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OBJECTIVE Extension fractures in the setting of diffuse idiopathic skeletal hyperostosis (DISH) represent highly unstable injuries. As a result, these fractures are most frequently treated with immediate surgical fixation to limit any potential risk of associated neurological injury. Although this represents the standard of care, patients with significant comorbidities, advanced age, or medical instability may not be surgical candidates. In this paper, the authors evaluated a series of patients with extension DISH fractures who were treated with orthosis alone and evaluated their outcomes. METHODS A retrospective review from 2015 to 2022 was conducted at a large level 1 trauma center. Patients with extension-type DISH fractures without neurological deficits were identified. All patients were treated conservatively with orthosis alone. Baseline patient characteristics and adverse outcomes are reported. RESULTS Twenty-seven patients were identified as presenting with extension fractures associated with DISH without neurological deficit. Of these, 22 patients had complete follow-up on final chart review. Of these 22 patients, 21 (95.5%) were treated successfully with external orthosis. One patient (4.5%) who was noncompliant with the brace had an acute spinal cord injury 1 month after presentation, requiring immediate surgical fixation and decompression. No other complications, including skin breakdown or pressure ulcers related to bracing, were reported. CONCLUSIONS Treatment of extension-type DISH fractures may be a reasonable option for patients who are not candidates for safe surgical intervention; however, a risk of neurological injury secondary to delayed instability remains, particularly if patients are noncompliant with the bracing regimen. This risk should be balanced against the high complication rate and potential mortality associated with surgical intervention in this patient population.

OBJECTIVE Lumbar synovial cysts (LSCs) represent a relatively rare clinical pathology that may result in radiculopathy or neurogenic claudication. Because of the potential for recurrence of these cysts, some authors advocate for segmental fusion, as opposed to decompression alone, as a way to eliminate the risk for recurrence. The objective of this study was to create a predictive score for synovial cyst recurrence following decompression without fusion. METHODS A retrospective chart review was completed of all patients evaluated at a single center over 20 years who were found to have symptomatic LSCs requiring intervention. Only patients undergoing decompression without fusion were included in the analysis. Following this review, baseline characteristics were obtained as well as radiological information. A machine learning method (risk-calibrated supersparse linear integer model) was then used to create a risk stratification score to identify patients at high risk for symptomatic cyst recurrence requiring repeat surgical intervention. Following the creation of this model, a fivefold cross-validation was completed. RESULTS In total, 89 patients were identified who had complete radiological information. Of these 89 patients, 11 developed cyst recurrence requiring reoperation. The Lumbar Synovial Cyst Score was then created with an area under the curve of 0.83 and calibration error of 11.0%. Factors predictive of recurrence were found to include facet inclination angle > 45°, canal stenosis > 50%, T2 joint space hyperintensity, and presence of grade I spondylolisthesis. The probability of cyst recurrence ranged from < 5% for a score of 2 or less to > 88% for a score of 7. CONCLUSIONS The Lumbar Synovial Cyst Score model is a quick and accurate tool to assist in clinical decision-making in the treatment of LSCs.

The optimal management of spinal epidural abscesses (SEA) secondary to primary spinal infections has demonstrated large variability in the literature. Although some literature suggests a high rate of neurological deterioration, others suggest failure of medical management is uncommon.To develop a predictive model to evaluate the likelihood of failure of medical therapy in the setting of SEA.A retrospective review was conducted of all patients presenting with SEA from primary spinal infections. Patients presenting with MRI evidence of SEA without neurological deficits were included. Failure of medical management was defined as requiring surgical intervention over 72 hours after the initiation of antibiotics. A machine learning method (Risk-Calibrated Supersparse Linear Integer Model) was used to create a risk stratification score to identify patients at high risk for requiring surgical intervention.In total, 159 patients were identified as presenting with MRI findings of SEA without evidence of neurological deficit. Of these patients, 50 required delayed surgery compared with 109 whose infection were successfully treated with surgical intervention. The Spinal Epidural Abscess Predictive Score was created using a machine learning model with an area under the curve of 0.8043 with calibration error of 14.7%. Factors included active malignancy, spondylodiscitis, organism identification, blood cultures, and sex. The probability of failure of medical management ranged from5% for a score of 2 or less and95% for a score of 7 or more.The Spinal Epidural Abscess Predictive Score model is a quick and accurate tool to assist in clinical decision-making in SEA.

Background: The use of instrumentation in the setting of primary spinal infections is controversial. While the instrumentation is often required in the presence of progressive deformity due to spinal osteomyelitis (SO), discitis (SD), or spinal epidural abscesses (SEA), many surgeons are concerned about instrumentation increasing the risk of infection recurrence and/or persistence warranting reoperation. Methods: We retrospectively reviewed the need for reoperations for persistent infections in 119 patients who presented with primary spinal infections. They were treated with decompressions with/without non-instrumented fusion (70 patients) versus decompressions with instrumented fusions (49 patients). Results: The use of primary spinal instrumentation in the presence of infection (SO/SD/SEA) did not increase the requirement for repeated surgery due to recurrent/residual infection when compared to those undergoing decompressions with/without non-instrumented fusions. Of 49 patients who initially required instrumentation, 6 (12.5%) required reoperations for recurrent or residual infection. For the 71 undergoing index decompressions for infection with/without non-instrumented fusion, 9 (12.7%), or nearly an identical percentage, required reoperations for recurrent/residual infection (P = 0.93). Conclusion: The use of instrumentation in the treatment of primary spinal infections in a small sample of just 49 patients did not increase the risk for persistent infection warranting reoperations versus 70 patients undergoing initial decompressions with/without non-instrumented fusions.

Background Atypical teratoid/rhabdoid tumor (AT/RT) is a rare tumor that is most frequently encountered in the pediatric patient population. AT/RT accounts for approximately 1%−2% of all pediatric central nervous system tumors and roughly 10%−20% of tumors in patients younger than 3 years of age. While AT/RT has been encountered in the adult population, the vast majority of the cases reported occur in the supratentorial space. In the existing literature, only 3 adult cases that arise from the cerebellum have ever been reported. Case Description A 38-year-old female presented with 6 months of worsening nausea, emesis, vertigo, diplopia, and coordination difficulty. Magnetic resonance imaging revealed a T1 avidly contrast-enhancing mass, composed of both cystic and solid areas, extending from the cerebellum into the fourth ventricle. Following a gross total resection, surgical pathology was consistent with AT/RT, with tumor cell loss of integrase interactor-1 (INI-1) observed via immunohistochemical staining. Conclusions This case represents just the fourth ever reported case of AT/RT arising from the cerebellum in an adult and the oldest reported age to date of a cerebellar AT/RT occurring in a female. Due to the paucity of reported adult AT/RT cases, little is known about adults with AT/RT. Further reports will function to improve the general understanding of AT/RT in the adult population.

Background: Health literacy profoundly impacts patient outcomes as patients with decreased health literacy are less likely to understand their illness and adhere to treatment regimens. Patient education materials supplement in-person patient education, especially in cerebrovascular diseases that may require a multidisciplinary care team. This study aims to assess the readability of online patient education materials related to cerebrovascular diseases and to contrast the readability of those materials produced by academic institutions with those of non-academic sources. Methods: The readability of online patient education materials was analyzed using Flesch-Kincaid Grade Level (FKGL) and Flesch Reading Ease (FRE) assessments. Readability of academic-based online patient education materials was compared to nonacademic online patient education materials. Online patient education materials from 20 academic institutions and five sources from the web were included in the analysis. Results: Overall median FKGL for neurovascular-related patient online education documents was 11.9 (95% CI: 10.8–13.1), reflecting that they are written at a 12th grade level, while the median FRE was 40.6 (95% CI: 34.1–47.1), indicating a rating as “difficult” to read. When comparing academic-based online patient education materials to other internet sources, there was no significant difference in FRE and FKGL scores (P = 0.63 and P = 0.26 for FKGL and FRE, respectively). Conclusion: This study demonstrates that online patient education materials pertaining to cerebrovascular diseases from major academic centers and other nonacademic internet sites are difficult to understand and written at levels significantly higher than that recommended by national agencies. Both academic and nonacademic sources reflect this finding equally. Further study and implementation are warranted to investigate how improvements can be made.

BACKGROUND Fractures in patients with diffuse idiopathic skeletal hyperostosis (DISH) are considered highly unstable injuries with high risk for neurological injury. Surgical intervention is the standard of care for these patients to avoid secondary spinal cord injuries. Despite this, certain cases may necessitate a nonoperative approach. Herein within, the authors describe three cases of cervical, thoracic, and lumbar fractures in the setting of DISH that were successfully treated via orthosis. OBSERVATIONS The authors present three cases of fractures in patients with DISH. A 74-year-old female diagnosed with an acute fracture of a flowing anterior osteophyte at C6–C7 treated with a cervical orthosis. A 78-year-old male with an anterior fracture of the ankylosed T7–T8 vertebrae managed with a Jewett hyperextension brace. Finally, a 57-year-old male with an L1–L2 disc space fracture treated with a thoraco-lumbo-sacral orthosis. All patients recovered successfully. LESSONS In certain cases, conservative treatment may be more appropriate for fractures in the setting of DISH as an alternative to the surgical standard of care. Most fractures in the setting of DISH are unstable, therefore it is necessary to manage these patients on a case-by-case basis.

Spinal epidural abscess (SEA) is a rare but serious pathology that may result in delayed neurologic injury despite treatment with antibiotic therapy or surgery. Given this, the development of predictive scores for risk stratification has value in clinical decision making; however, external validation is necessary to understand their generalizability and reliability.A retrospective review was conducted of all patients presenting with SEA at a single institution. Patients were reviewed and graded according to the proposed SEA predictive score by Baum et al. Clinical failure was defined as documented laboratory or radiographic progression requiring surgical intervention, increased deformity requiring surgical intervention, or repeat surgical intervention if prior surgical intervention was undertaken as the initial treatment strategy. Brier score and receiver operating characteristic were used to calculate reliability.There were 224 patients presenting with primary spinal infections with associated SEA. Of these, 209 patients had no history of intravenous drug abuse. Clinical failure was demonstrated in 52 of 209 patients (24.9%). Antibiotic treatment alone compared with antibiotic therapy and surgical treatment on initial presentation was found to have a significantly greater chance of clinical failure (odds ratio = 3.0930, P = 0.01). The proposed epidural abscess prediction score did not correlate with clinical outcomes with a Brier score of 0.229 and receiver operating characteristic area under the curve of 0.5944.The proposed risk stratification scale for patients was not correlated with risk of clinical failure. Additionally, patients treated with antibiotics and surgical intervention on initial presentation had a significantly lower clinical failure rate.

Lateral femoral cutaneous neuropathy, also known as meralgia paresthetica, is a pathology commonly encountered by neurosurgeons. Symptoms include numbness, tingling, and burning pain over the anterolateral thigh due to impingement on the lateral femoral cutaneous nerve (LFCN). Surgical treatment has traditionally involved nerve release or neurectomy. LFCN transposition is a relatively new approach that can provide excellent symptomatic relief. In this video, the authors highlight key operative techniques to ensure easy identification, adequate decompression, and transposition of the nerve. Key steps include ultrasound-guided wire localization, superficial decompression, opening of the inguinal ligament, deep decompression, and medial transposition. The video can be found here: https://stream.cadmore.media/r10.3171/2022.10.FOCVID2289

Background: Thoracic outlet syndrome (TOS) is a clinical diagnosis caused by compression of neurovascular structures in the thoracic outlet. There are a variety of structures that cause compression implicated in TOS. TOS patients frequently require surgical decompression. Various structural anomalies encountered during decompression have been reported in the literature. Case Description: We present two females (ages 42 and 45) that each underwent anterior scalenectomy for thoracic outlet decompression through a supraclavicular approach. A supraclavius muscle anomaly was observed in both patients. Analogous to the two reports previously described in the literature, the muscle inserted, along the medial superior undersurface of the clavicle and originated dorsally along the trapezius muscle. This is not to be confused with the subclavius posticus muscle, which originates from the first rib and inserts on the upper border of the scapula. Conclusion: These two cases represent just the third and fourth ever descriptions of a supraclavius muscle anomaly encountered during TOS surgery. Due to the wide variety of anatomical variations encountered during TOS surgery, it is not only crucial for continued reporting of such anatomical variations to be reported in the literature but equally important for clinicians that treat TOS to be aware of such variations.

Background: A Chance fracture is a traumatic fracture of the thoracic or lumbar spine that occurs secondary to a flexion-distraction injury. Although patients with chance fractures rarely present with neurologic deficits, a subset may become symptomatic from spinal epidural hematomas (SEH) warranting emergent decompressive surgery. Case Description: An 87-year-old female on anticoagulation presented with a T1 Chance fracture after a fall. She was originally neurologically intact, but became paraplegic over the next 10 h. When the cervical/thoracic magnetic resonance revealed a SEH markedly compressing the cord between the C7-T1 levels, she underwent an emergent decompression; she also had a C5-T4 instrumented fusion. Postoperatively, she regained lower limb function, but expired on postoperative day 5 due to respiratory complications likely attributed to the prolonged surgery for the spinal instrumentation. Conclusion: Delayed SEH rarely occur following spinal Chance fractures. Here, an 87-year-old female on anticoagulation developed the 10-h delayed onset of a SEH with paraplegia attributed to a T1 Chance fracture at the C7-T1 level. Although she regained neurological function following the emergent decompression, she expired 5 days later likely due to the extended operative time/blood loss from the C5-T4 fusion that could have been avoided.

BACKGROUND Noonan syndrome (NS) is a rare genetic RASopathy with multisystem implications. The disorder is typically characterized by short stature, distinctive facial features, intellectual disability, developmental delay, chest deformity, and congenital heart disease. NS may be inherited or arise secondary to spontaneous mutations of genes in the Ras/mitogen activated protein kinase signaling pathways. OBSERVATIONS Numerous case reports exist detailing the association between NS and Chiari I malformation (CM-I), although this relationship has not been fully established. Patients with NS who present with CM-I requiring operation have shown high rates reoperation for failed decompression. The authors reported two patients with NS, CM-I, and syringomyelia who had prior posterior fossa decompressions without syrinx improvement. Both patients received reoperation with successful outcomes. LESSONS The authors highlighted the association between NS and CM-I and raised awareness that patients with these disorders may be at higher risk for failed posterior fossa decompression, necessitating reoperation.

Background: Internuclear ophthalmoplegia (INO), characterized by impaired horizontal eye movement, occurred following an anterior cervical discectomy/fusions (ACDF). Case Description: A 48-year-old female with recurrent C5-6 foraminal stenosis presented with right C6 radiculopathy. She underwent a C5-6 ACDF, but postoperatively, complained of diplopia. Her examination revealed left-eye INO. Notably, the brain magnetic resonance imaging showed no significant radiological findings. The patient’s diplopia and INO resolved spontaneously on postoperative day 2 and never recurred. Conclusion: Ocular complications following anterior cervical spine procedures are rare. Here, a 48-year-old female developed left eye INO following an ACDF that spontaneously resolved on postoperative day 2.

Background The presence of symptomatic lumbar facet cysts has been associated with segmental instability. Given this association, decompression versus decompression with fusion is a frequently debated topic. Multiple grading scales have been devised to identify patients at high risk for development of cyst recurrence; however, there exists no external evaluation of these scales. Methods A retrospective review of 54 patients undergoing initial treatment for lumbar synovial cysts at a single institution over the past 12 years was conducted. Surgical treatment consisted of decompression with cystectomy without fusion. Patients were assessed and classified according to the NeuroSpine Surgery Research Group (NSURG) and Rosenstock Classification systems. Five neurosurgeons reviewed the preoperative magnetic resonance images, and results were classified. Interrater reliability was assessed using both Gwet’s AC1 coefficient and Krippendorff’s alpha. A 1-way analysis of variance was used to evaluate predictive ability of both classification systems. Results In total, of the 54 patients who underwent decompression, 7 had cyst recurrence. Overall cyst recurrence was most common in NSURG grade 2 cysts (3/12, 25%) followed by grade 1 cysts (4/27, 14.8%). Of the NSURG grade 3 and 4 patients, none had cyst recurrence. In the Rosenstock grades the most common recurrence was in grade 3 cysts (1/4, 25%) followed by grade 1 cysts (5/26, 19.2%). Interrater reliability demonstrated good reproducibility on Gwet’s AC1 and Krippendorff’s alpha on both grading scales. Neither score was predictive of cyst recurrence (P > 0.05). Conclusions The Rosenstock and NeuroSpine scores demonstrate good overall interrater reliability but are inconsistent in their ability to predict recurrence of lumbar facet cysts.

Background The management of lumbar synovial cysts (LSC) has been a controversial topic for many years. Whereas many authors label LSC as markers of instability and thus necessitating fusion, others suggest that decompression alone without fusion is a viable initial treatment option. Our objective was to clarify outcomes in patients undergoing decompression alone and decompression with fusion for symptomatic LSC and identify factors for cyst recurrence. Methods A retrospective case series was performed of all patients undergoing initial treatment for LSC at a single institution ranging from January 1999 to February 2020. Surgical treatment included either decompression with cystectomy or decompression with cystectomy and a fusion procedure. Preoperative symptoms were collected and included radicular pain, motor deficits, sensory deficits, or bowel/bladder changes. Radiographic data were calculated individually and confirmed with radiology reports. Categorical variables were assessed using χ2 analysis and continuous variables were assessed with the 2-sample t test. Results In total, 161 patients were identified as presenting with symptomatic LSC. Of these, 104 patients underwent decompression alone versus 57 who underwent decompression and fusion. In the decompression group 11 patients required reoperation at the level of the cyst compared with none in those undergoing fusion as their initial procedure (10.5% vs. 0%, P = 0.012). On subgroup analysis of those undergoing decompression as their initial procedure, patients with cyst recurrence demonstrated a statistically significant greater coronal facet inclination angle compared with those without cyst recurrence (52.4° vs. 40.6°, P = 0.02). Conclusions Decompression alone is a reasonable choice for the initial management of LSC, although it does carry a significant risk of same-level reoperation due to cyst recurrence and spondylolisthesis. Preoperative coronal facet inclination angle may be a useful measurement in predicting cyst recurrence following decompression.

Background Cerebral abscesses are rare, potentially life-threatening entities that result from local spread or hematogenous dissemination to the brain. Prompt diagnosis and initiation of treatment is key in lowering morbidity and preventing mortality associated with cerebral abscesses. Congenital heart diseases with right-to-left intracardiac shunts can be complicated by brain abscesses via paradoxical embolism of infected microthrombi. Hypoplastic left heart syndrome (HLHS) is a rare congenital heart disease characterized by an underdeveloped left heart that uses intracardiac shunting to achieve adequate systemic circulation. We present the first reported case of a cerebral abscess in a patient with HLHS. The pathophysiology of HLHS and how it predisposes patients to development of cerebral abscesses is discussed. Case Description A 25-year-old male was transferred to our institution complaining of headache, nausea, and vomiting. The patient was not an intravenous (IV) drug user, and serologic testing was negative for human immunodeficiency virus. Magnetic resonance imaging revealed a 2.6-cm left occipital abscess, which was surgically resected without complication, and the patient was treated with IV antibiotics. Conclusion HLHS is a rare congenital cardiac malformation. The long-term outcome of patients with this condition continues to improve as treatment paradigms evolve. As such, patients with HLHS are living longer, and their potential to develop cerebral abscesses secondary to their unique systemic circulation is increasing with improved life expectancy. Surgeons and physicians should maintain a high index of suspicion for cerebral abscess in the setting of HLHS.

IntroductionThe relationship between degree of angiographic venous sinus stenosis and the trans-stenosis pressure gradient magnitude in idiopathic intracranial hypertension (IIH) is poorly understood. The present study aimed to assess the utility of angiography, venography, and non-invasive imaging (MRV or CTV) for the diagnosis and characterization of clinically significant VSS.MethodsRetrospective analysis of a prospectively collected database was performed to identify patients with medically refractory IIH who were evaluated by angiography and venous manometry for the presence of VSS with associated clinically significant pressure gradient. Angiographic stenosis was measured by two independent raters using novel methodology.ResultsThirty-seven patients met inclusion criteria for the study. In total, 70% of patients had clinically significant pressure gradients and were selected for stenting. The optimal percentage stenosis for detection of a significant pressure gradient was 34% stenosis on venous phase arteriography (sensitivity 0.81 and specificity 0.91) and 31% stenosis on venography (0.92 and 0.73). For every 10% increase in stenosis, an approximate increase in pressure gradient of 3.5 mmHg is seen. MRV/CTV had a calculated sensitivity of 0.42, and a negative predictive value of 22%.ConclusionThe degree of stenosis predictive of a clinically significant pressure gradient (30–35%) in the venous sinuses is considerably lower than the arterial stenosis at which pathologic hemodynamic alterations occur. While highly predictive of a venous pressure gradient when a stenosis is identified, non-invasive imaging does not appear to be a suitable diagnostic evaluation for the purpose of ruling out clinically significant cerebral VSS.

IntroductionVenous outflow obstruction is recognized as a contributing factor in a subset of patients with idiopathic intracranial hypertension (IIH). Little is known about venous sinus waveform morphology or how it changes after stenting.MethodsFifteen patients with IIH underwent waveform recording during catheter venography and manometry. Ten patients (Group A) with venous sinus stenosis and pressure gradient ≥7 mm Hg underwent waveform recording during awake venography and during stenting under general anesthesia. Five control IIH patients (Group B) without a gradient underwent awake recording only.ResultsGroup A patients underwent successful stenting with reduction of their gradient from 15.1±6.19 mm Hg to 1.2±0.60 mm Hg. This resulted in an amplitude reduction from 8.3 mm Hg to 2.8 mm Hg (P=0.02). Qualitative evaluation of the waveform yielded a number of novel findings. In Group A before stenting, the observed waveform progressed from an intracranial pressure (ICP)-dominated to central venous pressure (CVP)-dominated waveform. Stenting abolished the high amplitude waveform and smoothed the transition from the intracranial to central venous measurement points. Group B displayed primarily CVP-influenced waveforms distal and proximal to the transverse-sigmoid junction along with respiratory variability of the waveform, absent in 8/10 Group A patients. General anesthesia appeared to blunt the waveform in 5/10 Group A patients.ConclusionThe cerebral venous waveform appears to be influenced by both the ICP and CVP waveforms. As measurement moves proximally, the waveform progressively changes to mirror the CVP waveform. Venous sinus stenosis results in a high amplitude waveform which improves with treatment of the stenosis.

Introduction Almost one third of all cancer patients will develop a spinal metastasis at some time in their lives. Traditionally, management of these metastatic lesions has been multi-modal, involving a combination of oral pain medication with radiation as well as the potential for surgical intervention if there is mechanical instability or compression of neural elements. Recently, the application of percutaneous radiofrequency ablation (RFA) with vertebroplasty has been described as a safe method for treatment for acute reduction in pain associated with these lesions. This potential for acute pain control prior to radiation presents an attractive option to bridge the palliation gap when treating patients with painful spinal metastases. The majority of previous studies examining RFA have described the use of a monopolar probe to deliver the thermal energy. Studies describing the safe and effective use of bipolar RFA are lacking, and this lack of knowledge can be intimidating to providers as they adopt this new technology. Herein we describe our single-institution experience with bipolar RFA for the treatment of spinal metastases and highlight technical considerations we have found important during the first phase of our adoption of this new technology. Methods The interventional radiology database from June 2017 to December 2017 was reviewed for patients who were treated with bipolar RFA for painful spinal metastases. After Institutional Review Board approval, these records were reviewed for: age, primary cancer type, location of spinal metastases, size of ablated lesions, presence and extent of epidural extension, procedural characteristics of bipolar RFA and subsequent application of poly-methylmethacrylate (PMMA) if indicated as well as follow up imaging when available. Results Over review of the medical records identified 10 patients with 14 ablated vertebral metastases who were treated at our institution. The average age of these patients was 63.3 years old and there were a wide variety of primary cancers, 5 patients had breast or prostate and the remaining 5 patients each had a different primary. All patients presented with back pain and 5 of the patients presented with concomitant leg pain. The average visual analog score (VAS) was 7.0 pre-intervention which improved to 3.0 post-intervention in the patients for which VAS was recorded. There was 1 occurrence of symptomatic cement extravasation causing radiculopathy, which eventually resolved on follow-up. Conclusion RFA for the treatment of spinal metastases is a safe therapy for palliation of back pain. There are several nuances to the application of RFA and subsequent vertebroplasty to spinal metastatic disease compared to a traditional osteoporotic compression fracture. Careful attention to detail when adopting this new technology is important in preventing potentially avoidable complications from cement embolization or extravasation. Disclosures J. West: None. G. Greeneway: None. K. Fargen: None. S. Quintero-Wolfe: None.

Introduction/purpose Idiopathic intracranial hypertension (IIH), otherwise known as pseudotumor cerebri or benign intracranial hypertension, is a syndrome defined by a severe headache in the setting of increased intracranial pressure (ICP) in the absence of an intracranial mass. The pathophysiology of IIH remains poorly understood. However, venous outflow obstruction detected by cerebral venous manometry at the transverse sinus has been recognized as a contributing factor in a subset of patients with IIH, and stent placement in this subset of patients is associated with good clinical outcomes. Surgeons often determine candidacy for stent placement based on the magnitude of the venous pressure gradient across the site of stenosis. Furthermore, there is little known about venous sinus pressure waveform morphology in patients with this condition or how it changes after stenting. The purpose of this study was to prospectively analyze patients’ venous sinus waveforms, their component peaks, and the influence of stenosis or anesthesia on waveform morphology with a goal of ultimately providing insight into the waveform and pathological morphologic changes seen with venous sinus stenosis. Materials and methods Fifteen patients with IIH were enrolled prospectively and underwent waveform recording during catheter venography and manometry. Ten patients (Group A) with venous sinus stenosis and pressure gradient >8 mmHg underwent waveform recording during awake venography and then pre- and post-stent manometry while under general anesthesia. Five control IIH patients (Group B) without a trans-stenosis gradient underwent awake recording only. Results All Group A patients underwent successful stenting with reduction of their gradient from 15.1 (+6.19) mmHg to 1.2 (+0.60) mmHg. This resulted in statistically significant reduction of the transverse sinus amplitude from 8.3 mmHg to 2.8 mmHg (p Conclusion In conclusion, the cerebral venous waveform morphology appears to be influenced by both the intracranial pressure (ICP) waveform and the central venous pressure (CVP) waveform. Additionally, venous sinus stenosis with significant venous outflow obstruction results in morphologic changes to the waveforms. After performing stenting in patients with stenosis, waveforms return to match the control group. Future studies should expand on the qualitative patterns described in this study and place a significant amount of consideration in determining the clinical and hemodynamic ramifications of these findings. Disclosures J. West: None. R. Garner: None. G. Greeneway: None. J. Traunero: None. C. Aschenbrenner: None. J. Singh: None. S. Wolfe: None. K. Fargen: None.

Craniopharyngiomas frequently recur locally or less commonly along the path of prior resection. Ectopic recurrence is rare, although cases are reported along the neuraxis spanning from the subgaleal space down to the S1 nerve root. This case reports on a girl with a history of craniopharyngioma first resected at 23 months of age with two local suprasellar recurrences managed with repeat craniotomy and external beam radiation therapy. At age 14 she complained of worsening headaches and brain MRI demonstrated an enhancing 1.2-cm cystic lesion in the posterior body of the left lateral ventricle. Pathology following endoscopic resection of the lesion was consistent with an adamantinomatous craniopharyngioma. This case report serves to describe the first reported recurrence of a craniopharyngioma in the lateral ventricle and emphasizes the need for a high index of suspicion along with long-term follow-up of patients with a history of craniopharyngioma.

IntroductionAlthough venous sinus stenting (VSS) has emerged as a promising treatment option for patients with idiopathic intracranial hypertension (IIH) and associated venous sinus stenosis, there is considerable ambiguity regarding patient selection criteria, treatment protocols, and management strategies.MethodsAn extensive literature review was performed to identify all reports of VSS in patients with IIH using PubMed. Recommendations for the selection and treatment of patients with IIH with VSS are outlined as determined based on author opinion from supporting studies. Due to the lack of randomized trials and few published prospective studies, standard grading scales for recommendations and level of evidence are not fully applicable and therefore a revised grading scale has been provided for recommendations.ResultsThe literature review identified a total of eight systematic reviews or meta-analyses and 29 published patient series on VSS. Recommendations for patient selection for diagnostic catheter angiography, angiography procedural considerations, stenting procedural considerations, and retreatment are provided based on the literature. Recommendations that were considered strong included: performance of venous sinus manometry to assess candidacy for treatment prior to stenting; administration of antiplatelet agents prior to stenting and for a follow-up period of at least 3–6 months; performance of post-stenting manometry to confirm resolution of pressure gradient; and performance of repeat angiography and manometry on patients with recurrence of symptoms after resolution with stenting to evaluate for recurrent stenosis.ConclusionVSS for patients with IIH with venous sinus stenosis is now an established and effective treatment option. These recommendations have been provided, based on a summative review of the available published literature, to assist in standardizing care for patients with IIH undergoing VSS.