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Background The medial occipital lobe, composed of the lingual gyrus and cuneus, is necessary for both basic and higher level visual processing. It is also known to facilitate cross-modal, nonvisual functions, such as linguistic processing and verbal memory, after the loss of the visual senses. A detailed cortical model elucidating the white matter connectivity associated with this area could improve our understanding of the interacting brain networks that underlie complex human processes and postoperative outcomes related to vision and language. Methods Generalized q-sampling imaging tractography, validated by gross anatomic dissection for qualitative visual agreement, was performed on 10 healthy adult controls obtained from the Human Connectome Project. Results Major white matter connections were identified by tractography and validated by gross dissection, which connected the medial occipital lobe with itself and the adjacent cortices, especially the temporal lobe. The short- and long-range connections identified consisted mainly of U-shaped association fibers, intracuneal fibers, and inferior fronto-occipital fasciculus, inferior longitudinal fasciculus, middle longitudinal fasciculus, and lingual–fusiform connections. Conclusions The medial occipital lobe is an extremely interconnected system, supporting its ability to perform coordinated basic visual processing, but also serves as a center for many long-range association fibers, supporting its importance in nonvisual functions, such as language and memory. The presented data represent clinically actionable anatomic information that can be used in multimodal navigation of white matter lesions in the medial occipital lobe to prevent neurologic deficits and improve patients' quality of life after cerebral surgery.

OBJECTIVETraditionally, stent-assisted coiling and balloon remodeling have been the primary endovascular treatments for wide-necked intracranial aneurysms with complex morphologies. PulseRider is an aneurysm neck reconstruction device that provides parent vessel protection for aneurysm coiling. The objective of this study was to report early postmarket results with the PulseRider device.METHODSThis study was a prospective registry of patients treated with PulseRider at 13 American neurointerventional centers following FDA approval of this device. Data collected included clinical presentation, aneurysm characteristics, treatment details, and perioperative events. Follow-up data included degree of aneurysm occlusion and delayed (> 30 days after the procedure) complications.RESULTSA total of 54 aneurysms were treated, with the same number of PulseRider devices, across 13 centers. Fourteen cases were in off-label locations (7 anterior communicating artery, 6 middle cerebral artery, and 1 A1 segment anterior cerebral artery aneurysms). The average dome/neck ratio was 1.2. Technical success was achieved in 52 cases (96.2%). Major complications included the following: 3 procedure-related posterior cerebral artery strokes, a device-related intraoperative aneurysm rupture, and a delayed device thrombosis. Immediately postoperative Raymond-Roy occlusion classification (RROC) class 1 was achieved in 21 cases (40.3%), class 2 in 15 (28.8%), and class 3 in 16 cases (30.7%). Additional devices were used in 3 aneurysms. For those patients with 3- or 6-month angiographic follow-up (28 patients), 18 aneurysms (64.2%) were RROC class 1 and 8 (28.5%) were RROC class 2.CONCLUSIONSPulseRider is being used in both on- and off-label cases following FDA approval. The clinical and radiographic outcomes are comparable in real-world experience to the outcomes observed in earlier studies. Further experience is needed with the device to determine its role in the neurointerventionalist’s armamentarium, especially with regard to its off-label use.

Objective Primary repair of posteriorly located anterior skull base (ASB) dural defects following cranial trauma is made difficult by narrow operative corridors and adherent dura mater. Inadequate closure may result in continued cerebrospinal fluid (CSF) leak and infectious sequelae. Here, we report surgical outcomes following the use of nonpenetrating titanium microclips as an adjunctive repair technique in traumatic anterior skull base dural defects extending from the olfactory groove to the tuberculum sellae. Methods All trauma patients who underwent a bifrontal craniotomy from January 2013 to October 2019 were retrospectively reviewed. Patients with ASB defects located at posterior to the olfactory groove were analyzed. Patients with isolated frontal sinus fractures were excluded. All patients presented with CSF leak or radiographic signs of dural compromise. Patients were divided according to posterior extent of injury. Patient characteristics, imaging, surgical technique, and outcomes are reported. Results A total of 19 patients who underwent a bifrontal craniotomy for repair of posteriorly located ASB dural defects using nonpenetrating titanium microclips were included. Defects were divided by location: olfactory groove (10/19), planum sphenoidale (6/19), and tuberculum sellae (3/19). No patients demonstrated a postoperative CSF leak. No complications related to the microclip technique was observed. Clip artifact did not compromise postoperative imaging interpretation. Conclusion Primary repair of posteriorly located ASB dural defects is challenging due to narrow working angles and thin dura mater. Use of nonpenetrating titanium microclips for primary repair of posteriorly located dural defects is a reasonable adjunctive repair technique and was associated with no postoperative CSF leaks in this cohort.

OBJECTIVEGlioblastoma (GBM) during infancy is rare, and the clinical outcomes of congenital GBM are not well understood. Correspondingly, the aim of this study was to present a long-term survivor case from the authors’ institution, and establish an integrated cohort of cases across the published literature to better understand the clinical course of this disease in this setting.METHODSThe authors report the outcomes of an institutional case of congenital GBM diagnosed within the first 3 months of life, and performed a comprehensive literature search for published cases from 2000 onward for an integrated survival analysis. All cases were integrated into 1 cohort, and Kaplan-Meier estimations, Fisher’s exact test, and logistic regression were used to interrogate the data.RESULTSThe integrated cohort of 40 congenital GBM cases consisted of 23 (58%) females and 17 (42%) males born at a median gestational age of 38 weeks (range 22–40 weeks). Estimates of overall survival (OS) at 1 month was 67%, at 1 year it was 59%, and at 10 years it was 45%, with statistically superior outcomes for subgroups in which patients survived to be treated by resection and chemotherapy. In the overall cohort, multivariable analysis confirmed resection (p < 0.01) and chemotherapy (p < 0.01) as independent predictors of superior OS. Gestational age > 38 weeks (p < 0.01), Apgar scores ≥ 7 at 5 minutes (p < 0.01), absence of prenatal hydrocephalus (p < 0.01), and vaginal delivery (p < 0.01) were associated with greater odds of surgical diagnosis versus autopsy diagnosis.CONCLUSIONSCongenital GBM can deviate from the expected poor prognosis of adult GBM in terms of OS. Both resection and chemotherapy confer statistically superior prognostic advantages in those patients who survive within the immediate postnatal period, and should be first-line considerations in the initial management of this rare disease.

The most recent cIMPACT-NOW update highlighted the homozygous deletion of the Cyclin Dependent Kinase Inhibitor 2A (CDKN2A) gene as a clinically important molecular alteration in IDH-mutant glioma. Correspondingly, we systematically reviewed the contemporary literature to affirm the contemporary stance of the literature on the prognostic significance of this alteration in this setting based on the current World Health Organization (WHO) Grade classification. A systematic search of seven electronic databases from inception to February 2020 was conducted following PRISMA guidelines. Articles were screened against pre-specified criteria to include lower-grade glioma (LGG, WHO Grade II/III) and glioblastoma (GBM, WHO Grade IV) separately. Progression free survival (PFS) and overall survival (OS) from Kaplan–Meier and multivariable analyses were outcomes of interest. Nine institutional studies describing 2193 IDH-mutant gliomas satisfied criteria for evaluation, with 1756 (80%) LGG and 437 (20%) GBM. When reported, the proportion of CDKN2A homozygous deleted gliomas ranged from 9 to 43%, with a median incidence of 22%. For LGG, Kaplan–Meier analyses demonstrated shorter PFS in the presence of CDKN2A homozygous deletion in three studies (median values, 31 versus 91 months), and shorter OS in five studies (median values, 61 versus 154 months). For GBM, Kaplan–Meier analyses demonstrated shorter PFS in the presence of CDKN2A homozygous deletion in two studies (median values, 16 versus 30 months), and shorter OS in four studies (median values, 38 versus 86 months). By multivariable analyses, CDKN2A homozygous deletion was a predictor of significantly shorter PFS and OS in both LGG and GBM across all included studies. The CDKN2A homozygous deletion is an important prognostic factor for survival outcomes of IDH-mutant glioma patients across multiple histologic WHO grades with specific molecular features likely dependent on IDH-mutant status. Greater understanding of how identifying this deletion can assist in the stratification of management for these tumors to optimize clinical course is required.

Background Laser interstitial thermal therapy (LITT) is a growing technology to treat a variety of brain lesions. It offers an alternative to treatment options, such as open craniotomy and stereotactic radiosurgery. Objective To analyze our experience using LITT for metastatic melanoma. Methods This is a retrospective chart review of the patients from our institution. Our case series involves 5 patients who had previously failed radiation treatment. Results Our patients have low complication rates and short hospital stays. Both are considerably lower when compared to the literature for metastatic melanoma. Conclusion LITT is a safe therapy, with few complications and short hospital stays.

Objective To investigate predictive factors and develop an outcome assessment tool to determine clinical outcome after endovascular mechanical thrombectomy (EMT) in patients presenting with large vessel occlusion (LVO). Methods A retrospective analysis was carried out of a prospective cohort of patients presenting with LVO who underwent EMT after adoption of an expanded time window of ≤24 hours. Final cerebral infarction volume (CIV) after EMT was estimated using magnetic resonance imaging segmentation software. Stepwise linear regression models were used to identify factors that determined clinical outcome and to develop a predictive scale. Results Ninety patients underwent EMT over 19 months (68 within 6 hours and 22 between 6 and 24 hours). Clinical outcome determined using modified Rankin Scale (mRS) score at discharge and 3 months was no different among these subcohorts. A threshold of 16.99 mL of CIV, using the Youden index, resulted in a sensitivity of 90.5% and specificity of 58.1% for predicting mRS score of 0–2. A regression model identified gender, age, diabetes mellitus status, CIV, and smoking status as outcome determinants, which were used to develop the GADIS (Gender, Age, Diabetes Mellitus History, Infarct Volume, and Sex) scoring system to predict good clinical outcome. Using the GADIS score, Conclusions The GADIS score for patients with LVO-related acute ischemic stroke includes CIV after EMT and helps in early short-term prognostication. It is not intended to predict preintervention patient selection or outcome prediction.

Anterior cervical discectomy and fusion (ACDF) is the most common surgical procedure utilized for degenerative diseases of the cervical spine. The authors present the case of a 64-year-old man who underwent an ACDF for degenerative changes causing cervical stenosis with myelopathy. The patient’s symptoms consisted of pain and weakness of the bilateral upper extremities that slowly progressed over 1.5 years. During the procedure, the superior horn of the thyroid cartilage impeded proper retraction, preventing adequate visualization due to its prominent size. At this point, otorhinolaryngology was consulted, which allowed for safe resection of this portion of the thyroid cartilage while preserving nearby critical structures. With the frequent usage of this surgical approach for various etiologies, the importance of proper recognition and consultation is paramount. Encountering prominent thyroid cartilage resulting in surgical obstruction has not been described in the literature and this report represents a paradigm for the proper course of action.

Background and purpose Cerebral vasospasm in the setting of subarachnoid hemorrhage causes morbidity and mortality due to delayed cerebral ischemia and permanent neurological deficits. Vasospasm treatment includes intra-arterial injection of a spasmolytic during cerebral angiography. To evaluate effectiveness, neurointerventionalists subjectively examine a posttreatment cerebral angiogram to determine change in vessel diameter or increase in microvascular perfusion. Flat-detector computed tomography (FDCT) scanner has the ability to quantitatively measure cerebral blood volume (CBV) within the parenchyma and detect a quantitative change following treatment. Methods This is a prospective study at a single institution between October 5, 2017 and June 3, 2019 that examines CBV studies from the Artis Q biplane (Siemens). Regions of interest were made in various territories to measure the CBV within the parenchyma before and after treatment with the spasmolytic verapamil. All instances of vasospasm involved vasculature within the left middle cerebral artery or internal carotid artery. The Wilcoxon signed-rank test was used to determine significance before and after treatment. Results Our cohort consists of 6 patients who underwent Digital Subtraction Angiography (DSA) and FDCT scans for cerebral vasospasm within the left hemisphere. After intra-arterial injection of 20 mg of verapamil, average increases in blood volume were 59%, 22%, and 24% for the temporal, frontal, and parietal lobes, respectively. P-values associated were .03. We also observed decrease in the mean arterial blood pressure and transcranial Doppler values after treatment. Conclusion In conclusion, FDCT could measure the effectiveness of a change in CBV from infusion of verapamil in the setting of cerebral vasospasm. The authors believe quantifying the change allows for reassurance of improvement of cerebral vasospasm.

Background Before the advent of radiosurgery, neurosurgical treatment of meningiomas typically involved gross total resection of the mass whenever surgery was deemed possible. Over the past 4 decades, though, Gamma Knife radiosurgery (GKRS) has proved to be an effective, minimally invasive means to control the growth of these tumors. However, the variables associated with treatment failure (regrowth or clinical progression) after GKRS and GKRS-related complications, such as cerebral edema, are less well understood. Methods We retrospectively collected data between 2009 and 2018 for patients who underwent GKRS for meningiomas. After data collection, we performed univariate and multivariable modeling of the factors that predict treatment failure and cerebral edema after GKRS. Hazard ratios (HR) and P values were determined for these variables. Results Fifty-two patients were included our analysis. The majority of patients were female (38/52,73%), and nearly all patients presented with a suspected or confirmed World Health Organization grade 1 meningioma (48/52, 92%). The median tumor volume was 3.49 cc (range, 0.22–20.11 cc). Evidence of meningioma progression after treatment developed in 5 patients (10%), with a median time to continued tumor growth of 5.9 months (range, 2.7–18.3 months). In multivariable analysis, patients in whom treatment failed were more likely to be male (HR = 8.42, P = 0.045) and to present with larger tumor volumes (HR = 1.27, P = 0.011). In addition, 5 patients (10%) experienced treatment-related cerebral edema. On univariate analysis, patients who experienced cerebral edema were more likely present with larger tumors (HR = 1.16, P = 0.028). Conclusions Increasing meningioma size and male gender predispose to meningioma progression after treatment with GKRS. Increasing tumor size also predicts the development of postradiosurgery cerebral edema.

Background Trigeminal schwannomas are fifth cranial nerve tumors that originate from the nerve sheath. They rarely occur within the pediatric population and can cause dysfunction of the trigeminal nerve and surrounding structures. When patients become symptomatic, neurosurgeons should consider resection. Case Desription We report the case of a 14-year-old adolescent boy who presented with an isolated sixth nerve palsy manifested by diplopia. The patient was found to have a trigeminal schwannoma involving the ophthalmic and maxillary branches of the trigeminal nerve. A modified mini-pterional craniotomy was performed for an extended middle fossa approach with an anterior petrosectomy to gain access to the inferior aspect of the posterior fossa tumor component. Intraoperatively, the sixth nerve was compressed within Dorello's canal. Postoperatively, the patient's sixth nerve palsy resolved, and magnetic resonance imaging demonstrated near-total resection with residual enhancement along the superior orbital fissure near the oculomotor nerve entry zone and foramen rotundum. Conslusions We present a rare case of pediatric trigeminal schwannoma type Mp treated surgically with a near-total resection via a novel mini-pterional approach and use of cranial nerve diffusion tensor imaging.

OBJECTIVEA shifting emphasis on efficient utilization of hospital resources has been seen in recent years. However, reduced screening for blunt vertebral artery injury (BVAI) may result in missed diagnoses if risk factors are not fully understood. The authors examined the records of blunt trauma patients with fractures near the craniocervical junction who underwent CTA at a single institution to better understand the risk of BVAI imposed by occipital condyle fractures (OCFs).METHODSThe authors began with a query of their prospectively collected trauma registry to identify patients who had been screened for BVAI using ICD-9-CM diagnostic codes. Grade and segment were recorded in instances of BVAI. Locations of fractures were classified into 3 groups: 1) OCFs, 2) C1 (atlas) fractures, and 3) fractures of the C2–6 vertebrae. Univariate and multivariate analyses were performed to identify any fracture types associated with BVAI.RESULTSDuring a 6-year period, 719 patients underwent head and neck CTA following blunt trauma. Of these patients, 147 (20%) had OCF. BVAI occurred in 2 of 43 patients with type I OCF, 1 of 42 with type II OCF, and in 9 of 62 with type III OCF (p = 0.12). Type III OCF was an independent risk factor for BVAI in multivariate modeling (OR 2.29 [95% CI 1.04–5.04]), as were fractures of C1–6 (OR 5.51 [95% CI 2.57–11.83]). Injury to the V4 segment was associated with type III OCF (p < 0.01).CONCLUSIONSIn this study, the authors found an association between type III OCF and BVAI. While further study may be necessary to elucidate the mechanism of injury in these cases, this association suggests that thorough cerebrovascular evaluation is warranted in patients with type III OCF.

Shunt failure requiring reintervention remains a common complication of hydrocephalus treatment. Here, we report a novel cause of mechanical shunt obstruction in an adult patient: position-dependent intermittent occlusion via an infusion port catheter. A 51-year-old woman with a grade II oligodendroglioma presented in a delayed fashion following surgery with a pseudomeningocele. She underwent ventriculoperitoneal shunt placement due to communicating hydrocephalus, resolving her pseudomeningocele. Shortly thereafter, she underwent placement of a subclavian infusion port at an outside institution. Her pseudomeningocele returned. Imaging demonstrated close proximity of her port catheter to the shunt catheter overlying the clavicle. Her shunt was tapped demonstrating a patent ventricular catheter with normal pressure. She underwent shunt exploration after her pseudomeningocele did not respond to valve adjustment. Intraoperative manometry demonstrated head position-dependent distal catheter obstruction. Repeat manometry following distal catheter revision demonstrated normal runoff independent of position. Her pseudomeningocele was resolved on follow-up. To our knowledge, this is the only reported case of intermittent, position-dependent distal catheter obstruction. Shunted patients with concern for malfunction following subclavian infusion port placement should be evaluated for possible dynamic obstruction of their distal catheter when the two catheters are in close proximity along the clavicle.

The prediction of outcome after mechanical thrombectomy (MT) of basilar artery occlusion (BAO) remains an area of investigation. The objective of this study was to evaluate the prognostic role of presenting National Institute Health of Stroke Scale (NIHSS) scores in predicting favorable 90-day functional outcome. A survey of 7 electronic databases from inception to May 2020 was conducted following PRISMA guidelines. Articles were screened against pre-specified criteria. Multivariate odds ratios (ORs) for favorable 90-day function outcome (modified Rankin Score 0-2) were extracted and pooled by meta-analysis of proportions with random effects modeling. A total of 10 individual studies satisfied criteria for selection and described a total of 941 BAO patients managed by MT. Analysis revealed 590 (63%) males with a mean age of 66.6 years. The median presenting NIHSS was 19, and 316 (34%) patients were reported to have a favorable functional status 90-days after treatment. Lower presenting NIHSS scores independently and significantly predicted favorable 90-day functional outcome in BAO patients with a pooled OR of 0.89 (95% CI, 0.87-0.92; I2 = 18%; P-heterogeneity = 0.28). Meta-regression did not detect any clinical parameter that influenced this trend direction or its significance, and bias assessments were unremarkable. We confirm in this study via a consensus within the literature that the presenting NIHSS score predicts 90-day functional outcome in BAO patients treated by MT. Further, its standardized use allows more meaningful comparisons between interventions and anatomical locations.

The fusiform gyrus is understood to be involved in the processing of high-order visual information, particularly related to faces, bodies, and stimuli characterized by high spatial frequencies. A detailed understanding of the exact location and nature of associated white-tracts could significantly improve post-operative morbidity related to declining capacity. Through generalized q-sampling imaging (GQI) validated by gross dissection as a direct anatomical method of identifying white matter tracts, we have characterized these connections based on relationships to other well-known structures. We created the white matter tracts using GQI and confirmed the tracts using gross dissection. These dissections demonstrated connections to the occipital lobe from the fusiform gyrus along with longer association fibers that course through this gyrus. The fusiform gyrus is an important region implicated in such tasks as the visual processing of human faces and bodies, as well as the perception of stimuli with high spatial frequencies. Post-surgical outcomes related to this region may be better understood in the context of the fiber-bundle anatomy highlighted by this study.

Cryptococcus neoformans is a fungus that commonly invades the central nervous system. While the choroid plexus, the site of the blood-cerebrospinal fluid barrier, serves as one potential entry point for the pathogen, disease involvement of the choroid plexus itself remains a very rare manifestation of Cryptococcus infection. In cases in which choroid plexus involvement blocks cerebrospinal fluid flow, obstructive hydrocephalus may occur. Here we report the case of a 63-year-old woman who presented with choroid plexitis causing obstructive hydrocephalus at the foramen of Monro. Endoscopic biopsy confirmed Cryptococcus neoformans, and the patient was successfully treated with amphotericin, flucytosine, and fluconazole. With proper recognition and treatment of this pathology, patients can fully recover from this condition.

A 62-year-old woman with history of chronic back pain and vertebral osteomyelitis presented with right hemiparesis and aphasia with last known well 10 h prior to presentation and a CT angiography demonstrating a left M1 occlusion. A thrombectomy was performed with resultant TICI-2b improving NIHSS from 28 pre-thrombectomy to 19 post-thrombectomy. Pathologic examination of the embolus demonstrated abundant bacterial colonies. While echocardiography was negative for valvular vegetations, fluoroscopy demonstrated abnormal mechanical valve motion. Blood cultures grew Enterococcus faecalis for which antibiotics were initiated. NIHSS continued to improve to a score of 12. There are rare cases in the literature that discuss diagnosis and initiation of antibiotics assisted by histopathologic examination of the embolus. Routine histopathologic evaluation of emboli may facilitate timely diagnosis and early antibiotic initiation in the setting of septic emboli. Keywords: Acute ischemic stroke, Infective endocarditis, Septic embolus, Thrombectomy

There have been publications that propose the use of laser interstitial thermal therapy (LITT) as a viable alternative to craniotomy for the treatment of glioblastoma (GBM). The aim of this study was to retrospectively compare outcomes after LITT versus craniotomy for patients with recurrent GBM. To adequately match the cohorts, we included only pre-treatment tumor volumes of under 15 cc. We retrospectively collected data on all patients presenting with recurrent GBM, with a recurrence volume under 15 cc. These patients were either treated with LITT or craniotomy by the senior author. Data included demographics, tumor location and volume, tumor markers, perioperative complications, re-initiation of adjuvant chemotherapy, and long-term follow up data. We performed 23 LITT treatments and 34 craniotomies for recurrent GBM in patients that met selection criteria. There was no significant difference in the patients’ age, tumor volume (6.38 for craniotomy versus 5.765 cc for LITT), location, and post-procedure KPS. Patients that underwent LITT had significantly reduced inpatient stays in comparison to craniotomy (1.7 versus 4.2 days). They also had less perioperative complications (13.0% versus 32.3% for craniotomy). It was found that 28 out of the 34 patients that underwent craniotomy were able to undergo adjuvant therapy; in comparison, 15 out of the 23 patients who underwent LITT had undergone adjuvant therapy. Of these patient’s that underwent adjuvant therapy, 87% of patients were able to receive bevacizumab or a clinical trial versus 42% after craniotomy. Progression-free survival (PFS) and overall survival (OS) after procedure were similar for LITT versus craniotomy, respectively: % PFS-survival at 6 months = 23.5% versus 21.7%. Overall survival did not significantly differ at 9 months versus 9.9 months respectively. LITT appears to be safe and may be as efficacious as craniotomy in achieving progression free survival for small to moderate volume recurrent GBM.

Laser interstitial thermal therapy (LITT) is being used for the treatment of recurrent glioblastoma multiforme (GBM). Lesions can be treated using 1 or multiple LITT fibers depending on the preference of surgeons. Usually, more fibers are needed for coverage of larger tumors.To investigate and analyze how tumor size affected the number of LITT fibers used.This is a retrospective review of patients undergoing treatment of recurrent GBM. Patients were treated with up to 4 LITT fibers for adequate tumor coverage. Patient demographics, tumor characteristics, length of stay, complications, and biopsy results were recorded.A total of 43 cases were treated using LITT, and of these cases, 31 consisted of contiguous lesions. We used more fibers to treat larger tumor volumes. On average, for each 5 cc of tumor volume, a fiber was added for proper coverage (P = .554). Complications and length of stay were similar across the groups (P = .378, P = .941).LITT can be used for the treatment of recurrent GBM. For each 5 cc of tumor volume, a LITT fiber can be added to the treatment plan.

Objective In the healthy spine, the spinal cord moves unimpeded with spinal fluid pulsation in the rostral and caudal directions. When a portion of the spinal cord becomes attached to lesions within the spinal column, excess strain can cause signs and symptoms such as pain, motor deficits, sensory deficits, bladder dysfunction, and bowel dysfunction. This condition is termed tethered cord syndrome. There are no clear guidelines for offering surgical intervention, although there is a general consensus that worsening signs and symptoms increase the likelihood that patients will need surgery. Methods In this article, we conduct a systematic review and meta-analysis for all available literature within the Ovid (MEDLINE), PubMed, and Google Scholar databases to evaluate common symptoms among patients with tethered cord and to examine how surgery affects symptoms. Results Within the cohort of 730 patients, 708 (97%) were treated surgically by a detethering procedure. The most common preoperative sign or symptom was pain (81%), followed by motor deficits (63%), sensory deficits (61%), bladder dysfunction (56%), and bowel dysfunction (15%). One percent of patients had no deficit or symptom. Pain was the symptom that was most responsive to surgery, with 81% of patients reporting that their pain improved after detethering. Conclusions Tethered cord syndrome should be included in the differential diagnosis in patients presenting with back or leg pain, somatosensory symptoms of the lower extremities, muscular weakness, urodynamic dysfunction, or bowel dysfunction. After a definitive diagnosis is made, patients should be counseled about surgical detethering as an option

To investigate predictive factors and develop an outcome assessment tool to determine clinical outcome after endovascular mechanical thrombectomy (EMT) in patients presenting with large vessel occlusion (LVO).A retrospective analysis was carried out of a prospective cohort of patients presenting with LVO who underwent EMT after adoption of an expanded time window of ≤24 hours. Final cerebral infarction volume (CIV) after EMT was estimated using magnetic resonance imaging segmentation software. Stepwise linear regression models were used to identify factors that determined clinical outcome and to develop a predictive scale.Ninety patients underwent EMT over 19 months (68 within 6 hours and 22 between 6 and 24 hours). Clinical outcome determined using modified Rankin Scale (mRS) score at discharge and 3 months was no different among these subcohorts. A threshold of 16.99 mL of CIV, using the Youden index, resulted in a sensitivity of 90.5% and specificity of 58.1% for predicting mRS score of 0-2. A regression model identified gender, age, diabetes mellitus status, CIV, and smoking status as outcome determinants, which were used to develop the GADIS (Gender, Age, Diabetes Mellitus History, Infarct Volume, and Sex) scoring system to predict good clinical outcome. Using the GADIS score,6 predicted mRS score 0-2 at discharge with a sensitivity of 83.3% and specificity of 80.6%.The GADIS score for patients with LVO-related acute ischemic stroke includes CIV after EMT and helps in early short-term prognostication. It is not intended to predict preintervention patient selection or outcome prediction.

A 5-year-old girl was brought to the clinic because of chronic intermittent left-sided headaches. The patient underwent computed tomographic angiography, which demonstrated a giant aneurysm that involved the P2 segment of the left posterior cerebral artery. Before treatment proceeded, consent was obtained from the patient's legal guardian. A trapping-evacuation technique was used for proximal control and decompression so that a clip could be placed on the proximal inflow artery of the aneurysm. First, embolization was performed for aneurysm trapping and for sacrifice of the parent vessel. Two days later, the patient was taken to the operating room for open surgical decompression, clipping, and reconstruction. Heparin was administered during the embolization stage of the operation. The patient did well postoperatively and was discharged home. The 3-month follow-up evaluation demonstrated a right superior homonymous quadrantanopia and no other neurologic deficits. The patient's clinical course is summarized in Video 1.

Intrathalamic aneurysms are a cause of patient morbidity and mortality. Aneurysms in this location can be accessed microsurgically when they cannot be accessed endovascularly. Care must be taken to avoid critical white matter tracts when approaching the thalamus microsurgically. Use of a tubular retractor can offer safe brain retraction during the approach. A 53-year-old female with a history of hypertension and cerebrovascular accidents presented with slurred speech, altered mental status, and right-sided weakness. CT demonstrated an acute parenchymal hemorrhage within the left thalamus and the internal capsule. CT angiography demonstrated a left dorsal thalamic aneurysm. Following angiography with consideration for embolization, the patient was taken to the operating room for microsurgical clip ligation with the use of minimally invasive techniques. The aneurysm was accessed using a contralateral transventricular approach with a tubular retractor for microsurgical clip ligation. Postoperative imaging demonstrated successful interval clipping of the aneurysm within the thalamus. This is the first report using our described surgical approach for treatment of a dorsal intrathalamic aneurysm. We combined the use of diffusion tensor imaging with a tubular retractor to clip a dorsal thalamic aneurysm.

White matter tracts link different regions of the brain, and the known functions of those interconnected regions may offer clues about the roles that white matter tracts play in information relay. The authors of this report discuss the structure and function of the lateral occipital lobe and how the lateral occipital lobe communicates with other regions via white matter tracts. The authors used generalized q-sampling imaging and cadaveric brain dissections to uncover the subcortical white matter connections of the lateral occipital lobe. The authors created GQI of ten healthy controls and dissected ten cadaveric brains. The middle longitudinal fasciculus, vertical occipital fasciculus, inferior fronto-occipital fasciculus, inferior longitudinal fasciculus, optic radiations, and a diverse array of U-shaped fibers connect the lateral occipital lobe to itself, parts of the temporal, parietal, and medial occipital cortices. The complex functional processes attributed to the lateral occipital lobe, including object recognition, facial recognition, and motion perception are likely related to the subcortical white matter tracts described within this study. There was good concordance between the white matter tracts generated using GQI and the white matter tracts that were found after dissection of the cadaveric brains. This article presents the anatomic connections of the lateral occipital lobe and discusses the associated functions.

Background The PulseRider (Pulsar Vascular, Inc, Los Gatos, California, USA) device was developed to treat wide-neck aneurysms, and the Adjunctive Neurovascular Support of Wide-neck aneurysm Embolization and Reconstruction (ANSWER) Trial showed efficacy in the treatment of unruptured wide-neck aneurysms. Our case series demonstrates the use of the PulseRider device in the treatment of ruptured wide-neck aneurysms. Case Description The 2 patients in our series presented with subarachnoid hemorrhage secondary to ruptured basilar apex aneurysms. The patients were taken to the neurointervention suite for embolization of their aneurysms with the PulseRider and platinum microcoils. Conclusions In both cases, a Roy Raymond class III embolization was achieved. The patients recovered from their subarachnoid hemorrhage and were discharged with resolution of their symptoms. The presented cases document the safety and efficacy of treating ruptured aneurysms with the PulseRider device.

Background: Spinal osteochondromas are rare, benign tumors arising from the cartilaginous elements of the spine that may appear as solitary lesions versus multiple lesions in patients with hereditary multiple exostoses. Here, we present a 15-year-old female with a solitary C3-C4 osteochondroma who presented with a progressive quadriparesis and hand contracture successfully managed with a laminectomy/posterior spinal fusion. Case Description: A 15-year-old female presented with a 3-month history of progressive quadriparesis and hand contracture secondary to a magnetic resonance (MR) documented C3-C4 cervical spine osteochondroma. The MR imaging revealed a solitary osseous extramedullary outgrowth arising from the left laminar cortex of the C-3 vertebral body extending to C-4. Due to the marked resultant canal stenosis, the patient underwent a cervical laminectomy of C3- C4 with posterior spinal fusion. Gross total resection was achieved, and the pathology confirmed an osteochondroma. The patient’s myelopathy resolved, and 2 years later, she demonstrated no residual deficits or tumor recurrence. Conclusion: Here, we report the successful management of a 15-year-old female with a C3-C4 osteochondroma and progressive quadriparesis through cervical laminectomy/fusion.

Stereotactic radiosurgery (SRS) and whole brain radiation therapy (WBRT) have been established as non-invasive treatment modalities for intracranial metastasis from malignant melanoma, with SRS emerging as a safe and effective stand along therapy. However, either due to tumor regrowth or radiation necrosis, these radiation modalities can fail. MR-guided laser interstitial thermal therapy (LITT) has emerged as an option for these tumors. Clinical data for five patients at our institution was retrospectively reviewed. These were all the patients that had undergone LITT for intracranial metastatic melanoma after prior treatment failure that included a radiation modality. Demographics, prior treatments, surgical data, perioperative complications, adjuvant treatments, and follow imaging data were gathered. Of the five patients, one patient had received WBRT, three patients had received prior SRS to the area that underwent LITT, and one patient had a prior craniotomy with adjuvant SRS. Two of the tumors were located in the premotor area (frontal lobe), two tumors were located in the motor strip, and one tumor was located in the cerebellum. The average tumor volume was 4.32 cc (range 1.86 - 7.84 cc). Median time of hospital stay was 2 days (with a 2.6 day average). No perioperative complications were encountered. Three of the patients had received adjuvant therapy at our institution; these patients were not delayed in receiving adjuvant therapy. Of these three patients, only one patient had a BRAF mutation detected. Four patients received follow up imaging at our institution, with no patients demonstrating tumor regrowth in the site of LITT. Regrowth of intracranial metastasis of malignant melanoma is a known possibility of traditional radiation therapies. LITT should be considered as a safe, effective option for those that fail these traditional therapies, especially those located in areas difficult to access. The low complication rate allows patients to restart adjuvant therapies.

A 67-year-old male presented to the hospital with a left anterior cranial fossa arteriovenous fistula connecting the anterior ethmoidal artery to the cavernous sinus and superior sagittal sinus. After failed embolization, the patient was taken for a supra-orbital (eyebrow) craniotomy for surgical dissection and clipping of the fistula. An intraoperative angiogram confirmed successful fistula ligation. The patient was discharged without complications.The video can be found here: https://youtu.be/79Pk11SEkJg.