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Social media have revolutionized access to educational content. Given the extensive presence of social media, these platforms have the potential to influence neurosurgical training and education of residents and fellows. We explored the attitudes of neurosurgical trainees (postgraduate years 1-9) toward social media and their perceived influence on training and education.This study was a survey of trainees at North American neurosurgery residency programs. A 22-item survey, including 2 free-text questions, was distributed through the Congress of Neurological Surgeons listserv. The survey consisted of questions regarding demographics, social media platform use, and trainee views on social media; their perceived impact on education and job performance was gauged using a 5-point Likert scale. Descriptive analysis was performed.The survey was disseminated to 1160 neurosurgery trainees, with a response rate of 15.3%. Of 178 respondents, 132 (74.2%) were men; 142 (79.8%) were 25-34 years old. All respondents used social media. The most commonly used platforms were Facebook (87.1%), followed by YouTube (84.3%), Instagram (81.5%), and Twitter (74.7%). The most common reasons for social media use were personal social (89.8%), networking (65.5%), and academic resources (65.0%); 113 respondents (63.5%) reported spending25% of their time on social media for academics. The Neurosurgical Atlas (63.3%), Congress of Neurological Surgeons (11.2%), and American Association of Neurological Surgeons (10.1%) social media accounts were the most commonly used academic platforms.Social media use was ubiquitous among trainees. Although most used social media for personal social communication, most also used it for academic purposes.

Introduction Studies have begun investigating grit (continued fortitude in the face of hardship) and resilience (ability to recover from a setback) and their relationship to burnout (emotional exhaustion [EE] caused by prolonged stress or frustration) within medicine. We investigated the prevalence of burnout among neurosurgery residents and aimed to determine the relationship among burnout, grit, and resilience. Methods We surveyed U.S. neurosurgical residents to perform a discretional analysis of prevalence of burnout. Multivariate analysis was performed to determine which variables were associated with higher and lower levels of EE, depersonalization (DP), personal accomplishment (PA), burnout, grit, and resilience. Results Of 1385 U.S. neurosurgery residents, 427 (30.8%) responded to our survey. Burnout prevalence was 33.0% (95% confidence interval, 28.6%–37.7%). High grit was associated with U.S. graduates (P = 0.006), married residents (P = 0.025), and fewer social/personal stressors (P = 0.003). Lower resilience was associated with female sex (P = 0.006), whereas higher resilience was associated with international medical graduates (P = 0.017) and fewer social/personal stressors (P = 0.005). High burnout was associated with greater social/personal stressors (P = 0.002), clinical rotations (P = 0.001), and lack of children (P = 0.016). There were positive correlations between EE and DP and among PA, grit, and resilience. There were negative correlations for EE and DP with PA, grit, and resilience and between grit/resilience and burnout. Conclusions There is an inverse relationship between grit/resilience and burnout. Increased social/personal stressors are associated with increased levels of burnout and decreased grit and resilience. Grit and resilience are higher when social and personal stressors are decreased, indicating that these characteristics may fluctuate over time.

BackgroundA Pipeline embolization device (PED; Medtronic, Dublin, Ireland) can be deployed using either a biaxial or a triaxial catheter delivery system.ObjectiveTo compare the use of these two catheter delivery systems for intracranial aneurysm treatment with the PED.MethodsA retrospective study of patients undergoing PED deployment with biaxial or triaxial catheter systems between 2014 and 2016 was conducted. Experienced neurointerventionalists performed the procedures. Patients who received multiple PEDs or adjunctive coils were excluded. The two groups were compared for PED deployment time, total fluoroscopy time, patient radiation exposure, complications, and cost.ResultsEighty-two patients with 89 intracranial aneurysms were treated with one PED each. In 49 cases, PEDs were deployed using biaxial access; triaxial access was used in 33 cases. Time (min) from guide catheter run to PED deployment was significantly shorter in the biaxial group (24.0±18.7 vs 38.4±31.1, P=0.006) as was fluoroscopy time (28.8±23.0 vs 50.3±27.1, P=0.001). Peak radiation skin exposure (mGy) in the biaxial group was less than in the triaxial group (1243.7±808.2 vs 2074.6±1505.6, P=0.003). No statistically significant differences were observed in transient and permanent complication rates or modified Rankin Scale scores at 30 days. The triaxial access system cost more than the biaxial access system (average $3285 vs $1790, respectively). Occlusion rates at last follow-up (mean 6 months) were similar between the two systems (average 88.1%: biaxial, 89.2%: triaxial).ConclusionOur results indicate near-equivalent safety and effectiveness between biaxial and triaxial approaches. Some reductions in cost and procedure time were noted with the biaxial system.

OBJECTIVEFlow diversion for posterior circulation aneurysms performed using the Pipeline embolization device (PED) constitutes an increasingly common off-label use for otherwise untreatable aneurysms. The safety and efficacy of this treatment modality has not been assessed in a multicenter study.METHODSA retrospective review of prospectively maintained databases at 8 academic institutions was performed for the years 2009 to 2016 to identify patients with posterior circulation aneurysms treated with PED placement.RESULTSA total of 129 consecutive patients underwent 129 procedures to treat 131 aneurysms; 29 dissecting, 53 fusiform, and 49 saccular lesions were included. At a median follow-up of 11 months, complete and near-complete occlusion was recorded in 78.1%. Dissecting aneurysms had the highest occlusion rate and fusiform the lowest. Major complications were most frequent in fusiform aneurysms, whereas minor complications occurred most commonly in saccular aneurysms. In patients with saccular aneurysms, clopidogrel responders had a lower complication rate than did clopidogrel nonresponders. The majority of dissecting aneurysms were treated in the immediate or acute phase following subarachnoid hemorrhage, a circumstance that contributed to the highest mortality rate in those aneurysms.CONCLUSIONSIn the largest series to date, fusiform aneurysms were found to have the lowest occlusion rate and the highest frequency of major complications. Dissecting aneurysms, frequently treated in the setting of subarachnoid hemorrhage, occluded most often and had a low complication rate. Saccular aneurysms were associated with predominantly minor complications, particularly in clopidogrel nonresponders.

Background Flow diversion for basilar apex aneurysms has rarely been reported. Objective To assess flow diversion for basilar apex aneurysms in a multicenter cohort. Methods Retrospective review of prospectively maintained databases at 8 academic institutions was performed from 2009 to 2016 to identify patients with basilar apex aneurysms treated with flow diversion. Clinical and radiographic data were analyzed. Results Sixteen consecutive patients (median age 54.5 yr) underwent 18 procedures to treat 16 basilar apex aneurysms with either the Pipeline Embolization Device (Medtronic Inc, Dublin, Ireland) or Flow Redirection Endoluminal Device (Microvention, Tustin, California). Five aneurysms (31.3%) were treated in the setting of subarachnoid hemorrhage. Seven aneurysms (43.8%) were treated with flow diversion alone, while 9 (56.2%) underwent flow diversion and adjunctive coiling. At a median follow-up of 6 mo, complete (100%) and near-complete (90%-99%) occlusion was noted in 11 (68.8%) aneurysms. Incomplete occlusion occurred more commonly in patients treated with flow diversion alone compared to those with adjunctive coiling. Patients with partial occlusion were significantly younger. Retreatment with an additional flow diverter and adjunctive coiling occurred in 2 aneurysms with wide necks. There was 1 mortality in a patient (6.3%) who experienced posterior cerebral artery and cerebellar strokes as well as subarachnoid hemorrhage after the placement of a flow diverter. Minor complications occurred in 2 patients (12.5%). Conclusion Flow diversion for the treatment of basilar apex aneurysms results in acceptable occlusion rates in highly selected cases. Both primary flow diversion and rescue after failed clipping or coiling resulted in a modified Rankin Scale score that was either equal or better than at presentation and the technology represents a viable alternative or adjunctive option.

Objective Precise morphologic evaluation is important for intracranial aneurysm (IA) management. At present, clinicians manually measure the IA size and neck diameter on 2-dimensional (2D) digital subtraction angiographic (DSA) images and categorize the IA shape as regular or irregular on 3-dimensional (3D)-DSA images, which could result in inconsistency and bias. We investigated whether a computer-assisted 3D analytical approach could improve IA morphology assessment. Methods Five neurointerventionists evaluated the size, neck diameter, and shape of 39 IAs using current and computer-assisted 3D approaches. In the computer-assisted 3D approach, the size, neck diameter, and undulation index (UI, a shape irregularity metric) were extracted using semiautomated reconstruction of aneurysm geometry using 3D-DSA, followed by IA neck identification and computerized geometry assessment. Results The size and neck diameter measured using the manual 2D approach were smaller than computer-assisted 3D measurements by 2.01 mm (P Conclusions Computer-assisted 3D morphology analysis can improve accuracy and consistency in measurements compared with manual 2D measurements. It can also more reliably quantify shape irregularity using the UI. Future application of computer-assisted analysis tools could help clinicians standardize morphology evaluations, leading to more consistent IA evaluations.

The benefit of surgical treatment of ruptured aneurysms is well established.To determine whether ultra-early ruptured aneurysm treatment leads to not only improved outcomes but also reduced hospitalization cost.Using 2008-2011 Nationwide Inpatient Sample data, we analyzed demographic, clinical, and hospital factors for nontraumatic subarachnoid hemorrhage (SAH) patients who were "directly" admitted to the treating hospital where they underwent intervention (clipping/coiling). Patients treated on the day of admission (day 0) formed the ultra-early cohort; others formed the deferred treatment cohort. All Patient Refined Diagnosis-Related Groups were also included in regression analyses.A total of 17 412 patients were directly admitted to a hospital following nontraumatic SAH where they underwent intervention (clipping/coiling). Mean patient age was 53.87 yr (median 53.00, standard deviation 14.247); 68.3% were women (n = 11 893). A total of 6338 (36.4%) patients underwent treatment on the day of admission (ultra-early). Patients who underwent treatment on day 0 had significantly more routine discharge dispositions than those treatedadmission day 0 (P.0001). In regression analysis, treatment on day 0 was protective against other than routine discharge disposition outcome (P.0001; odds ratio 0.657; 95% confidence interval 0.614-0.838). Total cost incurred by hospitals was $4.36 billion. Mean cost of hospital charges in the ultra-early cohort was $239 126.05, which was significantly lower than that for the cohort treatedday 0 ($272 989.56, P.001), Mann-Whitney U-test). Performance of an intervention on admission day 0 was protective against higher hospitalization cost (P .0001; odds ratio 0.811; 95% confidence interval 0.732-0.899).Ultra-early treatment of ruptured aneurysms is significantly associated with better discharge disposition and decreased hospitalization cost.

BACKGROUND AND PURPOSE: Tandem aneurysms are defined as multiple aneurysms located in close proximity on the same parent vessel. Endovascular treatment of these aneurysms has rarely been reported. Our aim was to evaluate the safety and efficacy of a single Pipeline Embolization Device for the treatment of tandem aneurysms of the internal carotid artery. MATERIALS AND METHODS: A retrospective analysis of consecutive aneurysms treated with the Pipeline Embolization Device between 2009 and 2016 at 3 institutions in the United States was performed. Cases included aneurysms of the ICA treated with a single Pipeline Embolization Device, and they were divided into tandem versus solitary. Angiographic and clinical outcomes were compared. RESULTS: The solitary group (median age, 58 years) underwent 184 Pipeline Embolization Device procedures for 184 aneurysms. The tandem group (median age, 50.5 years) underwent 34 procedures for 78 aneurysms. Aneurysms were primarily located along the paraophthalmic segment of the ICA in both the single and tandem groups (72.3% versus 78.2%, respectively, P = .53). The median maximal diameters in the solitary and tandem groups were 6.2 and 6.7 mm, respectively. Complete occlusion on the last angiographic follow-up was achieved in 75.1% of aneurysms in the single compared with 88.6%% in the tandem group (P = .06). Symptomatic thromboembolic complications were encountered in 2.7% and 8.8% of procedures in the single and tandem groups, respectively (P = .08). CONCLUSIONS: Tandem aneurysms of the ICA can be treated with a single Pipeline Embolization Device with high rates of complete occlusion. While there appeared to be a trend toward higher thromboembolic complication rates, this did not reach statistical significance.

Background Surgical site infections (SSIs) are noteworthy and costly complications. New recommendations from a national organization have urged the elimination of traditional surgeon's caps (surgical skull caps) and mandated the use of bouffant caps to prevent SSIs. Objective To report SSI rates for >15 000 class I (clean) surgical procedures 13 mo before and 13 mo after surgical skull caps were banned at a single site with 25 operating rooms. Methods SSI data were acquired from hospital infection control monthly summary reports from January 2014 to March 2016. Based on a change in hospital policy mandating obligatory use of bouffant caps since February 2015, data were categorized into nonbouffant and bouffant groups. Monthly and cumulative infection rates for 13 mo before (7513 patients) and 13 mo after (8446 patients) the policy implementation were collected and analyzed for the groups, respectively. Results An overall increase of 0.07% (0.77%-0.84%) in the cumulative rate of SSI in all class I operating room cases and of 0.03% (0.79%-0.82%) in the cumulative rate of SSI in all spinal procedures was noted. However, neither increase reached statistical significance (P > .05). The cumulative rate of SSI in neurosurgery craniotomy/craniectomy cases decreased from 0.95% to 0.75%; this was also not statistically significant (P = 1.00). Conclusion National efforts at improving healthcare performance are laudable but need to be evidence based. Guidelines, especially when applied in a mandatory fashion, should be assessed for effectiveness. In this large, single-center series of patients undergoing class I surgical procedures, elimination of the traditional surgeon's cap did not reduce infection rates.

Background Neuroendovascular intervention has become a key treatment option for acute ischemic stroke. The Sofia (6F) PLUS catheter was designed for neurovascular access for diagnostic or therapeutic interventions. Objective To report the first series describing use of the Sofia PLUS intermediate/distal access reperfusion catheter in the treatment of acute ischemic stroke. Methods In this retrospective study, 41 stroke cases were identified in which the catheter was utilized for thrombolysis/thrombectomy. Mean preprocedure National Institutes of Health Stroke Scale score was 16.5 ± 5.2 (range 4-29). Occluded vessels included the M1 segment, M2 segment, internal carotid artery terminus, cervical internal carotid artery, and basilar artery. Results Successful positioning of the Sofia PLUS catheter near the occlusion site was achieved in 38 (92.7%) of 41 cases in which thrombectomy or thrombolysis was attempted using intraarterial tissue plasminogen activator, a direct aspiration first-pass technique, and/or stent retrieval. A postprocedure thrombolysis in cerebral infarction (TICI) score of 2b/3 was achieved in 37 of 41 cases. Of 15 cases where the Sofia PLUS was used for a direct aspiration first-pass technique, TICI 2b/3 was achieved in 11 (73.3%). In one case where intra-arterial tissue plasminogen activator was used as the only treatment modality, TICI 2a was achieved. No device-related or catheter-related complications were observed. The mean 7-d-postprocedure National Institutes of Health Stroke Scale score among the 39 survivors was 8.5 ± 7.3 (range 0-23). Conclusion Initial results with use of the Sofia (6F) PLUS for endovascular treatment of acute ischemic stroke have been encouraging. Experience with a larger series is warranted to further evaluate the safety and efficacy of this device and compare it with other reperfusion catheters.

Objective Endovascular treatment has largely replaced open reconstruction of proximal brachiocephalic and left common carotid ostial arterial stenoses. The objective of this study was to report the technical feasibility and safety of a flow-based embolic protection system in stenting of single and tandem stenotic lesions of supra-aortic arch vessels. Methods All cases used flow-based neuroprotection by the ENROUTE Transcarotid Neuroprotection System (Silk Road Medical, Sunnyvale, Calif). Case specifics, such as the stents used, the details of flow-based neuroprotection, the order in which lesions were treated, and the case-specific exceptions, are detailed in the body of the publication. The primary end point of this study was the occurrence of stroke or transient ischemic attack. Results Sixteen patients (12 women) with an average age of 68 years (range, 54-83 years) underwent endovascular stenting to treat single (11 patients) or tandem (5 patients) stenotic lesions of supra-aortic arch vessels. A total of 21 lesions were treated: 7 in the innominate artery, 1 in the right common carotid artery, 8 in the left common carotid artery, and 5 in the internal carotid artery (tandem cases). Eleven patients (69%) were symptomatic, and the stenoses of the five asymptomatic patients were identified during routine workup for comorbidities. Technical success was obtained in all cases. There were no strokes or transient ischemic attacks during the 30 days after the procedure. Minor complications included a minor wound dehiscence that healed secondarily without sequelae and a hematoma at the neck incision that resolved spontaneously without further intervention. Conclusions The use of a transcarotid retrograde approach with flow-based neuroprotection is technically feasible for the endovascular stenting of single and tandem stenotic lesions of the supra-aortic arch vessels. These data further support the advantages of a transcarotid approach and flow-based neuroprotection to minimize the risk of intraoperative complications and embolic events during and after the procedure.

Background Concerns exist that neurosurgery might fail to lead the field of endovascular surgical neuroradiology (ESN), as other specialties are allowed to train and practice ESN. This study aimed to assess the current breakdown of specialties and their relative academic productivity in accredited ESN fellowship programs. Methods A list of fellowship programs was obtained from the Accreditation Council for Graduate Medical Education and Committee on Advanced Subspecialty Training directories. Primary specialty (i.e., residency) training for each faculty member in these programs was determined using information provided by the programs. A bibliometric search was performed for each member using Web of Science (Clarivate Analytics, Philadelphia, Pennsylvania, USA). Cumulative and ESN-specific h indices were calculated; h indices were compared between each specialty group and between international medical graduates and US medical graduates, regardless of specialty training. Results Thirty-one ESN fellowship programs with 88 faculty members were included. Neurosurgeons constituted 61.4% (n = 54) of the total ESN faculty, followed by radiologists with 30.7% (n = 27), and neurologists with 7.9% (n = 7). The mean ESN-specific h index for neurosurgery-trained ESN faculty was 16.2 ± 14.6 compared with 14.4 ± 10.9 for radiologists and 13.0 ± 12.6 for neurologists (P = 0.76). There were 12 IMGs and 76 USMGs. The mean ESN-specific h index was greater for IMGs than USMGs, 24.7 ± 14.3 versus 14.0 ± 12.7 (P = 0.008), respectively. Conclusions Neurosurgery is leading the ESN field in numbers; however, the h index is not significantly different among ESN faculty based on primary training. The number of IMGs is relatively small, yet IMGs have significantly higher mean h indices.

Akutni ischemicka cevni mozkova přihoda (CMP) je celosvětově jednou z hlavnich přicin invalidity dospělých osob. Moderni endovaskularni lecba akutnich ischemických CMP je založena na použiti vyspělých zobrazovacich metod a vyhledavani tkani, ktere lze jestě zachranit. Na rozdil od nekontrastni výpocetni tomografie (CT) nebo tradicni magneticke rezonance nabizi CT zobrazeni perfuze mozku (CTP) aktivni pohled na fyziologii mozkove vaskulatury s jejimi cetnými parametry. Přes omezeni různých zařizeni a analytickeho softwaru použivaných ke kvantitativnimu hodnoceni rozsahu ischemie a penumbry představuje CTP vynikajici nastroj pro neurointervencionisty. Rychlost, s niž lze ziskat CT skeny perfuze, spolu se schopnosti teto metody predikovat vznik infarktu mohou zkratit dobu do provedeni potřebne intervence. I když každa zobrazovaci metoda ma sve výhody a nevýhody, představuje podle nasich zkusenosti použiti CTP v kombinaci s klinickým vysetřenim ucinný nastroj pro vyhledavani pacientů vhodných pro endovaskularni výkon.

Although the study of medicine and the tradition of medical students gaining clinical experience on hospital wards have not significantly changed over the years, the experience of physicians practicing in the current climate has changed dramatically. Physicians are confronted with increasing regulations aimed at improving quality of care and are often overwhelmed by their position in a tug-of-war between administrators, staff, colleagues and most importantly, patients. With more than half of the US physicians experiencing professional burnout, questions arise regarding their mental health and work-life balance. Blendon et al 1 reported an overall decline in the public’s confidence and trust in physicians, which may be explained by cultural changes as well as displeasure with medical leaders’ responses to healthcare needs. As the next generation of physicians emerges in this evolving healthcare environment, adaptation to new practices and regulations will be imperative. Emotional intelligence (EI) and mindfulness provide a possible solution to the struggles physicians will invariably face. The term EI, which refers to a person’s ability to recognise, discriminate and label their own emotions and those of others, was coined by Salovey and Mayer and popularised by Goleman.2 3 Mindfulness is the process by which an individual actively observes his or her thoughts and feelings without judgement.4 With foundations in Eastern meditation, mindfulness is now an accepted method of stress reduction in Western culture.4 The practice and employment of synergistic EI and mindfulness is grossly lacking from medical school curricula, postgraduate training and continuing medical education (CME) programmes. The systemic deficiency of both EI and mindfulness in healthcare has become more apparent as studies have demonstrated high burnout rates,5 increasing public mistrust in physicians1 and disheartening data indicating that 300–400 physicians commit suicide each year; a surprising figure that equals approximately one physician per day.6 Identifying …

Background The Pipeline Embolization Device (PED; Medtronic, Dublin, Ireland) has become an important tool for the treatment of cerebral aneurysms. Since FDA approval, there are ongoing efforts to increase aneurysm occlusion rates and reduce the incidence of complications. Objective To assess aneurysm occlusion and complication rates over time. Methods Retrospective analysis of consecutive anterior circulation aneurysms treated with a single PED between 2011 and 2016 at 3 academic institutions in the US was performed. Factors contributing to changes in aneurysm occlusion and complication rates over time were identified and evaluated. Results A total of 284 procedures were performed on 321 anterior circulation aneurysms in 284 patients. At a median follow-up of 13 mo (mean 18 mo), complete or near complete occlusion (>90%) was achieved in 85.9% of aneurysms. There was no significant change in aneurysm occlusion rate or procedure length over time. Thromboembolic complication occurred in 8.1% of procedures, and there was a trend toward decreased incidence from 16.3% in 2011/2012 to 3.3% in 2016 (P = .14). Hemorrhagic complications significantly decreased from 8.2% in 2011/2012 to 0 to 1.0% in 2014-2016 (P = .1). Conclusion We report a notable drop in the rate of hemorrhagic and to a lesser extent thromboembolic complications with increased experience with PED in a multicenter cohort. Multiple factors are believed to contribute to this drop, including the evolved interpretation of platelet function testing, the switching of clopidogrel nonresponders to ticagrelor, and the reduced use of adjunctive coiling.

BACKGROUND AND PURPOSE: To identify the potential for incomplete occlusion of intracranial aneurysms treated by flow-diverters (FD), we investigated if aneurysm ostium size in relation to parent artery size affects angiographic outcomes of FD-treated sidewall aneurysms. MATERIALS AND METHODS: FD-treated sidewall aneurysms were divided into “occluded” and “residual” (incomplete occlusion) groups based on 6-month angiographic follow-up. We calculated ostium ratio (OsR), a new parameter defined as the aneurysm ostium surface area versus the circumferential surface area of the parent artery. As a two-dimensional surrogate, we also calculated neck ratio (NR), defined as clinical aneurysm neck diameter versus parent artery diameter from pretreatment two-dimensional DSA. We compared the performance of these ratios with existing aneurysm morphometrics (size, neck-diameter, volume, aspect ratio, size ratio, undulation index, non-sphericity index, ellipticity index, bottleneck factor, aneurysm angle, parent vessel angle) and FD-related parameters (metal coverage rate, pore-density). Statistical tests and receiver-operating characteristic (ROC) analyses were performed to identify significantly different parameters between the two groups and test their predictive performances. RESULTS: Sixty-three FD-treated aneurysms were included: 46 occluded and 17 residual. OsR and NR were significantly higher in the residual group than the occluded group (p

Background: Papillary tumor of the pineal region (PTPR) is a rare neoplasm with only anecdotal data to guide the treatment. Results of treatment with surgery, radiation therapy, and chemotherapy have been reported to have varying degrees of success. Here we report a patient with a PTPR, who underwent subtotal resection, gamma knife stereotactic radiosurgery, and adjuvant temozolomide chemotherapy. Case Description: During 9 years of clinical and radiographic follow-up, the patient has had regression of residual tumor and remains asymptomatic. Conclusion: When gross total resection of a PTPR is not possible, treatment with gamma knife stereotactic radiosurgery and temozolomide chemotherapy may provide long-term tumor control.

Endovascular treatment of pathologies of the great vessels leading to the cerebrovasculature is becoming increasingly common. This is achieved by use of stents to reinforce an injured vessel lumen or expand the lumen in stenotic segments. Here we discuss the indication for stenting, types of stents available, and associated complications from these procedures and their management.

BACKGROUND AND PURPOSE: Flow diversion with the Pipeline Embolization Device is increasingly used for endovascular treatment of intracranial aneurysms due to high reported obliteration rates and low associated morbidity. While obliteration of covered branches in the anterior circulation is generally asymptomatic, this has not been studied within the posterior circulation. The aim of this study was to evaluate the association between branch coverage and occlusion, as well as associated ischemic events in a cohort of patients with posterior circulation aneurysms treated with the Pipeline Embolization Device. MATERIALS AND METHODS: A retrospective review of prospectively maintained databases at 8 academic institutions from 2009 to 2016 was performed to identify patients with posterior circulation aneurysms treated with the Pipeline Embolization Device. Branch coverage following placement was evaluated, including the posterior inferior cerebellar artery, anterior inferior cerebellar artery, superior cerebellar artery, and posterior cerebral artery. If the Pipeline Embolization Device crossed the ostia of the contralateral vertebral artery, its long-term patency was assessed as well. RESULTS: A cohort of 129 consecutive patients underwent treatment of 131 posterior circulation aneurysms with the Pipeline Embolization Device. Adjunctive coiling was used in 40 (31.0%) procedures. One or more branches were covered in 103 (79.8%) procedures. At a median follow-up of 11 months, 11% were occluded, most frequently the vertebral artery (34.8%). Branch obliteration was most common among asymptomatic aneurysms (P < .001). Ischemic complications occurred in 29 (22.5%) procedures. On multivariable analysis, there was no significant difference in ischemic complications in cases in which a branch was covered (P = .24) or occluded (P = .16). CONCLUSIONS: There was a low occlusion incidence in end arteries following branch coverage at last follow-up. The incidence was higher in the posterior cerebral artery and vertebral artery where collateral supply is high. Branch occlusion was not associated with a significant increase in ischemic complications.

The University at Buffalo's neuroendovascular fellowship is one of the longest running fellowship programs in North America. The burgeoning neurointerventional workforce and the rapid growth in the neurointerventional space on the heels of groundbreaking clinical trials prompted us to assess the fellowship's academic impact and its graduates' perceptions and productivity. An anonymized web-based survey was sent to all former neuroendovascular fellows with specific questions pertaining to current practice, research and funding, and perceptions about the fellowship's impact on their skills, competitiveness, and compensation. Additionally, the h-index was calculated to assess the academic productivity of each graduated fellow. Among 50 former fellows, 42 (84%) completed the survey. The fellows came from various countries, ethnic backgrounds, and specialties including neurosurgery (n = 39, 93%), neurology (n = 2, 5%), and neuroradiology (n = 1, 2%). Twenty (48%) respondents were currently chairs or directors of their practice. Most (n = 30, 71%) spent at least 10% of their time on research activities, with 27 (64%) receiving research funding. The median h-index of all 50 former fellows was 14. The biggest gains from the fellowship were reported to be improvement in endovascular skills (median = 10 on a scale of 0-10 [highest]) and increase in competitiveness for jobs in vascular neurosurgery (median = 10), followed by increase in academic productivity (median = 8), and knowledge of vascular disease (median = 8). In an era with open calls for moratoriums on endovascular fellowships, concerns over market saturation, and pleas to improve training, fellowship programs perhaps merit a more objective assessment. The effectiveness of a fellowship program may best be measured by the academic impact and leadership roles of former fellows.

Introduction Flow diversion for posterior circulation aneurysms using flow diversion constitutes an increasingly common off-label use. Basilar apex aneurysms are daunting lesions that present a significant treatment challenge. This is the largest series of basilar apex aneurysms treated with flow diversion to-date. Methods A retrospective review of prospectively maintained databases at eight academic institutions was performed from the years 2009 to 2016 to identify patients with basilar apex aneurysms treated with PED placement. Clinical and radiographic data were analyzed with emphasis on occlusion and complication rates. Results 16 consecutive patients (median age 62 years, male:female ratio of 1:2.2) underwent 18 procedures to treat 131 posterior circulation aneurysms with either Pipeline Embolization Device or Flow Redirection Endoluminal Device. All but one patient (94%) had a neurologic deficit attributable to the aneurysm prior to their procedure. Four attempts (25%) at flow-diversion were performed for aneurysmal subarachnoid hemorrhage, with 3 for saccular and 1 for blister morphology.At a median follow-up of 9 months, complete (100%) and near-complete (90%–99%) occlusion was noted in 69% of aneurysms. The rate of partial ( Conclusion Flow diversion for the treatment of basilar apex aneurysms results in acceptable occlusion rates, and compares favorably with the natural history of the disease. Both primary flow diversion and rescue after clipping/coiling resulted in mRS that was either equal or better than at presentation, and the technology represents a viable alternative to primary coiling or clipping in patients who are poor candidates for these. Disclosures A. Dmytriw: None. N. Adeeb: None. A. Kumar: None. C. Griessenauer: None. C. Ogilvy: None. P. Foreman: None. H. Shallwani: None. N. Limbucci: None. S. Mangiafico: None. C. Michelozzi: None. T. Krings: None. V. Mendes Pereira: None. C. Matouk: None. Y. Zhang: None. M. Harrigan: None. K. Phan: None. H. Shakir: None. A. Siqqiqui: None. E. Levy: None. L. Renieri: None. C. Cognard: None. A. Thomas: 2; C; Research Steering Committee, Stryker. T. Marotta: None.

Introduction Flow diversion for posterior circulation aneurysms using the Pipeline Embolization Device (PED) constitutes an increasingly common off-label use for otherwise untreatable aneurysms. Safety and efficacy of this treatment modality has not been assessed in a multicenter study. Methods A retrospective review of prospectively maintained databases at eight academic institutions was performed from the years 2009 to 2016 to identify patients with posterior circulation aneurysms treated with PED placement. Results One-hundred and twenty-nine consecutive patients underwent 129 procedures to treat 131 aneurysms. Twenty-nine dissecting, 53 fusiform, and 49 saccular were included. At a median follow-up of 11 months, complete and near complete occlusion was recorded in 78.1%. Dissecting aneurysms had the highest occlusion rate and fusiform the lowest. Major complications were most frequent in fusiform aneurysms. Minor complications occurred most commonly in saccular aneurysms. In patients with saccular aneurysms, clopidogrel responders had a lower complication rate than clopidogrel non-responders. The majority of dissecting aneurysms were treated in the acute phase following subarachnoid hemorrhage and were associated with the highest mortality rate; however, the rate of other major or minor complications was the lowest among the three aneurysm morphologies. The difference between complications in the ruptured and unruptured group was not statistically significant. Conclusion In the largest series to date, fusiform aneurysms were found to have the lowest occlusion rate and highest frequency of major complications. Dissecting aneurysms, frequently treated in the setting of subarachnoid hemorrhage, occluded most often and had the lowest complication rate. Saccular aneurysms were associated with predominantly minor complications, particularly in clopidogrel non-responders.

Flow diversion after aneurysmal subarachnoid hemorrhage (SAH) is the last treatment option for aneurysm occlusion when other methods of aneurysm treatment cannot be used because of the need for dual antiplatelet therapy. The authors' general protocol for treatment selection after aneurysmal SAH is provided to share with readers our approach to securing the aneurysm before embarking flow diversion for primary treatment or delayed adjunctive treatment to primary coiling. The authors' experience with flow diversion after aneurysmal SAH, review of pertinent literature, and the future of flow diversion after aneurysmal SAH are discussed.

BACKGROUND Burnout is a syndrome of emotional exhaustion, depersonalization, and reduced personal accomplishment. Its prevalence among US physicians exceeds 50% and is higher among residents/fellows. This is important to the practice of neurosurgery, as burnout is associated with adverse physical health, increased risk of substance abuse, and increased medical errors. To date, no study has specifically addressed the prevalence of burnout among neurosurgery residents. OBJECTIVE To determine and compare the prevalence of burnout among US neurosurgery residents with published rates for residents/fellows and practicing physicians from other specialties. METHODS We surveyed 106 US neurosurgery residency training programs to perform a descriptive analysis of the prevalence of burnout among residents. Data on burnout among control groups were used to perform a cross-sectional analysis. Nonparametric tests assessed differences in burnout scores among neurosurgery residents, and the 2-tailed Fisher's exact test assessed burnout between neurosurgery residents and control populations. RESULTS Of approximately 1200 US neurosurgery residents, 255 (21.3%) responded. The prevalence of burnout was 36.5% (95% confidence interval: 30.6%-42.7%). There was no significant difference in median burnout scores between gender (P = .836), age (P = .183), or postgraduate year (P = .963) among neurosurgery residents. Neurosurgery residents had a significantly lower prevalence of burnout (36.5%) than other residents/fellows (60.0%; P

Neuroendovascular therapy for the management of cerebrovascular diseases has tremendously evolved since the periods around 1995-2002, mainly because of the rapid advancements in technology. Neuroendovascular technologies and procedures have been standardized to the point that these interventions are routinely performed at many medical centers. Cerebrovascular diseases managed through these therapies include, but are not limited to, ischemic stroke, intracranial and extracranial stenosis, intracranial aneurysms, intracranial arteriovenous malformations (AVMs), dural and pial fistulas, and intracranial vascular tumors. In this chapter, we present the current status of neuroendovascular management for the most common cerebrovascular diseases: ischemic stroke, intracranial aneurysms, and AVMs.

Introduction Treatment of large (≥20 mm) and giant (≥25 mm) intracranial aneurysms is challenging and can be associated with a high rate of morbidity and mortality. The Pipeline Embolization Device (PED) has been used effectively for the treatment of intracranial aneurysms achieving a high rate of complete occlusion. However, its safety and efficacy in treatment of large and giant aneurysms has not been evaluated fully. Methods A retrospective analysis of consecutive aneurysms treated with PED between 2009 and 2016 at 3 academic institutions within the United States was performed. Large (≥20 mm) and giant aneurysms (≥25 mm) were selected for evaluation of occlusion and complication rates following treatment with PED. Results A total of 50 large and giant aneurysms were individually treated using PED. Aneurysms were fusiform (74%) or saccular (26%) in morphology. PED alone was used for treating 78% of the aneurysms, whereas PED with adjunctive coiling was used for treating 22%. The median length of angiographic follow-up was 13 months (mean follow up 20.4 months). At last follow-up, complete or near-complete occlusion (90–100%) was achieved in 76.9% of aneurysms. Symptomatic thromboembolic complications were encountered in 12% of procedures and symptomatic hemorrhagic complications in 8%. Conclusions The use of PED for the treatment of large and giant intracranial aneurysms is associated with good occlusion rates, but also a greater complication rate compared to aneurysms of smaller size. There was no significant difference in occlusion rate based on aneurysm shape or size, number of PEDs placed, or adjunctive coiling.

Acute ischemic stroke (AIS) is the leading cause of premature mortality and morbidity worldwide for both men and women. Extracranial carotid artery stenosis/occlusion is responsible for approximately 11.5% of ischemic strokes, whereas extracranial large vessel disease comprises roughly 16.6% of ischemic strokes. Carotid artery disease has been the source of significant debate among neurovascular and cardiovascular specialists, as well as vascular surgeons, as to the best method of revascularization, surgical reconstruction versus endovascular recanalization. There are different treatment modalities and techniques related to AIS and extracranial carotid artery disease based on the different etiologies, and these include acute internal carotid artery occlusion (thrombectomy versus carotid stenting/angioplasty), tandem occlusions (stenting and thrombectomy), and non-emergent carotid stenting/angioplasty for chronic internal carotid artery stenosis. The continuing development of new endovascular technology has led to a major shift in treatment to a minimally invasive endovascular approach. Distal filter devices, proximal protection devices, balloon-guided catheters, open- or closed-cell stents, and flow-reversal stenting are some of the technologies that are now available. The latest treatment techniques, indications, and studies are discussed in this review.

Acute ischemic stroke is a leading cause of death and disability in the United States, responsible for 1 of every 20 deaths. The efficacy of intravenous tissue plasminogen activator (tPA) alone for recanalization of large-vessel occlusion (LVO) is low. Several randomized trials have now established endovascular treatment of LVO as a standard of care. Endovascular techniques continue to evolve at a rapid pace. This review seeks to report recent advances in endovascular technology, discuss the correlation between speed of reperfusion and patient outcomes, and present mobile stroke care, shortcoming of the recent technology (such as clot fragmentation), and potential solutions to overcome these drawbacks, as well as anesthetic considerations and cost-effectiveness.

Pediatric stroke is an underestimated disease process that affects 3–15/100,000 children per year. There are distinct etiologies that are more common in the pediatric population. Risk factors affecting this population include vasculopathies, congenital heart diseases, sickle cell anemia, and some metabolic disorders. The three primary disease processes that warrant specific discussion with respect to anticoagulation and thrombolysis-thrombectomy include ischemic stroke, cerebral venous sinus thrombosis, and hemorrhagic stroke. Current recommendations for anticoagulation and endovascular therapy are based on treatment for adults and center on antithrombotic therapy. Antiplatelet therapy and heparin therapy have been recommended across-the-board. The role of mechanical thrombolysis–thrombectomy in the treatment of pediatric stroke has increased with the development of more devices for this therapeutic approach.

The ability to traverse an anatomically challenging and complex arch is paramount to the success of any neuroendovascular procedure. With age, the aortic arch becomes elongated, calcified, and less compliant. The authors present the initial experience with a multiple parallel guidewire system (ZigiWire Mode 3) for catheterization through a complex tortuous aortic arch to access extracranial vessels. The ZigiWire is an organized guidewire system that uses consecutive delivery of 3 small-diameter (0.014-inch) guidewires that are progressively advanced in parallel to secure support-wire access. The authors have found it useful in situations in which traditional methods for great-vessel access have failed. Moreover, the progressive construction of a large wire from smaller wires prevents “kickback” force from a single larger guidewire, allowing stable distal access. The authors have been able to advance different diagnostic and guide catheters over the ZigiWire. This guidewire has allowed them to successfully complete neuroendovascular procedures in patients who were previously considered unsuitable for the procedure because of tortuous vascular access.

OBJECTIVE Acute tandem occlusions of the cervical internal carotid artery and an intracranial large vessel present treatment challenges. Controversy exists regarding which lesion should be addressed first. The authors sought to evaluate the endovascular approach for revascularization of these lesions at Gates Vascular Institute. METHODS The authors performed a retrospective review of a prospectively maintained, single-institution database. They analyzed demographic, procedural, radiological, and clinical outcome data for patients who underwent endovascular treatment for tandem occlusions. A modified Rankin Scale (mRS) score ≤ 2 was defined as a favorable clinical outcome. RESULTS Forty-five patients were identified for inclusion in the study. The average age of these patients was 64 years; the mean National Institutes of Health Stroke Scale score at presentation was 14.4. Fifteen patients received intravenous thrombolysis before undergoing endovascular treatment. Thirty-seven (82%) of the 45 proximal cervical internal carotid artery occlusions were atherothrombotic in nature. Thirty-eight patients underwent a proximal-to-distal approach with carotid artery stenting first, followed by intracranial thrombectomy, whereas 7 patients underwent a distal-to-proximal approach (that is, intracranial thrombectomy was performed first). Thirty-seven (82%) procedures were completed with local anesthesia. For intracranial thrombectomy procedures, aspiration alone was used in 15 cases, stent retrieval alone was used in 5, and a combination of aspiration and stent-retriever thrombectomy was used in the remaining 25. The average time to revascularization was 81 minutes. Successful recanalization (thrombolysis in cerebral infarction Grade 2b/3) was achieved in 39 (87%) patients. Mean National Institutes of Health Stroke Scale scores were 9.3 immediately postprocedure (p < 0.05) (n = 31), 5.1 at discharge (p < 0.05) (n = 31), and 3.6 at 3 months (p < 0.05) (n = 30). There were 5 in-hospital deaths (11%); and 2 patients (4.4%) had symptomatic intracranial hemorrhage within 24 hours postprocedure. Favorable outcomes (mRS score ≤ 2) were achieved at 3 months in 22 (73.3%) of 30 patients available for follow-up, with an mRS score of 3 for 7 of 30 (23%) patients. CONCLUSIONS Tandem occlusions present treatment challenges, but high recanalization rates were possible in the present series using acute carotid artery stenting and mechanical thrombectomy concurrently. Proximal-to-distal and aspiration approaches were most commonly used because they were safe, efficacious, and feasible. Further study in the setting of a randomized controlled trial is needed to determine the best sequence for the treatment approach and the best technology for tandem occlusion.

With the use of endovascular techniques and indwelling catheters, potential complications can include embolization of fragments or components of various systems. The authors describe the surgical retrieval of a guidewire introducer from the right common carotid artery (CCA). A 64-year-old man was found to have a foreign body within the right CCA on CT angiography after he had presented with a transient ischemic attack. He had undergone a complex mitral valve repair several months before presenting to the authors' facility. That procedure involved a femoral artery cutdown and the insertion of an endovascular aortic balloon for cardiac bypass. As in most endovascular procedures, guidewire introducers were probably used to facilitate the introduction of the guidewire into the system during the procedure. Although rare, iatrogenic embolization of the introducer probably occurred during use of the guidewire. The guidewire introducer was successfully retrieved without complication by using a standard carotid cutdown approach. It is extraordinarily unusual for an extracorporeal part of an implantable system to embolize to the carotid circulation. To the authors' knowledge, this is the only reported case of an embolized guidewire introducer and the use of a carotid exposure to retrieve an intraluminal foreign body. This case demonstrates that a carotid cutdown approach can be used successfully for the retrieval of intraluminal extracranial carotid artery foreign bodies.

Background Transsphenoidal tumor resection can lead to internal carotid artery (ICA) injury. Vascular disruption is often treated with emergent vessel deconstruction, incurring complications in a subset of patients with poor collateral circulation and resulting in minor and major ischemic strokes. Methods We attempted a novel approach combining a covered stent graft (Jostent) and two flow diverter stents [Pipeline embolization devices (PEDs)] to treat active extravasation from a disrupted right ICA that was the result of a transsphenoidal surgery complication. This disruption occurred during clival tumor surgery and required immediate sphenoidal sinus packing. Emergent angiography revealed continued petrous carotid artery extravasation, warranting emergent vessel repair or deconstruction for treatment. To preserve the vessel, we utilized a covered Jostent. Due to tortuosity and lack of optimal wall apposition, there was reduced, yet persistent extravasation from an endoleak after Jostent deployment that failed to resolve despite multiple angioplasties. Therefore, we used PEDs to divert the flow. Results Flow diversion relieved the extravasation. The patient remained neurologically intact post-procedure. Conclusions This case demonstrates successful combined use of a covered stent and flow diverters to treat acute vascular injury resulting from transsphenoidal surgery. However, concerns remain, including the requirement of dual antiplatelet agents increasing postoperative bleeding risks, stent-related thromboembolic events, and delayed in-stent restenosis rates.

Background Carotid angioplasty and stenting (CAS) is considered desirable treatment for patients at high risk for carotid endarterectomy. Despite a growing elderly population, scant data exist on CAS in nonagenarians. Nonagenarians represent a high risk population for open and endovascular interventions due to unique anatomic and physiologic characteristics presenting significant challenges to anesthesiologists and surgeons. Studies have quantified that symptomatic and asymptomatic patients should survive 2 and 5 years, respectively, to gain benefit from revascularization; thus doubt exists on the value of CAS in nonagenarian patients because of their extreme age and unique risk factors. We therefore evaluated CAS safety and efficacy in our hospital9s nonagenarian population. Methods CAS cases performed in patients aged ≥90 years between April 2005 and January 2013 were retrospectively examined. Relevant demographic and medical data were reviewed. Rates of perioperative complications and complications until end of follow-up (including stroke, myocardial infarction, death) were compiled. Results Among 21 nonagenarian cases of stent placement performed in 20 patients (11 symptomatic, nine asymptomatic), two patients suffered perioperative stroke after undergoing CAS and one died during the perioperative period. 50% of symptomatic patients were alive at 19 months; 50% of asymptomatic patients were alive at 47 months. Conclusions CAS in nonagenarian patients carried increased risk of perioperative ischemic events, compared with contemporary trial results in symptomatic and asymptomatic patients. Further, mean survival time postprocedure fell short of guidelines for receiving procedural benefit. Although larger scale multicenter research is needed, we recommend careful consideration of overall health status when contemplating stenting in nonagenarians.

OBJECTIVE Access to the floor of the middle cranial fossa (MCF) is often required for approaches to cranial base lesions. This study measures the craniocaudal distance between the zygomatic arch (ZA) and the floor of the MCF from a random sample of high-resolution computed tomography scans of the cranial base. METHODS Forty computed tomography scans were imported into an OsiriX station and reconstructed in multiple planes. The most caudal point of the MCF was determined in each computed tomography scan. The distances between that point and the root of the zygoma and the middle point of the ZA were calculated. The thickness of the temporalis muscle and the vertical height of the zygoma were also calculated. A 2-tailed, paired Student t test was used to compare right and left measurements with a 95% confidence interval and P value

Background Iatrogenic injury to the vertebral artery is a rare but potential complication of cervical spine surgery. Previous authors have commented on the use of flow-diverting stents for treatment of aneurysms of the V3 segment of the vertebral artery. Case description Here, we report a case in which injury occurred at the V2 segment of the vertebral artery with the development of a pseudoaneurysm, which was found on angiography. After decompressing the spinal cord from an epidural hematoma, the pseudoaneurysm was treated by deploying two Pipeline flow-diverting stents (Medtronic, Minneapolis, MN). Obliteration of the pseudoaneurysm was noted on follow-up angiography 4 days after the treatment. Conclusion This case highlights a unique treatment at a region which, to our knowledge, has not been mentioned in the literature.

Background: The authors present the unique case of a dural-based, infantile hemangioma located in the posterior fossa of a 15-day-old infant. Case Description: The patient presented with hydrocephalus. The lesion was identified by magnetic resonance imaging and was subsequently resected. Diagnosis of the lesion was confirmed with immunohistochemistry staining. The patient's hospital course was complicated by transverse sinus thrombosis and a cerebrospinal fluid leak that were treated with anticoagulation therapy and ventriculoperitoneal shunt placement, respectively. Conclusion: Although hemangiomas are benign entities, our patient's lesion was in the posterior fossa causing compression and hydrocephalus that necessitated resection. We encourage others to consider the possibility of hemangioma in the differential diagnosis of dural-based posterior fossa lesions in infants.

OBJECT Vertebral fractures are the most common osteoporotic fracture. Bone density testing and medical treatment with bisphosphonates or parathormone are recommended for all patients with an osteoporotic fracture diagnosis. Inadequate testing and treatment of patients presenting with low-impact fractures have been reported in various specialties. Similar data are not available from academic neurosurgery groups. The authors assessed compliance with treatment and testing of osteoporosis in patients with vertebral compression fractures evaluated by the authors’ academic neurosurgery service, and patient variable and health-systems factors associated with improved compliance. METHODS Data for patients who underwent percutaneous kyphoplasty for compression fractures was retrospectively collected. Diagnostic and medical interventions were tabulated. Pre-, intra-, and posthospital factors that had been theorized to affect the compliance of patients with osteoporosis-related therapies were tabulated and statistically analyzed. RESULTS Less than 50% of patients with kyphoplasty received such therapies. Age was not found to correlate with other variables. Referral from a specialist rather than a primary care physician was associated with a higher rate of bone density screening, as well as vitamin D and calcium therapy, but not bisphosphonate/parathormone therapy. Patients who underwent preoperative evaluation by their primary care physician were significantly more likely to receive bisphosphonates compared with those only evaluated by a hospitalist. Patients with unprovoked fractures were more likely to undergo multiple surgeries compared with those with minor trauma. CONCLUSIONS These results suggest poor compliance with current standard of care for medical therapies in patients with osteoporotic compression fractures undergoing kyphoplasty under the care of an academic neurosurgery service.

Background There are very few reports in the literature of Castleman's disease affecting the carotid artery and a single previous report of a case of Castleman's disease of the neck originally mistaken as a carotid body tumor. Case description We describe a rare case of Castleman's disease, manifesting with classic radiographic hallmarks of a carotid body tumor. The postoperative pathologic examination identified the resected mass as Castleman's lymphadenopathy. The management of this particular case is discussed, and the findings are highlighted. Conclusions We present a unique case of a tumor initially and incorrectly diagnosed as a carotid body tumor. However, after comprehensive treatment with endovascular and surgical modalities and subsequent pathologic examination, the diagnosis of this rare entity was made.