% of aneurysms were ruptured. The overall complication rate was 12%. Initial mean coil packing density was 26%, and the initial MRRC was I, II, IIIa, and IIIb in 24%, 26%, 35%, and 15%, respectively. At last follow-up (mean duration 7.7 ± 3.2 months), the MRRC was I, II, IIIa, and IIIb in 62%, 26%, 3%, and 9%, respectively. The retreatment rate was 14.7%. The SMART coil is efficacious for the treatment of appropriately selected aneurysms, with an acceptable risk profile. The majority of residual aneurysms after the initial embolization procedure will progress to complete or near-complete occlusion at interim follow-up.

Neoadjuvant endovascular embolization of skull base meningiomas may facilitate surgical resection, thereby potentially decreasing operative morbidity. However, due to variation in the reported efficacy and complication rates, the utility of embolization remains incompletely defined. The aim of this systematic review is to assess the outcomes of preoperative embolization for skull base meningiomas. A literature review was performed to identify studies reporting outcomes of patients with skull base meningiomas who underwent preoperative embolization. Baseline, treatment, and outcomes data were analyzed. Major complications included death, new cranial neuropathy, retinal artery ischemia, permanent neurologic deficit, or intracerebral hemorrhage. The pooled analysis consisted of 15 studies, comprising a total of 403 patients with skull base meningiomas treated with preoperative embolization. The most common locations were the sphenoid wing (34%, 87/256 cases), petroclival region (31%, 80/256 cases), and cavernous sinus (12%, 31/256 cases). The median tumor size ranged from 5.0 to 8.0 cm. Based on pooled data, angiographic absence of tumor blush was achieved in 17% (13/79 cases). The median estimated blood loss (EBL) ranged from 225 to 580 mL. Simpson grade I-III resection was achieved in 74% (40/54) of patients. The overall complication, major complication, and mortality rates were 12% (47/403 patients), 6% (21/328 patients), and 0.2% (1/403 patients), respectively. Preoperative embolization is a reasonable adjunct to resection for appropriately selected skull base meningiomas. Future comparative analyses are necessary to ascertain the benefits of preoperative embolization of skull base meningiomas with respect to extent of resection, operative duration, operative blood loss, and surgical morbidity.

Study Design: Systematic literature review. Objectives: The aims of this study were to (1) describe the clinical features, disabilities, and incidence of neurologic deficits of pyogenic spondylodiscitis prior to treatment and (2) compare the functional outcomes between patients who underwent medical treatment alone or in combination with surgery for pyogenic spondylodiscitis. Methods: A systematic literature review was performed using PubMed according to PRISMA guidelines. No year restriction was put in place. Statistical analysis of pooled data, when documented in the original report (ie, number of patients with desired variable and number of patients evaluated), was conducted to determine the most common presenting symptoms, incidence of pre- and postoperative neurologic deficits, associated comorbidities, infectious pathogens, approach for surgery when performed, and duration of hospitalization. Outcomes data, including return to work status, resolution of back pain, and functional recovery were also pooled among all studies and surgery-specific studies alone. Meta-analysis of studies with subgroup analysis of pain-free outcome in surgical and medical patients was performed. Results: Fifty of 1286 studies were included, comprising 4173 patients undergoing either medical treatment alone or in combination with surgery. Back pain was the most common presenting symptom, reported in 91% of patients. Neurologic deficit was noted in 31% of patients. Staphylococcus aureus was the most commonly reported pathogen, seen in 35% of reported cases. Decompression and fusion was the most commonly reported surgical procedure, performed in 80% of the surgically treated patients. Combined anterior-posterior procedures and staged surgeries were performed in 33% and 26% of surgeries, respectively. The meta-analysis comparing visual analog scale score at follow-up was superior among patients receiving surgery over medical treatment alone (mean difference −0.61, CI −0.90 to −0.25), while meta-analysis comparing freedom from pain in patients receiving medical treatment alone versus combined medical and surgical treatment demonstrated superior pain-free outcomes among surgical series (odds ratio 5.35, CI 2.27-12.60, P < .001), but was subject to heterogeneity among studies ( I2 = 56%, P = .13). Among all patients, freedom from pain was achieved in 79% of patients, and an excellent outcome was achieved in 73% of patients. Conclusion: Medical management remains first-line treatment of infectious pyogenic spondylodiscitis. Surgery may be indicated for progressive pain, persistent infection on imaging, deformity or neurologic deficits. If surgery is required, reported literature shows potential for significant pain reduction, improved neurologic function and a high number of patients returning to a normal functional/work status.

Background: The relationship between idiopathic intracranial hypertension (IIH) and cerebral sinovenous stenosis (CSS) remains unclear. The effects of cerebrospinal fluid (CSF) diversion on venous sinus physiology have not been rigorously investigated. We describe the effect of ventriculoperitoneal shunt (VPS) placement on sinovenous pressures in the setting of IIH and CSS. Case Description: A patient in their 30 s presented with headache and transient visual obscurations for few months and was diagnosed with IIH. Catheter cerebral venography showed focal stenosis of the right transverse sinus (TS) with a trans-stenosis pressure gradient (TSG) of 20 mmHg. The patient was treated with VPS. During the procedure, we performed a real-time measurement of ventricular CSF and cerebral sinovenous pressures. VPS selectively reduced the TS pressure and abolished the preoperative TS-TSG within 20 min of CSF diversion without altering the sigmoid sinus (SS) pressure. Our findings suggest that CSS can be an epiphenomenon, rather than the primary etiology in some patients with IIH. Conclusion: IIH is a challenging condition, in certain patients the radiographic stenosis and trans-stenosis gradient were an epiphenomenon because of the increased intracranial pressure that resulted in reversible TS-SS stenosis.

Objective Factors associated with favorable outcome after stereotactic radiosurgery (SRS) for dural arteriovenous fistulas (DAVFs) with cortical venous reflux (CVR) are not completely understood. The aim of this retrospective cohort study was to assess the outcomes after SRS for high-grade DAVFs and identify predictors. Methods We performed a retrospective review of consecutive patients with high-grade DAVFs, defined as the presence of CVR, who underwent SRS between 1989 and 2017. The primary outcome was defined as DAVF obliteration without a new permanent neurologic deficit. Predictors of outcomes were determined using multivariate logistic regression. Results The study cohort was composed of 41 high-grade DAVF patients with a mean age of 52 years. DAVF obliteration without a new permanent neurologic deficit was achieved in 62% of patients (13/21). The rates of complete obliteration and new permanent neurologic deficit were 63% (17/27) and 23% (7/30) of patients, respectively. No independent predictors of the primary outcome or angiographic obliteration were identified in the multivariate model. Presentation with a nonhemorrhagic neurologic deficit (NHND) was found to be an independent predictor of a new permanent neurologic deficit after SRS (odds ratio, 14.176; 95% confidence interval, 1.119–179.540; P = 0.041). Conclusions Obliteration without a new permanent neurologic deficit can be achieved in most appropriately selected patients with high-grade DAVFs after treatment with SRS. NHND at presentation is a risk factor for new permanent neurologic deficit after SRS.

OBJECTIVECyst formation can occasionally occur after stereotactic radiosurgery (SRS) for brain arteriovenous malformations (AVMs). Given the limited data regarding post-SRS cyst formation in patients with AVM, the time course, natural history, and management of this delayed complication are poorly defined. The aim of this systematic review was to determine the incidence, time course, and optimal management of cyst formation after SRS for AVMs.METHODSA literature review was performed using PubMed to identify studies reporting cyst formation in AVM patients treated with SRS. Baseline and outcomes data, including the incidence and management of post-SRS cysts, were extracted from each study that reported follow-up duration. The mean time to cyst formation was calculated from the subset of studies that reported individual patient data.RESULTSBased on pooled data from 22 studies comprising the incidence analysis, the overall rate of post-SRS cyst formation was 3.0% (78/2619 patients). Among the 26 post-SRS cyst patients with available AVM obliteration data, nidal obliteration was achieved in 20 (76.9%). Of the 64 cyst patients with available symptomatology and management data, 21 (32.8%) were symptomatic; 21 cysts (32.8%) were treated with surgical intervention, whereas the remaining 43 (67.2%) were managed conservatively. Based on a subset of 19 studies reporting individual time-to-cyst-formation data from 63 patients, the mean latency period to post-SRS cyst formation was 78 months (6.5 years).CONCLUSIONSCyst formation is an uncommon complication after SRS for AVMs, with a relatively long latency period. The majority of post-SRS cysts are asymptomatic and can be managed conservatively, although enlarging or symptomatic cysts may require surgical intervention. Long-term follow-up of AVM patients is crucial to the appropriate diagnosis and management of post-SRS cysts.

Background Endovascular mechanical thrombectomy (EMT) is the standard of care for eligible patients presenting with anterior circulation acute ischemic stroke (AIS) due to emergent large vessel occlusion (ELVO). The aim of this systematic review and meta-analysis is to compare the outcomes between patients undergoing general anesthesia (GA) versus conscious sedation (CS) for these procedures. Methods A literature review was performed to identify studies reporting the EMT outcomes of AIS patients who underwent GA or CS for the procedure. Baseline, treatment, and outcomes data were analyzed. Good outcome was defined as a modified Rankin Scale score of 0–2 at 3 months, and successful reperfusion was defined as modified thrombolysis in cerebral infarction grade of 2b–3. Results Nine studies, comprising a total of 1379 patients treated with GA (n = 761) or CS (n = 618) for EMT, were included. Based on pooled data, GA achieved good outcome in 35% and successful reperfusion in 81%, whereas CS achieved good outcome in 41% and successful reperfusion in 75%. Meta-analyses showed no significant differences in the rates of good outcome (P = 0.51) or successful reperfusion (P = 0.39) between the GA and CS groups. The rates of pneumonia were significantly higher in the GA group (21% vs. 11%; P = 0.01). Conclusions The use of either GA or CS during EMT for patients with anterior circulation acute ELVO does not yield significantly different rates of functional independence at 3 months.

OBJECTIVESeveral recent studies have improved our understanding of the outcomes of volume-staged (VS) and dose-staged (DS) stereotactic radiosurgery (SRS) for the treatment of large (volume > 10 cm3) brain arteriovenous malformations (AVMs). In light of these recent additions to the literature, the aim of this systematic review is to provide an updated comparison of VS-SRS and DS-SRS for large AVMs.METHODSA systematic review of the literature was performed using PubMed to identify cohorts of 5 or more patients with large AVMs who had been treated with VS-SRS or DS-SRS. Baseline data and post-SRS outcomes were extracted for analysis.RESULTSA total of 11 VS-SRS and 10 DS-SRS studies comprising 299 and 219 eligible patients, respectively, were included for analysis. The mean obliteration rates for VS-SRS and DS-SRS were 41.2% (95% CI 31.4%–50.9%) and 32.3% (95% CI 15.9%–48.8%), respectively. Based on pooled individual patient data, the outcomes for patients treated with VS-SRS were obliteration in 40.3% (110/273), symptomatic radiation-induced changes (RICs) in 13.7% (44/322), post-SRS hemorrhage in 19.5% (50/256), and death in 7.4% (24/323); whereas the outcomes for patients treated with DS-SRS were obliteration in 32.7% (72/220), symptomatic RICs in 12.2% (31/254), post-SRS hemorrhage in 10.6% (30/282), and death in 4.6% (13/281).CONCLUSIONSVolume-staged SRS appears to afford higher obliteration rates than those achieved with DS-SRS, although with a less favorable complication profile. Therefore, VS-SRS or DS-SRS may be a reasonable treatment approach for large AVMs, either as stand-alone therapy or as a component of a multimodality management strategy.

ObjectiveAlthough endovascular therapy has been widely adopted for the treatment of cerebral vasospasm after aneurysmal subarachnoid hemorrhage (aSAH), its effect on clinical outcomes remains incompletely understood. The aims of this retrospective cohort study are to evaluate the outcomes of endovascular intervention for post-aSAH vasospasm and identify predictors of functional independence at discharge and repeat endovascular vasospasm treatment.MethodsWe assessed the baseline and outcomes data for patients with aSAH who underwent endovascular vasospasm treatment at our institution, including intra-arterial (IA) vasodilator infusion and angioplasty. Statistical analyses were performed to determine factors associated with good outcome at discharge (modified Rankin Scale 0–2) and repeat endovascular vasospasm treatment.ResultsThe study cohort comprised 159 patients with a mean age of 52 years. Good outcome was achieved in 17% of patients at discharge (26/150 patients), with an in-hospital mortality rate of 22% (33/150 patients). In the multivariate analysis, age (OR 0.895; p=0.009) and positive smoking status (OR 0.206; p=0.040) were negative independent predictors of good outcome. Endovascular retreatment was performed in 34% (53/156 patients). In the multivariate analysis, older age (OR 0.950; p=0.004), symptomatic vasospasm (OR 0.441; p=0.046), initial treatment with angioplasty alone (OR 0.096; p=0.039), and initial treatment with combined IA vasodilator infusion and angioplasty (OR 0.342; p=0.026) were negative independent predictors of retreatment.ConclusionWe found a modest rate of functional independence at discharge in patients with aSAH who underwent endovascular vasospasm treatment. Older patients and smokers had worse functional outcomes at discharge. Initial use of angioplasty appears to decrease the need for subsequent retreatment.

Pituitary adenomas are a rare but important central nervous system tumor in children. Because of differences in growth and development, the manifestations of pituitary adenomas in children may differ from those seen in adults. Unlike adult patients, the pediatric population more often presents with clinically secretory adenomas. Although medical management is first-line treatment of prolactinomas, transsphenoidal surgery is appropriate for most children with Cushing disease and gigantism. Although some pediatric patients present surgical challenges because of small anatomic dimensions or an incompletely developed sphenoid sinus, transsphenoidal surgery can be safely and effectively undertaken in most children, with low complication rates.

OBJECTIVEThe goal of this study was to systematically review the outcomes of endoscopic endonasal surgery (EES) for pediatric craniopharyngiomas so as to assess its safety and efficacy.METHODSA systematic literature review was performed using the PubMed and MEDLINE databases for studies published between 1986 and 2019. All studies assessing outcomes following EES for pediatric craniopharyngiomas were included.RESULTSOf the total 48 articles identified in the original literature search, 13 studies were ultimately selected. This includes comparative studies with other surgical approaches, retrospective cohort studies, and case series.CONCLUSIONSEES for pediatric craniopharyngiomas is a safe and efficacious alternative to other surgical approaches. Achieving gross-total resection with minimal complications is feasible with EES and is comparable, if not superior in some cases, to traditional means of resection. Ideally, a randomized controlled trial might be implemented in the future to further elucidate the effectiveness of EES for resection of craniopharyngiomas.

Traumatic brain injury (TBI) is a significant cause of morbidity and mortality, especially among members of the armed services. Injuries sustained in the battlefield are subject to different mechanisms than those sustained in civilian life, particularly blast and high-velocity injury. Due to the unique nature of these injuries and the challenges associated with battlefield medicine, surgical interventions play a key role in acute management of TBI. However, the burden of chronic disease posed by TBI is poorly understood and difficult to investigate, especially in the military setting. The authors report the case logs of a United States Navy neurosurgeon, detailing the acute management and outcomes of 156 patients sustaining TBI between November 2010 and May 2011 during the war in Afghanistan. By demographics, more than half of the patients treated were local nationals. By mechanism of injury, blunt trauma (40.4%) and explosive injury (37.2%) were the most common contributors to TBI. Decompressive craniectomies (24.0%) and clot evacuations (14.7%) were the procedures most commonly performed. Nearly one-quarter of patients were transferred to receive further care, yet only 3 patients were referred for rehabilitative services. Furthermore, the data suggest that patients sustaining comorbid injuries in addition to TBI may be predisposed to worse outcomes. Improvements in documentation of military patients may improve knowledge of TBI and further identify potential variables or treatments that may affect prognosis. The increased survivability from TBI also highlights the need for additional research expenditure in the field of neurorehabilitation specifically.

To review the natural history of asymptomatic and symptomatic pediatric Chiari I malformations with and without syringomyelia. We reviewed the literature for case reports and case series describing the natural history of asymptomatic and symptomatic children with Chiari I malformations with and without syringomyelia. Our review included approximately 700 asymptomatic children without syringomyelia, 100 symptomatic children without syringomyelia, 22 asymptomatic children with syringomyelia, and 11 symptomatic children with syringomyelia. Symptomatic and imaging outcomes at the point of last reported follow-up were noted to describe the natural history of Chiari I malformations in children. Our review of about 700 asymptomatic children with CM-I without syrinx revealed that most children do not exhibit new-onset symptoms (5–6%) or syrinx (2–3%). The nearly 100 published cases of symptomatic CM-I without syrinx suggest that about half of children report symptomatic improvement (48%) and few report symptomatic worsening (7%). New-onset syrinx is rarely observed (2%). Few cases have been published about asymptomatic and symptomatic CM-I with syrinx as syringomyelia are generally regarded to be an indication for surgical intervention. Nevertheless, all 22 children with asymptomatic CM-I with syringomyelia included in this study were asymptomatic at follow-up, with syrinx resolution observed in 18 children and tonsillar herniation improvement observed in 16 children. Overall, our review of asymptomatic pediatric CM-I with or without syringomyelia suggests that its natural history is much more favorable than previously acknowledged and that the literature generally favors conservative management of these cases. Our review of asymptomatic pediatric CM-I with or without syringomyelia suggests that its natural history is much more favorable than previously acknowledged and that the literature generally favors conservative management of these cases. Further study of symptomatic pediatric CM-I is necessary to better understand its natural history.

OBJECTIVESyringogenesis in Chiari malformation type I (CM-I) is thought to occur secondary to impaction of the cerebellar tonsils within the foramen magnum (FM). However, the correlation between the CSF area and syringogenesis has yet to be elucidated. The authors sought to determine whether the diminution in subarachnoid space is associated with syringogenesis. Further, the authors sought to determine if syrinx resolution was associated with the degree of expansion of subarachnoid spaces after surgery.METHODSThe authors performed a retrospective review of all patients undergoing posterior fossa decompression for CM-I from 2004 to 2016 at the University of Virginia Health System. The subarachnoid spaces at the FM and at the level of the most severe stenosis were measured before and after surgery by manual delineation of the canal and neural tissue area on MRI and verified through automated CSF intensity measurements. Imaging and clinical outcomes were then compared.RESULTSOf 68 patients, 26 had a syrinx at presentation. Syrinx patients had significantly less subarachnoid space at the FM (13% vs 19%, p = 0.0070) compared to those without syrinx. Following matching based on degree of tonsillar herniation and age, the subarachnoid space was significantly smaller in patients with a syrinx (12% vs 19%, p = 0.0015). Syrinx resolution was associated with an increase in patients’ subarachnoid space after surgery compared with those patients without resolution (23% vs 10%, p = 0.0323).CONCLUSIONSSyrinx development in CM-I patients is correlated with the degree to which the subarachnoid CSF spaces are diminished at the cranial outlet. Successful syrinx reduction is associated with the degree to which the subarachnoid spaces are increased following surgery.

Traumatic brain injury (TBI) is associated with increased risk for psychological and substance use disorders. The study aim is to determine incidence and risk factors for persistent opioid prescription after hospitalization for TBI. Electronic medical records of patients age ≥ 18 admitted to a neuroscience intensive care unit between January 2013 and February 2017 for an intracranial injury were retrospectively reviewed. Primary outcome was opioid use through 12 months post-hospital discharge. A total of 298 patients with complete data were included in the analysis. The prevalence of opioid use among preadmission opioid users was 48 (87%), 36 (69%) and 22 (56%) at 1, 6 and 12-months post-discharge, respectively. In the opioid naive group, 69 (41%), 24 (23%) and 17 (19%) were prescribed opioids at 1, 6 and 12 months, respectively. Preadmission opioid use (OR 324.8, 95% CI 23.1-16907.5, p = 0.0004) and higher opioid requirements during hospitalization (OR 4.5, 95% CI 1.8-16.3, p = 0.006) were independently associated with an increased risk of being prescribed opioids 12 months post-discharge. These factors may be used to identify and target at-risk patients for intervention.

Background Targeted stereotactic radiosurgery (SRS) with sparing of the residual pituitary is the traditional radiosurgical method for pituitary adenomas. Whole-sella SRS is an alternative choice for radiologically indeterminate or large adenomas, the safety and efficacy of which has yet to be determined. Objective To determine if whole-sella SRS in acromegaly would have comparable radiographic and biochemical control to targeted SRS. We performed a multicenter, retrospective matched cohort study to compare outcomes between groups. Methods We conducted a retrospective review of acromegalic patients who underwent SRS from 1990 to 2016 at 10 centers participating in the International Radiosurgery Research Foundation. Whole-sella and targeted SRS patients were then matched in a 1:1 ratio. Results A total of 128 patients were eligible for inclusion. Whole-sella patients had a higher pre-SRS random serum growth hormone, larger treatment volume, and higher maximum point dose to the optic apparatus. The rates of initial/durable endocrine remission, new loss of pituitary function, and new cranial neuropathy were similar between groups. Mortality and new visual deficit were higher in the whole-sella cohort, though not statistically significant. Conclusion There was no difference in biochemical remission or recurrence between treatment groups. Although not statistically significant, the higher rates of tumor regression and lower rates of mortality and new visual deficit may suggest consideration of targeted SRS over whole-sella SRS in acromegaly treatment. Further research is needed to determine the association between visual deficits and mortality with whole-sella SRS.

OBJECTIVESignificant blood loss and coagulopathy are often encountered during adult spinal deformity (ASD) surgery, and the optimal intraoperative transfusion algorithm is debatable. Rotational thromboelastometry (ROTEM), a functional viscoelastometric method for real-time hemostasis testing, may allow early identification of coagulopathy and improve transfusion practices. The objective of this study was to investigate the effect of ROTEM-guided blood product management on perioperative blood loss and transfusion requirements in ASD patients undergoing correction with pedicle subtraction osteotomy (PSO).METHODSThe authors retrospectively reviewed patients with ASD who underwent single-level lumbar PSO at the University of Virginia Health System. All patients who received ROTEM-guided blood product transfusion between 2015 and 2017 were matched in a 1:1 ratio to a historical cohort treated using conventional laboratory testing (control group). Co-primary outcomes were intraoperative estimated blood loss (EBL) and total blood product transfusion volume. Secondary outcomes were perioperative transfusion requirements and postoperative subfascial drain output.RESULTSThe matched groups (ROTEM and control) comprised 17 patients each. Comparison of matched group baseline characteristics demonstrated differences in female sex and total intraoperative dose of intravenous tranexamic acid (TXA). Although EBL was comparable between ROTEM versus control (3200.00 ± 2106.24 ml vs 3874.12 ± 2224.22 ml, p = 0.36), there was a small to medium effect size (Cohen’s d = 0.31) on EBL reduction with ROTEM. The ROTEM group had less total blood product transfusion volume (1624.18 ± 1774.79 ml vs 2810.88 ± 1847.46 ml, p = 0.02), and the effect size was medium to large (Cohen’s d = 0.66). This difference was no longer significant after adjusting for TXA (β = −0.18, 95% confidence interval [CI] −1995.78 to 671.64, p = 0.32). More cryoprecipitate and less fresh frozen plasma (FFP) were transfused in the ROTEM group patients (cryoprecipitate units: 1.24 ± 1.20 vs 0.53 ± 1.01, p = 0.03; FFP volume: 119.76 ± 230.82 ml vs 673.06 ± 627.08 ml, p < 0.01), and this remained significant after adjusting for TXA (cryoprecipitate units: β = 0.39, 95% CI 0.05 to 1.73, p = 0.04; FFP volume: β = −0.41, 95% CI −772.55 to −76.30, p = 0.02). Drain output was lower in the ROTEM group and remained significant after adjusting for TXA.CONCLUSIONSFor ASD patients treated using lumbar PSO, more cryoprecipitate and less FFP were transfused in the ROTEM group compared to the control group. These preliminary findings suggest ROTEM-guided therapy may allow early identification of hypofibrinogenemia, and aggressive management of this may reduce blood loss and total blood product transfusion volume. Additional prospective studies of larger cohorts are warranted to identify the appropriate subset of ASD patients who may benefit from intraoperative ROTEM analysis.

OBJECTIVEGamma Knife radiosurgery (GKRS) provides a safe and effective management option for patients with all types of pituitary adenomas. The long-term adverse effects of targeted radiation to the hypothalamic-pituitary axis in relationship to radiation dose remain unclear. In this retrospective review, the authors investigated the role of differential radiation doses in predicting long-term clinical outcomes and pituitary function after GKRS for pituitary adenomas.METHODSA cohort of 236 patients with pituitary tumors (41.5% nonfunctioning, 58.5% functioning adenomas) was treated with GKRS between 1998 and 2015. Point dosimetric measurements, with no minimum volume, to 14 consistent points along the hypothalamus bilaterally, pituitary stalk, and normal pituitary were made. Statistical analyses were performed to determine the impact of doses to critical structures on clinical, radiological, and endocrine outcomes.RESULTSWith a median follow-up duration of 42.9 months, 18.6% of patients developed new loss of pituitary function. The median time to endocrinopathy was 21 months (range 2–157 months). The median dose was 2.1 Gy to the hypothalamus, 9.1 Gy to the pituitary stalk, and 15.3 Gy to the normal pituitary. Increasing age (p = 0.015, HR 0.98) and ratio of maximum dose to the pituitary stalk over the normal pituitary gland (p = 0.013, HR 0.22) were independent predictors of new or worsening hypopituitarism in the multivariate analysis. Sex, margin dose, treatment volume, nonfunctioning adenoma status, or ratio between doses to the pituitary stalk and hypothalamus were not significant predictors.CONCLUSIONSGKRS offers a low rate of delayed pituitary insufficiency for pituitary adenomas. Doses to the hypothalamus are low and generally do not portend endocrine deficits. Patients who are treated with a high dose to the pituitary stalk relative to the normal gland are at higher risk of post-GKRS endocrinopathy. Point dosimetry to specific neuroanatomical structures revealed that a ratio of stalk-to-gland radiation dose of 0.8 or more significantly increased the risk of endocrinopathy following GKRS. Improvement in the gradient index toward the stalk and normal gland may help preserve endocrine function.

BACKGROUND: The BRAF mutation has been identified as a potent target for the treatment of metastatic melanoma and BRAF inhibitors (BRAFi) have demonstrated promising results against melanoma brain metastases (BM). OBJECTIVE: To further investigate the effectiveness of this combined treatment regimen. METHODS: In this multicenter retrospective cohort study, 198 patients with known BRAF mutation status and treated with stereotactic radiosurgery (SRS) between 2011 and 2015 were identified. Kaplan–Meier methodology and multivariate regression analysis was then used to compare survival based on each parameter. RESULTS: The median survival after the diagnosis of BM in patients with BRAF mutation who received BRAFi was increased compared to survival in patients with wild-type BRAF (BRAF wt). In multivariate analysis, the BRAF mutation was an independent, positive prognostic factor with a hazard ratio of 0.59. BRAF mutated Patients who received BRAFi following SRS had improved survival compared to patients who received it before (P

The aims of this retrospective cohort study were to 1) identify new alignment risk factors for proximal junctional kyphosis (PJK) in adult spinal deformity (ASD) patients with lower thoracic upper instrumented vertebra (UIV) and 2) determine the effect of junctional tethers on PJK and UIV alignment.We analyzed consecutive ASD patients who underwent posterior instrumented fusion with lower thoracic UIV (T9-T11). Posteriorly anchored junctional tethers were used more recently for ligamentous augmentation to prevent PJK. In addition to regional and global parameters, upper segmental lumbar lordosis (ULL) versus lower segmental lumbar lordosis and UIV angle (measured from UIV inferior endplate to horizontal) were assessed. Primary outcome of PJK was defined as proximal junctional angle10° and10° greater than the corresponding preoperative measurement. Univariable and multivariable analyses were performed.The study cohort comprised 120 ASD patients (mean age, 67 years) with minimum 1-year follow-up. Preoperative ULL (P = 0.034) and UIV angle (P = 0.026) were associated with PJK. No independent preoperative alignment risk factors of PJK were identified in multivariable analysis. Tether use was protective against PJK (odds ratio, 0.063 [0.016-0.247]; P0.001). PJK in tethered patients was more common with greater postoperative ULL (P = 0.047) and UIV angle (P = 0.026).Junctional tethers significantly reduced PJK in ASD patients with lower thoracic UIV. In tethered patients, PJK was more common with greater postoperative lordosis of the upper lumbar spine and greater UIV angle. This finding suggests potential benefit of tethers to mitigate effects of segmental lumbar and focal UIV malalignment that may occur after deformity surgery.

The seizure outcomes for patients with brain arteriovenous malformations (AVM) who undergo intervention with stereotactic radiosurgery (SRS) are incompletely understood. We sought to determine, in a systematic review and meta-analysis, the rates of seizure control after SRS for patients with AVM-associated seizures and identify predictive factors.We performed a systematic review of PubMed and MEDLINE databases from January 1987 to January 2018, in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Studies reporting post-SRS outcomes data for ≥5 patients with AVM-associated seizures were included. The seizure outcomes and factors associated with seizure freedom were evaluated using meta-analysis.A total of 27 studies, comprising 4826 patients, met the inclusion criteria for analysis. One or more seizures occurred in 1456 of 4826 patients (34.7% [26.0-43.9%]), and the mean follow-up was 48 ± 7 months. Seizure control (seizure freedom or seizure improvement) was achieved in 910 of 1312 patients (73.1% [66.9-78.9%]). Seizure freedom was achieved in 597 of 1245 patients (55.7% [44.5-66.6%]). Of 259 patients with seizure freedom, cessation of antiepileptic drugs was achieved in 175 patients (67.3% [46.3-85.1%]). AVM obliteration (odds ratio [OR] 4.61; P 0.001), shorter seizure duration (OR 6.80; P 0.001), generalized seizure type (OR 2.27; P = 0.007), and previous AVM hemorrhage (OR 5.10; P0.001) were significantly associated with seizure freedom.SRS affords seizure control to the majority of patients with AVM-associated seizures, and approximately two thirds of those with seizure freedom are able cease anticonvulsants. Nidal obliteration appears to improve the likelihood of seizure freedom, and thus remains the primary goal of intervention with SRS.

Tranexamic acid (TXA) is an antifibrinolytic agent with demonstrated efficacy in reducing blood loss when administered systemically. However, in patients with contraindications to systemic or intravenous TXA, topical TXA (tTXA) has been shown to reduce perioperative blood loss, with some studies suggesting equivalence compared to systemic TXA. However, these studies have been conducted in healthy cohorts without contraindications to systemic TXA. In the surgical management of adult spinal deformity (ASD), comorbid disease is commonly encountered and may preclude use of systemic TXA. In this subset of patients with ASD who have contraindications for systemic TXA, use of tTXA has not been reported.The primary objective of this study was to conduct a systematic review on the use of tTXA in spine surgery and to present the authors’ initial experience with tTXA as a novel hemostatic technique for 2 patients with medically complex ASD. Both patients had contraindications to systemic TXA use and underwent high-risk, long-segment fusion operations for correction of ASD. Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were used to obtain studies related to spine surgery and tTXA from the National Institutes of Health PubMed (www.pubmed.gov) database. Criteria for final selection included a demonstration of quantitative data regarding operative or postoperative blood loss with the use of tTXA, and selection criteria were met by 6 articles.Topical TXA may offer a potential therapeutic role in reducing intra- and postoperative blood loss following long-segment spinal fusion surgeries, particularly for medically complex patients with contraindications to systemic TXA. It is reasonable to consider the use of tTXA as a salvage technique in complex high-risk patients with contraindications to systemic TXA, although further research is needed to delineate safety, magnitude of benefit, and optimization of dosing.

Proximal junctional kyphosis (PJK) is a common problem after multilevel spine instrumentation for adult spinal deformity. Various anti-PJK techniques such as junctional tethers for ligamentous augmentation have been proposed. We present an operative video demonstrating technical nuances of junctional tether "weave" application. A 70-yr-old male with prior L2-S1 instrumented fusion presented with worsening back pain and posture. Imaging demonstrated pathological loss of lumbar lordosis (flat back deformity), proximal junctional failure, and pseudarthrosis. The patient had severe global and segmental sagittal malalignment, with sagittal vertical axis (SVA, C7-plumbline) measuring 22.3 cm, pelvic incidence (PI) 55°, lumbar lordosis (LL) 8° in kyphosis, pelvic tilt (PT) 30°, and thoracic kyphosis (TK) 6°. The patient gave informed consent for surgery and use of imaging for medical publication. Briefly, surgery first involved re-instrumentation with bilateral pedicle screws from T10 to S1. After right-sided iliac screw fixation (left-sided iliac screw fixation was not performed due to extensive prior iliac crest bone graft harvesting), we then completed a L2-3 Smith-Petersen osteotomy, extended L4 pedicle subtraction osteotomy, and L3-4 interbody arthrodesis with a 12° lordotic cage (9 × 14 × 40 mm). Cobalt Chromium rods were placed spanning the instrumentation bilaterally, and accessory supplemental rods spanning the PSO were attached. An anti-PJK junctional tether "weave" was then implemented using 4.5 mm polyethylene tape (Mersilene tape [Ethicon, Somerville, New Jersey]). Postoperative imaging demonstrated improved alignment (SVA 2.8 cm, PI 55°, LL 53°, PT 25°, TK 45°) and no significant neurological complications occurred during convalescence or at 6 mo postop.

OBJECTIVEFixed sagittal spinal malalignment is a common problem in adult spinal deformity (ASD). Various three-column osteotomy techniques, including the extended pedicle subtraction osteotomy (ePSO), may correct global and regional malalignment in this patient population. In contrast to the number of reports on traditional PSO (Schwab grade 3 osteotomy), there is limited literature on the outcomes of ePSO (Schwab grade 4 osteotomy) in ASD surgery. The objective of this retrospective study was to provide focused investigation of radiographic outcomes and complications of single-level lumbar ePSO for ASD patients with fixed sagittal malalignment.METHODSConsecutive ASD patients in whom sagittal malalignment had been treated with single-level lumbar ePSO at the authors’ institution between 2010 and 2015 were analyzed, and those with a minimum 2-year follow-up were included in the study. Radiographic analyses included assessments of segmental lordosis through the ePSO site (sagittal Cobb angle measured from the superior endplate of the vertebra above and inferior endplate of the vertebra below the ePSO), lumbar lordosis (LL), pelvic tilt (PT), pelvic incidence and LL mismatch, thoracic kyphosis (TK), and sagittal vertical axis (SVA) on standing long-cassette radiographs. Complications were analyzed for the entire group.RESULTSAmong 71 potentially eligible patients, 55 (77%) had a minimum 2-year follow-up and were included in the study. Overall, the average postoperative increases in ePSO segmental lordosis and overall LL were 41° ± 14° (range 7°–69°, p < 0.001) and 38° ± 11° (range 9°–58°, p < 0.001), respectively. The average SVA improvement was 13 ± 7 cm (range of correction: −33.6 to 3.4 cm, p < 0.001). These measurements were maintained when comparing early postoperative to last follow-up values, respectively (mean follow-up 52 months, range 26–97 months): ePSO segmental lordosis, 34° vs 33°, p = 0.270; LL, 47.3° vs 46.7°, p = 0.339; and SVA, 4 vs 5 cm, p = 0.330. Rod fracture (RF) at the ePSO site occurred in 18.2% (10/55) of patients, and pseudarthrosis (PA) at the ePSO site was confirmed by CT imaging or during rod revision surgery in 14.5% (8/55) of patients. Accessory supplemental rods across the ePSO site, a more recently employed technique, significantly reduced the occurrence of RF or PA on univariate (p = 0.004) and multivariable (OR 0.062, 95% CI 0.007–0.553, p = 0.013) analyses; this effect approached statistical significance on Kaplan-Meier analysis (p = 0.053, log-rank test). Interbody cage placement at the ePSO site resulted in greater ePSO segmental lordosis correction (45° vs 35°, p = 0.007) without significant change in RF or PA (p = 0.304). Transient and persistent motor deficits occurred in 14.5% (8/55) and 1.8% (1/55) of patients, respectively.CONCLUSIONSExtended PSO is an effective technique to correct fixed sagittal malalignment for ASD. In comparison to traditional PSO techniques, ePSO may allow greater focal correction with comparable complication rates, especially with interbody cage placement at the ePSO site and the use of accessory supplemental rods.

OBJECTIVECavernous sinus invasion (CSI) in Cushing’s disease (CD) negatively affects the probability of complete resection, biochemical cure, and need for adjuvant therapy. However, the prediction of CSI based on MRI findings has been inconsistent and variable. Among macroadenomas, the Knosp classification is the most widely utilized radiographic predictor of CSI, but its accuracy in predicting CSI and the probability of gross-total resection is limited in the setting of microadenomas or Knosp grade 0–2 macroadenomas. The authors noticed that the presence of a triangular shape of adenomas adjacent to the cavernous sinus on coronal MR images is frequently associated with CSI. The authors aimed to determine the correlation of this radiographic finding (“sail sign” [SS]) with CSI.METHODSThe authors performed a retrospective review of all patients with a pituitary lesion < 20 mm and a biochemical diagnosis of CD treated with endoscopic or microscopic transsphenoidal resection from November 2007 to May 2017. Overall 185 patients with CD were identified: 27 were excluded for negative preoperative imaging, 32 for lacking tumors adjacent to the sinus, 7 for Knosp grade 3 or higher, and 4 for inadequate intraoperative assessment of the CSI. Following application of inclusion and exclusion criteria, 115 cases were available for statistical analysis. Intraoperative CSI was prospectively evaluated at the time of surgery by one of two neurosurgical attending surgeons, and MRI data were evaluated retrospectively by a neurosurgical resident and attending neuroradiologist blinded to the intraoperative results.RESULTSA positive SS was identified in 23 patients (20%). Among patients with positive SS, 91% demonstrated CSI compared to 10% without an SS (p < 0.001). Using the SS as a predictor of CSI provided a sensitivity of 0.7 and a specificity of 0.98, with a positive predictive value (PPV) of 0.91 and a negative predictive value of 0.9. Among patients with positive SS, 30% did not achieve immediate postoperative remission, compared to 3.3% of patients without an SS (p < 0.001).CONCLUSIONSThe presence of a positive SS among Cushing’s adenomas adjacent to the CS provides strong PPV, specificity, and positive likelihood ratio for the prediction of CSI. This can be a useful tool for preoperative planning and for predicting the likelihood of long-term biochemical remission and the need for adjuvant radiosurgery.

Objectives Endovascular technology for the treatment of intracranial aneurysms continues to rapidly evolve. The SMART coil (Penumbra Inc., Alameda, CA, USA) is a novel microcoil designed to enhance deliverability. The aim of this single-center, retrospective cohort study is to assess the initial outcomes after aneurysm embolization using SMART coils. Patients and methods We reviewed consecutive patients with intracranial aneurysms who underwent endovascular embolization using SMART coils from June 2016 to January 2017. Baseline and initial outcomes data were analyzed. Results The study cohort was comprised of 32 patients with 33 aneurysms. The mean age was 55.8 years. The majority (85%) of aneurysms were located in the anterior circulation. The mean aneurysm maximum diameter and neck width were 6.0 mm and 3.1 mm, respectively. Dome irregularity and fusiform aneurysm morphology were noted in 33% and 9% of aneurysms, respectively, and 15% presented with subarachnoid hemorrhage. No serious procedural complications occurred, including microcatheter prolapse, intraprocedural aneurysm rupture, or thromboembolism. Device malfunction occurred in one case (3%). The mean packing density was 25%, and the degree of immediate post-embolization aneurysm occlusion was a modified Raymond-Roy grade I, II, IIIa, and IIIb in 48%, 27%, 18%, and 6%, respectively. Conclusion Our preliminary findings suggest that the SMART coil has a favorable initial risk to benefit profile for the embolization of appropriately selected aneurysms. Additional studies of larger cohorts are necessary to determine the mid-term and long-term clinical and angiographic outcomes of aneurysm patients treated with the SMART coil.

PURPOSE: The aim of this systematic review is to evaluate the long-term endocrine outcomes and postoperative complications following endoscopic vs. microscopic transsphenoidal resection (TSR) for the treatment of acromegaly. METHODS: A literature review was performed, and studies with at least five patients who underwent TSR for acromegaly, reporting biochemical remission criteria and long-term remission outcomes were included. Data extracted from each study included surgical technique, perioperative complications, biochemical remission criteria and long-term remission outcomes. RESULTS: Fifty-two case series from 1976 to 2016 met the inclusion criteria, comprising 4,375 patients. Thirty-six reports were microsurgical (n=3,144) and thirteen were endoscopic (n=940). Three studies compared microsurgical (n=111) to endoscopic TSR outcomes (n=180). The overall initial and long-term remission rates were 58.2% vs. 57.4% and 69.2% vs. 70.2% for the microsurgical and endoscopic groups, respectively. For microadenomas, the initial and long-term remission rates were 77.6% vs. 82.2% and 76.9% vs. 73.5% for microsurgical and endoscopic approaches, respectively. For macroadenomas, the initial and long-term remission rates were 46.9% vs. 60.0% 40.2% vs. 61.5% for microsurgical and endoscopic approaches, respectively. The rates of postoperative CSF leak were 3.0% vs. 2.3% for the microscopic and endoscopic groups, respectively. The rates of hypopituitarism and transient diabetes insipidus were 6.7% vs. 6.4% and 9.0% vs. 7.8% for the microscopic and endoscopic groups, respectively. CONCLUSIONS: Both endoscopic and microsurgical approaches for TSR of growth hormone-secreting adenomas are viable treatment options for patients with acromegaly, and yield similarly high rates of remission under the most current consensus criteria.

Stenosis of the transverse sinus (TS) and sigmoid sinus (SS), with a trans-stenosis pressure gradient, has been implicated in the pathophysiology of idiopathic intracranial hypertension (IIH). MRI has shown improvement in TS and SS stenosis after high-volume lumbar puncture (HVLP) in a subset of patients with IIH. The authors present the first report of an IIH patient with immediate post-HVLP TS and SS trans-stenosis pressure gradient reduction and an attendant increase in TS and SS cross-sectional area confirmed using intravascular ultrasonography (IVUS). Recurrence of the patient’s TS-SS stenosis coincided with elevated HVLP opening pressure, and venous sinus stent placement resulted in clinical improvement. This report suggests that TS and SS stenosis may be a downstream effect of elevated intracranial pressure in IIH, rather than its principal etiological mechanism. However, the authors hypothesize that endovascular stenting may obliterate a positive feedback loop involving trans-stenosis pressure gradients, and still benefit appropriately selected patients.

OBJECTIVEExtracapsular resection of pituitary microadenomas improves remission rates, but the application of pseudocapsular techniques for macroadenomas has not been well described. In larger tumors, the extremely thin, compressed normal gland or its complete absence along the tumor’s anterior surface limits the application of the traditional pseudocapsular technique that can be used for microadenomas. However, in the authors’ experience, the interface between the pseudocapsule at the posterior margin of the adenoma and the compressed normal gland behind it is universally present, providing a surgical dissection plane. In mid-2010, the authors began using a new surgical technique to identify and use this interface for the resection of larger macroadenomas, a technique that can be used with the microscope or the endoscope.METHODSThe authors performed a cohort study using prospectively collected preoperative imaging reports and operative details and retrospectively reviewed postoperative images and clinical follow-up of patients with a pituitary macroadenoma 20–40 mm in maximum diameter undergoing microscopic transsphenoidal resection. Since dissection of the tumor capsule only pertains to encapsulated tumor within the sella and not to tumor invading the cavernous sinus, assessment of tumor removal of noninvasive tumors emphasized the entire tumor, while that of invasive tumors emphasized the intrasellar component only. The incidence of residual tumor on postoperative imaging, new-onset endocrinopathy, and recovery of preoperative pituitary deficits was compared between patients who underwent surgery before (Group A) and after (Group B) implementation of the new technique.RESULTSThere were 34 consecutive patients in Group A and 74 consecutive patients in Group B. Tumors in 18 (53%) Group A and 40 (54%) Group B patients had no evidence of cavernous sinus invasion on MRI. Use of the posterior pseudocapsule technique reduced the incidence of intrasellar residual tumor on postoperative MRI for tumors without cavernous sinus invasion (39% [Group A] vs 10%, p < 0.05) and in all tumors regardless of invasion (50% vs 18%, p < 0.005). The incidence of new endocrinopathy was less likely (25% vs 12%, p = 0.098) and the recovery of prior deficits more likely (13% vs 27%, p = 0.199) among patients treated using the pseudocapsule approach, although the differences are not statistically significant.CONCLUSIONSUse of the posterior pseudocapsule dissection plane can enhance the resection of pituitary macroadenomas.

Introduction It remains unclear whether stereotactic radiosurgery (SRS) offers the same benefit for patients with type 2 trigeminal neuralgia (TN2) as for those with type 1 trigeminal neuralgia (TN1). The objective of this study is to compare the outcomes of patients with TN1 and TN2 after SRS. Methods SRS outcomes of patients with trigeminal neuralgia treated at a single center from 1994 to 2016 were analyzed. Patients with TN1 were matched to those with TN2 in a 1:1 ratio based on sex, age, pretreatment Barrow Neurological Institute (BNI) pain score, previous treatment, previous facial numbness, and maximum dose. The primary outcome was defined as a BNI pain score of ≤3. Results The matched TN1 and TN2 cohorts each comprised 56 patients. There were no differences in BNI pain scores at last follow-up, new/worse facial numbness, or pain recurrence, or time to recurrence. Time to initial pain relief after SRS was longer for patients with TN2 (5.4 vs. 4.4 months; P = 0.0016). Actuarial initial pain relief rates were 75%, 90%, and 90% for TN1 and 47%, 77%, and 87% for TN2 at 5, 10, and 15 months, respectively. Actuarial pain relief maintenance rates were 72%, 67%, and 52% for TN1 and 53%, 32%, and 32% for TN2 at 1, 2, and 3 years, respectively. Conclusions SRS offers similar rates of initial pain relief, pain score distribution, pain recurrence, and time to pain recurrence between patients with TN1 and TN2. The time to initial pain relief was longer for patients with TN2.

OBJECTIVEEmbolization of brain arteriovenous malformations (AVMs) prior to stereotactic radiosurgery (SRS) has been reported to negatively affect obliteration rates. The goal of this systematic review and meta-analysis was to compare the outcomes of AVMs treated with embolization plus SRS (E+SRS group) and those of AVMs treated with SRS alone (SRS group).METHODSA literature review was performed using PubMed to identify studies with 10 or more AVM patients and obliteration data for both E+SRS and SRS groups. A meta-analysis was performed to compare obliteration rates between the E+SRS and SRS groups.RESULTSTwelve articles comprising 1716 patients were eligible for analysis. Among the patients with radiological follow-up data, complete obliteration was achieved in 48.4% of patients (330/681) in the E+SRS group compared with 62.7% of patients (613/978) in the SRS group. A meta-analysis of the pooled data revealed that the obliteration rate was significantly lower in the E+SRS group (OR 0.51, 95% CI 0.41–0.64, p < 0.00001). Symptomatic adverse radiation effects were observed in 6.6% (27/412 patients) and 11.1% (48/433 patients) of the E+SRS and SRS groups, respectively. The annual post-SRS hemorrhage rate was 2.0%–6.5% and 0%–2.0% for the E+SRS and SRS groups, respectively. The rates of permanent morbidity were 0%–6.7% and 0%–13.5% for the E+SRS and SRS groups, respectively.CONCLUSIONSArteriovenous malformation treatment with combined embolization and SRS is associated with lower obliteration rates than those with SRS treatment alone. However, this comparison does not fully account for differences in the initial AVM characteristics in the E+SRS group as compared with those in the SRS group. Further studies are warranted to address these limitations.

BACKGROUND CONTEXT Surgical correction of adult spinal deformity (ASD) is often associated with significant blood loss and coagulopathy. Optimal intraoperative transfusion algorithm remains debatable. Rotational thromboelastometry (ROTEM), a functional viscoelastometric method for real-time hemostasis testing, may allow early identification of coagulopathy, and hence improve transfusion practices during surgery. PURPOSE To investigate the effects of ROTEM-guided therapy on intraoperative estimated blood loss (EBL) and transfusion requirements in patients who underwent pedicle subtraction osteotomy (PSO) for ASD. STUDY DESIGN/SETTING Retrospective chart review of a prospectively maintained, single-center, multisurgeon database. PATIENT SAMPLE Consecutive ASD patients. OUTCOME MEASURES Primary outcomes: intraoperative EBL and total volume of blood product transfused. Secondary outcomes: packed red blood cells (pRBC), platelets, cryoprecipitate, and fresh frozen plasma (FFP) transfused during surgery. METHODS All ASD patients who underwent single-level lumbar PSO with ROTEM-guided transfusion at our institution were matched in a 1:1 ratio to a historical cohort with the conventional clinical and point-of-care (POC) transfusion algorithm. Covariates for matching were age, body mass index, revision operation status, number of instrumented levels, number of transforaminal lumbar interbody fusions, number of Smith-Petersen osteotomies, and preoperative hemoglobin. RESULTS The matched groups comprised 17 patients each, and comparison of baseline demographic and surgical parameters demonstrated more women (p=.04) and a higher total intraoperative dose of intravenous tranexamic acid (TXA) administered (p=.03) in the ROTEM group. Although not significant, EBL was lower in the ROTEM group (3200.00±2106.24vs. 3874.12±2224.22 mL; p=.36), with small-to-medium effect size (Cohen's d=0.31). Prior to adjusting for TXA, ROTEM-based transfusion was associated with lower volume of total blood products transfused (1624.18±1774.79vs. 2810.88±1847.46 mL; p=.02), with medium-to-large effect size (Cohen's d=0.66). This difference was no longer significant after adjustment for TXA (β=−0.18; 95% CI [−1995.78 to 671.64]; p=.32). pRBC and platelet transfusions were comparable between the matched cohorts. The ROTEM group was associated with greater number of cryoprecipitate units (1.24±1.20vs. 0.53±1.01 units; p=.03) and lower FFP (119.76±230.82vs. 673.06±627.08 mL; p CONCLUSIONS Compared to the conventional transfusion criteria, the use of ROTEM-guided transfusion algorithm in lumbar PSO for surgical correction of ASD was associated with greater number of cryoprecipitate units and lower FFP volume transfused. ROTEM-guided transfusion allowed early identification and treatment of hypofibrinogenemia, and aggressive management of this complication may reduce intraoperative EBL and total volume of blood products transfused.

OBJECTIVEA subset of patients with Chiari I malformation demonstrate patent subarachnoid spaces around the cerebellum, indicating that reduced posterior fossa volume alone does not account for tonsillar descent. The authors distinguish two subsets of Chiari I malformation patients based on the degree of “posterior fossa crowdedness” on MRI.METHODSTwo of the coauthors independently reviewed the preoperative MR images of 49 patients with Chiari I malformation and categorized the posterior fossa as “spacious” or “crowded.” Volumetric analysis of posterior fossa structures was then performed using open-source DICOM software. The preoperative clinical and imaging features of the two groups were compared.RESULTSThe posterior fossae of 25 patients were classified as spacious and 20 as crowded by both readers; 4 were incongruent. The volumes of the posterior fossa compartment, posterior fossa tissue, and hindbrain (posterior fossa tissue including herniated tonsils) were statistically similar between the patients with spacious and crowed subtypes (p = 0.33, p = 0.17, p = 0.20, respectively). However, patients in the spacious and crowded subtypes demonstrated significant differences in the ratios of posterior fossa tissue to compartment volumes as well as hindbrain to compartment volumes (p = 0.001 and p = 0.0004, respectively). The average age at surgery was 29.2 ± 19.3 years (mean ± SD) and 21.9 ± 14.9 years for spacious and crowded subtypes, respectively (p = 0.08). Syringomyelia was more prevalent in the crowded subtype (50% vs 28%, p = 0.11).CONCLUSIONSThe authors' study identifies two subtypes of Chiari I malformation, crowded and spacious, that can be distinguished by MRI appearance without volumetric analysis. Earlier age at surgery and presence of syringomyelia are more common in the crowded subtype. The presence of the spacious subtype suggests that crowdedness alone cannot explain the pathogenesis of Chiari I malformation in many patients, supporting the need for further investigation.

BACKGROUND CONTEXT Various three-column osteotomy techniques, including the extended pedicle subtraction osteotomy (ePSO), may correct global and regional malalignment in adult spinal deformity (ASD) patients. In contrast to the traditional PSO (Schwab grade 3 osteotomy), there is limited literature reporting outcomes for ePSO (Schwab grade 4 osteotomy) in ASD surgery. PURPOSE The objective of this study was to provide focused investigation of radiographic outcomes and complications for patients undergoing single-level lumbar ePSO for ASD. STUDY DESIGN/SETTING Retrospective review of prospectively-maintained, single-center, multisurgeon database of consecutive ASD patients. PATIENT SAMPLE Consecutive ASD patients. OUTCOME MEASURES Radiographic parameters (including segmental lordosis through the ePSO site) and associated complications. METHODS Fifty-five consecutive ASD patients in whom sagittal malalignment was treated with single-level lumbar ePSO at our institution between 2010 and 2015 were analyzed. Radiographic analyses included assessment of segmental lordosis through the ePSO site (sagittal Cobb's angle measured from the superior endplate of the vertebra above and inferior endplate of the vertebra below the ePSO), lumbar lordosis (LL), pelvic tilt (PT), pelvic incidence and LL mismatch, thoracic kyphosis (TK), and sagittal vertical axis (SVA) on standing long-cassette radiographs. Patients with minimum 2-year follow-up were included and complications were analyzed for the entire group. RESULTS Overall, the average postoperative increase in ePSO segmental lordosis and overall LL was 41°±14° (range: 7°–69°, p CONCLUSIONS ePSO is an effective technique to correct sagittal malalignment in ASD. In comparison to traditional PSO techniques, ePSO may allow greater focal correction with comparable complication rates, especially with interbody cage placement at the ePSO site and use of accessory supplemental rods.