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

Objective: Negative and positive urgency are risk factors for alcohol escalation during college, partly through increasing motives for alcohol use, which then contribute to subsequent drinking. Research has focused on the causal direction from trait to motives to alcohol consumption. The current study conducted an initial test of how alcohol use might drive changes in urgency, and subsequent changes in motives over the first year of college. Participants: 418 first-year college students (Mage = 18.16, 73.7% female, 86.5% White) were sampled at three timepoints. Methods: Mediation models were used to test hypotheses. Results: Alcohol use at baseline predicted increased enhancement motives through increased positive urgency ( B  = .0028, 95% CI [.0000, .0007]). Alcohol use at baseline did not predict coping motives through changes in negative urgency ( B  = .0002, 95% CI [-0.0020, .0030]). Conclusions: Changes in positive urgency and enhancement motives secondary to alcohol use appear to occur early in one's drinking history, making them prime targets for early prevention strategies.

Interest in the relational anatomy of the anterior neck among spine surgeons grew following the popularization of the anterior cervical discectomy and fusion (ACDF) in the 1950's. Five surface landmarks and their relationship to specific spinal levels have been routinely described including; the angle of the mandible for the C2-C3 interspace, the hyoid bone for the C3 body, the thyroid cartilage for the C4-C5 disc, and the cricoid cartilage and carotid tubercle for the C6 body. We aimed to investigate the origins of these anatomic relationships and their application in modern practice., (Copyright © 2024. Published by Elsevier Inc.)

Background: The surgical management of aneurysms involving the proximal third of the anterior inferior cerebellar artery (AICA) usually necessitates complex and invasive approaches, thus posing major challenges. We aimed to investigate the infratentorial presigmoid retrolabyrinthine suprameatal approach (PRSA) as a surgical corridor for premeatal AICA aneurysms., Methods: We performed 10 PRSA dissections in five cadaveric heads. Twelve morphometric parameters were measured, analyzed, and categorized into pre-procedural, intra-procedural, and additional parameters. The typical anatomic-radiological characteristics and variations were evaluated, and the related anatomical and radiological parameters were analyzed to predict surgical accessibility., Results: Preoperative anatomic-radiological parameters provide valuable information to select patients with favorable anatomy that may offer appropriate surgical accessibility to the premeatal AICA through a PRSA corridor. The position of the basilar artery from the midline determines the degree of accessibility to the origin of AICA through the infratentorial PRSA. The PRSA for targeting proximal AICA aneurysms was also compared to other surgical approaches based on the available current literature., Conclusion: Premeatal AICA aneurysms can be accessed and clipped through the infratentorial PRSA corridor. This would allow surgeons to avoid the sacrifice of hearing and balance as compared to other available invasive alternative approaches. The selection of the appropriate patients should be based on the individualized preoperative radiological characteristics for both the vascular and bony anatomy., Competing Interests: There are no conflicts of interest., (Copyright: © 2024 Surgical Neurology International.)

Negative and positive urgency are two closely related personality traits that reflect the tendency for an individual to engage in maladaptive risk-taking in response to extreme negative and positive emotions, respectively. However, other prominent emotion theories describe how emotions contribute to adaptive, rather than maladaptive, decision-making. This conceptual review considers how Urgency Theory can be integrated with these broader existing emotion theories. We proceed as follows: a) briefly define what is meant by emotions in science and summarize basic human neuroscience underlying emotions; b) briefly describe select theories and research linking emotions to adaptive decision-making, including brain correlates of this effect; c) review Urgency Theory, including contrasting evidence that emotions lead to maladaptive outcomes and brain correlates of this effect; d) discuss how urgency can be integrated into theories that view emotions as both adaptive and maladaptive for decision-making; and e) propose future directions to advance research in this field. We identified four, not mutually exclusive, viable options to integrate Urgency Theory into existing theories: urgency as model-free emotion regulation, urgency as being driven by incidental emotions, urgency as a reflexive response to emotions, or urgency as an individual difference factor. We conclude that although all four options are viable, individual difference and model-free emotion regulation have the most empirical support to date. Importantly, the other two options are less well-researched. Direct tests comparing these integrations is necessary to determine the most accurate way to integrate urgency with existing emotion theories. We believe that this research can identify mechanisms underlying urgency and help inform future intervention and prevention development to reduce negative effects of urgency across numerous maladaptive behaviors and clinical disorders., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2024 Fisher-Fox, Prestigiacomo and Cyders.)

Ischemic stroke, which accounts for 87% of cerebrovascular accidents, is responsible for massive global burden both in terms of economic cost and personal hardship. Many stroke survivors face long-term disability-a phenotype associated with an increasing number of genetic variants. While clinical variables such as stroke severity greatly impact recovery, genetic polymorphisms linked to functional outcome may offer physicians a unique opportunity to deliver personalized care based on their patient's genetic makeup, leading to improved outcomes. A comprehensive catalogue of the variants at play is required for such an approach. In this review, we compile and describe the polymorphisms associated with outcome scores such as modified Rankin Scale and Barthel Index. Our search identified 74 known genetic polymorphisms spread across 48 features associated with various poststroke disability metrics. The known variants span diverse biological systems and are related to inflammation, vascular homeostasis, growth factors, metabolism, the p53 regulatory pathway, and mitochondrial variation. Understanding how these variants influence functional outcome may be helpful in maximizing poststroke recovery., (© 2024. The Author(s).)

Objectives: Incidents of discrimination against Asian Americans have increased in the United States during the COVID-19 pandemic. The aims of this study are to (a) examine the overall psychological impact of incidents of discrimination on Asian Americans adults, (b) identify whether East Asians experience worse psychological outcomes following experiences of discrimination compared to other Asian Americans, and (c) identify culturally relevant factors that moderate the relationship between incidents of discrimination and psychological outcomes., Method: Two hundred eighty-nine participants who identified racially as Asian American ( M age = 33.1 years, ±10.5 SD , 57.1% male, and 54.3% East Asian) completed an online survey including measures of demographics, psychological outcomes, culturally relevant factors (e.g., acculturative stress, collective self-esteem), and racial discrimination., Results: We found that, overall, experiencing increased frequency of discrimination related to more depressive symptoms and alcohol use ( p s < .05). When comparing Asian subgroups (East Asian vs. other Asian), there were no significantly different relationships between discrimination frequency and attribution to race on psychological outcomes ( p s > .098). Collective self-esteem ( p = .041) weakened, while acculturative stress strengthened ( p < .001) the relationship between discrimination frequency and alcohol use; collective self-esteem weakened the relationship between attribution to race and social anxiety ( p = .021); and internalized racism weakened the relationship between discrimination frequency and depression ( p = .038)., Conclusions: We identified moderators of the relationship between experiences of discrimination and psychological outcomes in Asian Americans. Because the moderators held for all Asian groups under study, they are strong candidates for points of intervention to mitigate the harmful effects of discrimination for Asian Americans. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Background: Transcortical approaches, encompassing various surgical corridors, have been employed to treat an array of intraparenchymal or intraventricular brain pathologies, including tumors, vascular malformations, infections, intracerebral hematomas, and epileptic surgery. Designing cortical incisions relies on the lesion location and characteristics, knowledge of eloquent functional anatomy, and advanced imaging such as tractography. Despite their widespread use in neurosurgery, there is a noticeable lack of systematic studies examining their common lobe access points, associated complications, and prevalent pathologies. This scoping review assesses current evidence to guide the selection of transcortical approaches for treating a variety of intracranial pathologies., Methods: A scoping review was conducted using the PRISMA-ScR guidelines, searching PubMed, EMBASE, Scopus, and Web of Science. Studies were included if ≥5 patients operated on using transcortical approaches, with reported data on clinical features, treatments, and outcomes. Data analysis and synthesis were performed., Results: A total of 50 articles encompassing 2604 patients were included in the study. The most common primary pathology was brain tumors (60.6%), particularly gliomas (87.4%). The transcortical-transtemporal approach was the most frequently identified cortical approach (70.48%), and the temporal lobe was the most accessed brain lobe (55.68%). The postoperative course outcomes were reported as good (55.52%), poor (28.38%), and death (14.62%)., Conclusion: Transcortical approaches are crucial techniques for managing a wide range of intracranial lesions, with the transcortical-transtemporal approach being the most common. According to the current literature, the selective choice of cortical incision and surgical corridor based on the lesion's pathology and anatomic-functional location correlates with acceptable functional outcomes., Competing Interests: There are no conflicts of interest., (Copyright: © 2024 Surgical Neurology International.)

Background: Imaging modalities with increased spatial resolution have allowed for more precise quantification of cerebral aneurysm shape in 3-dimensional (3D) space. We conducted a systematic review and meta-analysis to assess the correlation of individual 3D morphometric measures with cerebral aneurysm rupture status., Methods: Two independent reviewers performed a PRISMA (preferred reporting items of systematic reviews and meta-analysis)-guided literature search to identify articles reporting the association between 3D morphometric measures of intracranial aneurysms and rupture status., Results: A total of 15,122 articles were identified. After screening, 39 studies were included. We identified 17 3D morphometric measures, with 11 eligible for the meta-analysis. The meta-analysis showed a significant association with rupture status for the following measures: nonsphericity index (standardized mean difference [SMD], 0.66; 95% confidence interval [CI], 0.53-0.79; P < 0.0001; I 2  = 55.2%), undulation index (SMD, 0.55; 95% CI, 0.26-0.85; P = 0.0017; I 2  = 68.1%), ellipticity index (SMD, 0.53; 95% CI, 0.29-0.77; P = 0.0005; I 2  = 70.8%), volume (SMD, 0.18; 95% CI, 0.02-0.35; P = 0.0320; I 2  = 82.3%), volume/ostium ratio (SMD, 0.43; 95% CI, 0.16-0.71; P = 0.0075; I 2  = 90.4%), elongation (SMD, -0.94; 95% CI, -1.12 to -0.76; P = 0.0005; I 2  = 0%), flatness (SMD, -0.87; 95% CI, -1.04 to -0.71; P = 0.0005; I 2  = 0%), and sphericity (SMD, -0.62; 95% CI, -1.06 to -0.17; P = 0.0215; I 2  = 67.9%). A significant risk of publication bias was estimated for the ellipticity index (P = 0.0360) and volume (P = 0.0030)., Conclusions: Based on the results of a meta-analysis containing 39 studies, the nonsphericity index, undulation index, elongation, flatness, and sphericity demonstrated the most consistent correlation with rupture status., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Background and Importance: Neurointervention is a very competitive specialty in the United States due to the limited number of training spots and the larger pool of applicants. The training standards are continuously updated to ensure solid training experiences. Factors affecting candidate(s) selection have not been fully established yet. Our study aims to investigate the factors influencing the selection process., Methods: A 52-question survey was distributed to 93 program directors (PDs). The survey consisted of six categories: (a) Program characteristics, (b) Candidate demographics, (c) Educational credentials, (d) Personal traits, (e) Research and extracurricular activities, and (f) Overall final set of characteristics. The response rate was 59.1%. As per the programs' characteristics, neurosurgery was the most involved specialty in running the training programs (69%). Regarding demographics, the need for visa sponsorship held the greatest prominence with a mean score of 5.9 [standard deviation (SD) 2.9]. For the educational credentials, being a graduate from a neurosurgical residency and the institution where the candidate's residency training is/was scored the highest [5.4 (SD = 2.9), 5.4 (SD = 2.5), respectively]. Regarding the personal traits, assessment by faculty members achieved the highest score [8.9 (SD = 1)]. In terms of research/extracurricular activities, fluency in English had the highest score [7.2 (SD = 1.9)] followed by peer-reviewed/PubMed-indexed publications [6.4 (SD = 2.2)]., Conclusion: Our survey investigated the factors influencing the final decision when choosing the future neurointerventional trainee, including demographic, educational, research, and extracurricular activities, which might serve as valuable guidance for both applicants and programs to refine the selection process., Competing Interests: Declaration of conflicting interestsThe authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Objective: Patients with dural venous sinus thrombosis (DVST) in select populations following traumatic brain injury (TBI), including those with blunt mechanism or depressed skull fractures, have been shown to have an increased risk of mortality. The purpose of this study was to assess these findings in a mixed population of head trauma patients., Methods: The authors performed a case-control study using propensity score matching by reviewing 17 years (2004-2021) of data from their institutional trauma registry. Patients with imaging-confirmed DVST were matched to a control group of TBI patients without identified DVST based on age, sex, postresuscitation Glasgow Coma Scale (GCS) score, and Injury Severity Score. All age groups and injury mechanisms were included with a head Abbreviated Injury Scale score ≥ 3. Data on demographics, injury and radiographic characteristics, and patient outcomes were collected. Multivariable logistic regression was performed to identify predictors of inpatient mortality. An additional subgroup analysis of patients with concurrent DVST and blunt cerebrovascular injury (BCVI) was planned a priori., Results: The authors identified 9875 patients who presented to their institution over the study period with TBIs, with a 1.64% incidence of DVST. Concurrent BCVI was diagnosed in 23.5% of patients with a DVST. Following matching, the presence of DVST itself was not significantly associated with inpatient mortality (OR 0.68, 95% CI 0.24-1.88). On regression analysis, penetrating injuries (8.19, 95% CI 1.21-80.0) and lower postresuscitation GCS scores (0.69, 95% CI 0.53-0.84) were independently associated with inpatient mortality for patients with traumatic DVST. Significantly worse functional outcomes were observed in those with DVST at 3 months, with no significant difference at 6 months., Conclusions: The authors observed a prevalence of traumatic DVST of 1.64% in a mixed population of head-injured patients, with 23.5% of patients with DVST having concurrent BCVI. Traumatic DVST alone was not associated with a significantly increased risk of inpatient mortality.

Background and Objectives: Access to the anterolateral pontine lesions can be achieved through the peritrigeminal and supratrigeminal safe entry zones using Kawase, retrosigmoid, or translabyrinthine approaches. However, these approaches entail shallow extensive dissection, tangential access, and compromise vestibulocochlear function. We aimed to investigate infratentorial presigmoid retrolabyrinthine approach to access pontine lesions through the peritrigeminal zone., Methods: We performed 10 presigmoid retrolabyrinthine suprameatal approach dissections in 5 cadaveric heads. Anatomic-radiological characteristics and variations were evaluated. Six morphometric parameters were measured and analyzed to predict surgical accessibility., Results: The pontine infratrigeminal area was accessible in all patients. The mean exposed area of the anterolateral pontine surface was 98.95 cm 2 (±38.11 cm 2 ). The mean length of the exposed trigeminal nerve was 7.9 cm (±2.9 cm). Preoperative anatomic-radiological parameters may allow to select patients with favorable anatomy that offers appropriate surgical accessibility to the anterior pontine cavernoma through a presigmoid retrolabyrinthine corridor., Conclusion: Anterolateral pontine lesions can be accessed through a minimally invasive infratentorial presigmoid retrolabyrinthine approach by targeting the infratrigeminal safe entry zone. Further clinical studies should be conducted to evaluate the viability of this technique for treating these complex pathologies in real clinical settings., (Copyright © Congress of Neurological Surgeons 2023. All rights reserved.)

Objectives: Thrombectomy improves outcomes in patients with basilar artery (BA) occlusion. We hypothesized that the anatomic configuration of the BA bifurcation, classified as T- or Y-shaped, may impact the outcome as a T-shaped BA would involve more deep penetrating arteries of the midbrain and thalamus., Materials and Methods: In this 2-center retrospective cohort study, we included patients with stroke due to distal BA occlusion and performed blinded classification of their BA distal bifurcation as either T- or Y-shaped. The primary outcomes were favorable outcome at 90-days (modified Rankin Scale 0 - 2) and successful recanalization (TICI scores 2B or 3)., Results: 70 patients (mean age 66 years, 36% women) were included. 38 had T- and 32 had Y-shaped bifurcations. Baseline characteristics were similar for both groups, including demographics, onset to arterial puncture time, baseline NIHSS, THRIVE score, posterior circulation collateral score, and presence of tandem occlusion. Comparing the T- to the Y- shape, there was no difference in the likelihood of successful recanalization (RR: 1.02, CI: [0.86-1.21], p=1.00) nor 90-day favorable mRS (0-2) score (RR: 0.58, CI: [0.25-1.32]; p=0.18). Similarly, mortality at 30 and 90-days were not significantly affected by the type of bifurcation., Conclusions: The configuration of the basilar artery does not significantly impact on recanalization success or stroke outcome in our study. Further studies are needed to confirm our observations., Competing Interests: Declaration of Competing Interest Authors declare no conflicting of interest in the subject matter of this paper., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Preincisional localization has become ubiquitous within spinal neurosurgery and has served as the foundation for modern minimally invasive surgery techniques. Dr. Ralph Bingham Cloward, renowned for his contributions to the field of spinal fusion, was a strong advocate and early adopter of diskography. In fact, Cloward credited cervical diskography for inspiring his anterior approach to the cervical disk. In his landmark 1958 article on what is now known as anterior cervical diskectomy and fusion, Cloward commented on a case of wrong-level surgery that motivated him to implement a standardized technique for spinal level localization with the patient under anesthesia in the operating room before skin incision. We trace the origins of the use of preincisional radiographs to localize the pathologic level at the time of diskectomy and highlight this original contribution by Cloward., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Importance: The effects of moderate systolic blood pressure (SBP) lowering after successful recanalization with endovascular therapy for acute ischemic stroke are uncertain., Objective: To determine the futility of lower SBP targets after endovascular therapy (<140 mm Hg or 160 mm Hg) compared with a higher target (≤180 mm Hg)., Design, Setting, and Participants: Randomized, open-label, blinded end point, phase 2, futility clinical trial that enrolled 120 patients with acute ischemic stroke who had undergone successful endovascular therapy at 3 US comprehensive stroke centers from January 2020 to March 2022 (final follow-up, June 2022)., Intervention: After undergoing endovascular therapy, participants were randomized to 1 of 3 SBP targets: 40 to less than 140 mm Hg, 40 to less than 160 mm Hg, and 40 to 180 mm Hg or less (guideline recommended) group, initiated within 60 minutes of recanalization and maintained for 24 hours., Main Outcomes and Measures: Prespecified multiple primary outcomes for the primary futility analysis were follow-up infarct volume measured at 36 (±12) hours and utility-weighted modified Rankin Scale (mRS) score (range, 0 [worst] to 1 [best]) at 90 (±14) days. Linear regression models were used to test the harm-futility boundaries of a 10-mL increase (slope of 0.5) in the follow-up infarct volume or a 0.10 decrease (slope of -0.005) in the utility-weighted mRS score with each 20-mm Hg SBP target reduction after endovascular therapy (1-sided α = .05). Additional prespecified futility criterion was a less than 25% predicted probability of success for a future 2-group, superiority trial comparing SBP targets of the low- and mid-thresholds with the high-threshold (maximum sample size, 1500 with respect to the utility-weighted mRS score outcome)., Results: Among 120 patients randomized (mean [SD] age, 69.6 [14.5] years; 69 females [58%]), 113 (94.2%) completed the trial. The mean follow-up infarct volume was 32.4 mL (95% CI, 18.0 to 46.7 mL) for the less than 140-mm Hg group, 50.7 mL (95% CI, 33.7 to 67.7 mL), for the less than 160-mm Hg group, and 46.4 mL (95% CI, 24.5 to 68.2 mL) for the 180-mm Hg or less group. The mean utility-weighted mRS score was 0.51 (95% CI, 0.38 to 0.63) for the less than 140-mm Hg group, 0.47 (95% CI, 0.35 to 0.60) for the less than 160-mm Hg group, and 0.58 (95% CI, 0.46 to 0.71) for the high-target group. The slope of the follow-up infarct volume for each mm Hg decrease in the SBP target, adjusted for the baseline Alberta Stroke Program Early CT score, was -0.29 (95% CI, -0.81 to ∞; futility P = .99). The slope of the utility-weighted mRS score for each mm Hg decrease in the SBP target after endovascular therapy, adjusted for baseline utility-weighted mRS score, was -0.0019 (95% CI, -∞ to 0.0017; futility P = .93). Comparing the high-target SBP group with the lower-target groups, the predicted probability of success for a future trial was 25% for the less than 140-mm Hg group and 14% for the 160-mm Hg group., Conclusions and Relevance: Among patients with acute ischemic stroke, lower SBP targets less than either 140 mm Hg or 160 mm Hg after successful endovascular therapy did not meet prespecified criteria for futility compared with an SBP target of 180 mm Hg or less. However, the findings suggested a low probability of benefit from lower SBP targets after endovascular therapy if tested in a future larger trial., Trial Registration: ClinicalTrials.gov Identifier: NCT04116112.

Background: Delayed cerebral ischemia (DCI) may significantly worsen the functional status of patients with aneurysmal subarachnoid hemorrhage (aSAH). Several authors have designed predictive models for early identification of patients at risk of post-aSAH DCI. In this study, we externally validate an extreme gradient boosting (EGB) forecasting model for post-aSAH DCI prediction., Methods: A 9-year institutional retrospective review of patients with aSAH was performed. Patients were included if they underwent surgical or endovascular treatment and had available follow-up data. DCI was diagnosed as new-onset neurologic deficits at 4-12 days after aneurysm rupture, defined as worsening Glasgow Coma Scale score for ≥2 points, and new ischemic infarcts at imaging., Results: We collected 267 patients with aSAH. At admission, median Hunt-Hess score was 2 (range, 1-5), median Fisher score 3 (range, 1-4), and median modified Fisher score 3 (range, 1-4). One-hundred and forty-five patients underwent external ventricular drainage placement for hydrocephalus (54.3%). The ruptured aneurysms were treated with clipping (64%), coiling (34.8%), and stent-assisted coiling (1.1%). Fifty-eight patients (21.7%) were diagnosed with clinical DCI and 82 (30.7%) with asymptomatic imaging vasospasm. The EGB classifier correctly predicted 19 cases of DCI (7.1%) and 154 cases of no-DCI (57.7%), achieving sensitivity of 32.76% and specificity of 73.68%. The calculated F1 score and accuracy were 0.288% and 64.8%, respectively., Conclusions: We validated that the EGB model is a potential assistant tool to predict post-aSAH DCI in clinical practice, finding moderate-high specificity but low sensitivity. Future research should investigate the underlying pathophysiology of DCI to allow the development of high-performing forecasting models., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Background: Aneurysm morphology has been correlated with rupture. Previous reports identified several morphologic indices that predict rupture status, but they measure only specific qualities of the morphology of an aneurysm in a semiquantitative fashion. Fractal analysis is a geometric technique whereby the overall complexity of a shape is quantified through the calculation of a fractal dimension (FD). By progressively altering the scale of measurement of a shape and determining the number of segments required to incorporate the entire shape, a noninteger value for the dimension of the shape is derived. We present a proof-of-concept study to calculate the FD of an aneurysm for a small cohort of patients with aneurysms in 2 specific locations to determine whether FD is associated with aneurysm rupture status., Methods: Twenty-nine aneurysms of the posterior communicating and middle cerebral arteries were segmented from computed tomography angiograms in 29 patients. FD was calculated using a standard box-counting algorithm extended for use with three-dimensional shapes. Nonsphericity index and undulation index (UI) were used to validate the data against previously reported parameters associated with rupture status., Results: Nineteen ruptured and 10 unruptured aneurysms were analyzed. Through logistic regression analysis, lower FD was found to be significantly associated with rupture status (P = 0.035; odds ratio, 0.64; 95% confidence interval, 0.42-0.97 per FD increment of 0.05)., Conclusions: In this proof-of-concept study, we present a novel approach to quantify the geometric complexity of intracranial aneurysms through FD. These data suggest an association between FD and patient-specific aneurysm rupture status., (Copyright © 2023. Published by Elsevier Inc.)

Purpose: Basilar artery stenosis (BAS) carries high morbidity and mortality, with variable outcomes after endovascular treatments. We systematically reviewed the literature on percutaneous transluminal angioplasty and/or stenting (PTAS) for BAS., Methods: PubMed, EMBASE, Web-of-Science, Scopus, and Cochrane were searched upon the PRISMA guidelines to include prospective/retrospective cohort studies describing PTAS for BAS. Pooled rates of intervention-related complications and outcomes were analyzed with random-effect model meta-analyses., Results: We included 25 retrospective cohort studies comprising 1016 patients. All patients were symptomatic, presenting with transient ischemic attack or ischemic stroke. BAS frequently involved the middle basilar artery (51.4%), mostly classified as Mori-B (57.4%). PTAS for BAS was indicated in severe (≥ 50-70%), symptomatic BAS refractory to dual antiplatelet therapy. Patients underwent angioplasty (95.5%) and/or stenting (92.2%), preferably using Wingspan or Apollo stents. Median baseline BAS was 81% (range, 53-99%), while median post-intervention BAS was 13% (0-75%). Actuarial rates of successful intervention and "good" final outcome were 100% (95% CI: 100-100%) and 89% (95% CI: 85-93%). Intervention-related recurrent ischemic stroke occurred in 85 patients (8.3%) with actuarial rates of 5% (95% CI: 4-7%), differentiated into perforator (5.4%), in-stent (2.6%), and embolic (0.4%). Actuarial rates of intervention-related dissection, restenosis, and death were 0% (95% CI: 0-0%), 1% (95% CI: 0-1%), and 0% (95% CI: 0-2%)., Conclusion: Elective PTAS appears to be safe and effective in selected patients with medically refractory, severe, symptomatic, and non-acute BAS. Different stent types and angioplasty-assisted procedures should be considered based on specific clinico-radiological characteristics of the lesions. Future randomized controlled trials are required to corroborate these findings., (© 2023. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

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

Background: Color-labeling injections of cadaveric heads have revolutionized education and teaching of neurovascular anatomy. Silicone-based and latex-based coloring techniques are currently used, but limitations exist because of the viscosity of solutions used., Objective: To describe a novel "triple-injection method" for cadaveric cranial vasculature and perform qualitative and semiquantitative evaluations of colored solution penetration into the vasculature., Methods: After catheter preparation, vessel cannulation, and water irrigation of embalmed cadaveric heads, food coloring, gelatin, and silicone solutions were injected in sequential order into bilateral internal carotid and vertebral arteries (red-colored) and internal jugular veins (blue-colored). In total, 6 triple-injected embalmed cadaveric heads and 4 silicone-based "control" embalmed cadaveric heads were prepared. A qualitative analysis was performed to compare the vessel coloring of 6 triple-injected heads with that of 4 "control" heads. A semiquantitative evaluation was completed to appraise sizes of the smallest color-filled vessels., Results: Naked-eye and microscope evaluations of embalmed experimental and control cadaveric heads revealed higher intensity and more distal color-labeling following the "triple-injection method" compared with the silicone-based method in both the intracranial and extracranial vasculature. Microscope assessment of 1-mm-thick coronal slices of triple-injected brains demonstrated color-filling of distal vessels with minimum diameters of 119 μm for triple-injected heads and 773 μm for silicone-based injected heads., Conclusion: Our "triple-injection method" showed superior color-filling of small-sized vessels as compared with the silicone-based injection method, resulting in more distal penetration of smaller caliber vessels., (Copyright © Congress of Neurological Surgeons 2022. All rights reserved.)

Purpose: Odontoidectomy for ventral compressive pathology may result in O-C1 and/or C1-2 instability. Same-stage endonasal C1-2 spinal fusion has been advocated to eliminate risks associated with separate-stage posterior approaches. While endonasal methods for C1 instrumentation and C1-2 trans-articular stabilization exist, no hypothetical construct for endonasal occipital instrumentation has been validated. We provide an anatomic description of anterior occipital condyle (AOC) screw endonasal placement as proof-of-concept for endonasal craniocervical stabilization., Methods: Eight adult, injected cadaveric heads were studied for placing 16 AOC screws endonasally. Thin-cut CT was used for registration. After turning a standard inferior U-shaped nasopharyngeal flap endonasally, 4 mm × 22 mm AOC screws were placed with a 0° driver using neuronavigation. Post-placement CT scans were obtained to determine: site-of-entry, measured from the endonasal projection of the medial O-C1 joint; screw angulation in sagittal and axial planes, proximity to critical structures., Results: Average site-of-entry was 6.88 mm lateral and 9.74 mm rostral to the medial O-C1 joint. Average angulation in the sagittal plane was 0.16° inferior to the palatal line. Average angulation in the axial plane was 23.97° lateral to midline. Average minimum screw distances from the jugular bulb and hypoglossal canal were 4.80 mm and 1.55 mm., Conclusion: Endonasal placement of AOC screws is feasible using a 0° driver. Our measurements provide useful parameters to guide optimal placement. Given proximity of hypoglossal canal and jugular bulb, neuronavigation is recommended. Biomechanical studies will ultimately be necessary to evaluate the strength of AOC screws with plate-screw constructs utilizing endonasal C1 lateral mass or C1-2 trans-articular screws as inferior fixation points., (© 2023. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Background: The German Anatomist Hubert Von Luschka first described the foramina of Luschka (FOL) in 1855 as lateral holes in the fourth ventricle. By his discovery, he refuted previous beliefs about the lateral recess as blind ends of the fourth ventricle, proving the continuity of the ventricular system with the central canal of the spinal cord. In this paper, we question the outline variations of the patent parts of FOL and their consistency, drawing attention to the apparent query of the valvular mechanism of FOL., Methods: We conducted a literature review in PubMed and Google Scholar databases to review the existing literature describing the history, pertinent anatomy, and function of FOL. In addition, we reviewed the original German book written by Luschka., Results: While reading the available articles and original works regarding FOL, we noticed the developmental phases through which FOL was discovered, tracking the process from Aristotle till Luschka's discovery. We also discussed controversies and opinions about FOL's existence and function., Conclusion: FOL is halved into two compartments: choroidal and patent. The function of FOL resembles a oneway valve mechanism, and it depends on the patent slit-like part. Luschka had discovered over 20 anatomical structures, including several foramina, confusion in a debate may result from eponyms., Competing Interests: There are no conflicts of interest., (Copyright: © 2022 Surgical Neurology International.)

Background: The purpose of this review is to summarize the data available for the role of angiography and embolization in the comprehensive multidisciplinary management of brain arteriovenous malformations (AVMs METHODS: We performed a structured literature review for studies examining the indications, efficacy, and outcomes for patients undergoing endovascular therapy in the context of brain AVM management. We graded the quality of the evidence. Recommendations were arrived at through a consensus conference of the authors, then with additional input from the full Society of NeuroInterventional Surgery (SNIS) Standards and Guidelines Committee and the SNIS Board of Directors., Results: The multidisciplinary evaluation and treatment of brain AVMs continues to evolve. Recommendations include: (1) Digital subtraction catheter cerebral angiography (DSA)-including 2D, 3D, and reformatted cross-sectional views when appropriate-is recommended in the pre-treatment assessment of cerebral AVMs. (I, B-NR) . (2) It is recommended that endovascular embolization of cerebral arteriovenous malformations be performed in the context of a complete multidisciplinary treatment plan aiming for obliteration of the AVM and cure. (I, B-NR) . (3) Embolization of brain AVMs before surgical resection can be useful to reduce intraoperative blood loss, morbidity, and surgical complexity. (IIa, B-NR) . (4) The role of primary curative embolization of cerebral arteriovenous malformations is uncertain, particularly as compared with microsurgery and radiosurgery with or without adjunctive embolization. Further research is needed, particularly with regard to risk for AVM recurrence. (III equivocal, C-LD) . (5) Targeted embolization of high-risk features of ruptured brain AVMs may be considered to reduce the risk for recurrent hemorrhage. (IIb, C-LD) . (6) Palliative embolization may be useful to treat symptomatic AVMs in which curative therapy is otherwise not possible. (IIb, B-NR) . (7) The role of AVM embolization as an adjunct to radiosurgery is not well-established. Further research is needed. (III equivocal, C-LD) . (8) Imaging follow-up after apparent cure of brain AVMs is recommended to assess for recurrence. Although non-invasive imaging may be used for longitudinal follow-up, DSA remains the gold standard for residual or recurrent AVM detection in patients with concerning imaging and/or clinical findings. (I, C-LD) . (9) Improved national and international reporting of patients of all ages with brain AVMs, their treatments, side effects from treatment, and their long-term outcomes would enhance the ability to perform clinical trials and improve the rigor of research into this rare condition. (I, C-EO) ., Conclusions: Although the quality of evidence is lower than for more common conditions subjected to multiple randomized controlled trials, endovascular therapy has an important role in the management of brain AVMs. Prospective studies are needed to strengthen the data supporting these recommendations., Competing Interests: Competing interests: SWH research is supported by NIH (R01CA194533, R42CA265316, R01EB012031). SWH has consulting agreements with Medtronic, Kaneka, Imperative, and Cerenovus. SWH’s institution has contract and grant support from Siemens, Stryker Neurovascular, and Route 92. SAA research is supported by NIH (R01NS114632, R01HL149787, R01HL115267). SAA has consulting agreements with Medtronic, Boston Scientific, Microvention, Rapid Medical, and Imperative Care. RDL has research grant support from Kaneka. RDL has consulting contracts with Cerenovus, Asahi Intec, Imperative Care, Spartan Micro and Stryker. RDL has equity interest in Synchron, Spartan Micro, Endostream, Vastrax and Q’Apel. CMS has research support from Penumbra and ownership interest in NTI., (© Author(s) (or their employer(s)) 2022. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Odontoidectomy may pose some risks for O-C1 and/or C1-C2 instability, with previous authors reporting techniques for endonasal C1-C2 fusion. However, no technique for endonasal O-C1 fusion currently exists. We sought to describe the feasibility of endonasal anterior C1 (AC1) screw placement for endonasal O-C1 fusion., Methods: Seven adult cadaveric heads were studied for endonasal placement of 14 C1 screws. Using thin-cut computed tomography (CT)-based "snapshot" neuronavigation assistance, 4 mm x 22 mm screws were placed in the C1 lateral mass using a 0° driver. Post-placement CT scans were obtained to determine site-of-entry measured from C1 anterior tubercle, screw angulation in axial and sagittal planes, and screw proximity to the central canal and foramen transversarium., Results: Average site-of-entry was 16.57 mm lateral, 2.23 mm rostral, and 5.53 mm deep to the anterior-most portion of the C1 ring. Average axial angulation was 19.49° lateral to midline, measured at the C1 level. Average sagittal angulation was 13.22° inferior to the palatal line, measured from the hard palate to the opisthion. Bicortical purchase was achieved in 11 screws (78.6%). Partial breach of the foramen transversarium was observed in 2 screws (14.3%), violation of the O-C1 joint space in 1 (7.1%), and violation of the central canal in 0 (0%). Average minimum screw distances from the unviolated foramen transversaria and central canal were 1.97 mm and 4.04 mm., Conclusions: Navigation-assisted endonasal placement of AC1 screws is feasible. Additional studies should investigate the biomechanical stability of anterior C1 screw-plating systems, with anterior condylar screws as superior fixation point, compared to traditional posterior O-C1 fusion., (Copyright © 2022 Elsevier Inc. All rights reserved.)

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

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

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

Carotid artery stenosis is implicated in up to 40% of all ischemic strokes. Accordingly, symptomatic, high-grade carotid artery stenosis portends an especially high risk of future stroke. Intervention via open or endovascular approaches drastically reduces this risk. Under the appropriate conditions, carotid artery stenting serves as a safe and effective alternative to carotid endarterectomy. We present the case of a 57-yr-old male with symptomatic, high-grade stenosis of his right internal carotid artery, for whom a history of radiation to the head and neck represented a relative contraindication to carotid endarterectomy, and thus endovascular treatment with angioplasty and stenting was performed. Informed consent was obtained prior to the procedure. Intraprocedurally, stent delivery past the area of stenosis proved somewhat challenging. However, by employing several nuanced maneuvers, we utilized our guiding catheter in a nonconventional manner in order to successfully perform the procedure. As the field of neuroendovascular surgery evolves, each case provides us unique lessons, which in turn expands our interventional capabilities and adds to the armamentarium of neuroendovascular techniques. We present this surgical video both as a means to provide a general overview of carotid artery stenting, and to share a lesson learned through the implementation of an interesting technical nuance., (© Congress of Neurological Surgeons 2021.)

The purpose of this publication is to provide a review of social media usage by neurointerventionalists. Using published literature and available local, regional, and national guidelines or laws, we reviewed data on social media usage as it pertains to neurointerventional surgery. Recommendations are provided based on the quality of information and conformity of medico-legal precedent and law. Social media is a growing entity as it is used both promotionally and educationally. Neurointerventionalists may post de-identified radiographic images with discussions, but should be conscientious and adhere to applicable laws and regulations, strict ethical codes, and institutional policies., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2021. No commercial re-use. See rights and permissions. Published by BMJ.)

Background and Aims: Despite widespread negative perceptions, the prevalence of alcohol-impaired driving (AID) in the United States remains unacceptably high. This study used a novel decision task to evaluate whether individuals considered both ride service cost and alcohol consumption level when deciding whether or not to drive, and whether the resulting strategy was associated with engagement in AID., Design: A two-sample study, where sample 1 developed a novel AID decision task to classify participants by decision strategy. Sample 2 was used to cross-validate the task and examine whether decision strategy classifications were predictive of prior reported AID behavior., Setting: A laboratory setting at the University of Missouri, USA., Participants: Sample 1 included 38 student participants from introductory psychology classes at the University of Missouri. Sample 2 included 67 young adult participants recruited from the local community., Measurements: We developed a decision task that presented hypothetical drinking scenarios that varied in quantity of alcohol consumption (one to six drinks) and the cost of a ride service ($5-25). We applied a Bayesian computational model to classify choices as consistent with either: integrating both ride cost and consumption level (compensatory) or considering only consumption level (non-compensatory) when making hypothetical AID decisions. In sample 2, we assessed established AID risk factors (sex, recent alcohol consumption, perceived safe limit) and recent (past 3 months) engagement in AID., Findings: In sample 1, the majority of participants were classified as using decision strategies consistent with either a compensatory or non-compensatory process. Results from sample 2 replicated the overall classification rate and demonstrated that participants who used a compensatory strategy were more likely to report recent AID, even after accounting for study covariates., Conclusions: In a hypothetical alcohol-impaired driving (AID) decision task, individuals who considered both consumption level and ride service cost were more likely to report recent AID than those who made decisions based entirely on consumption level., (© 2020 Society for the Study of Addiction.)

Admiral Lord Horatio Nelson is perhaps the most renowned naval commander, who allowed Britain to have dominion over the sea for 100 years after his victory at the Battle of Trafalgar. He was able to do so despite suffering from a multitude of communicable diseases and traumatic injuries, including the functional loss of his right eye, amputation of his right arm, scalp laceration, head injury, and finally a spinal injury. These injuries had permanent consequences but did not stop him from leading the charge and allowing the British to defeat the French and Spanish fleets in the decisive Battle of Trafalgar., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background: The goal of this study was to empirically examine the degree to which alcohol use and drinking motives changed during the first month of the pandemic and to examine individual differences associated with such changes. Methods: A U.S. nationwide survey of 500 adults was conducted; data from 201 individuals (Mage=38.98, SD=12.04, 52.2% female, 76.1% White) who endorsed current alcohol use were included in this study. Results: Paired-samples t-tests indicated that there was a significant decrease in drinking quantity [ t (199)=3.74, p <.001], but no change in drinking frequency [ t (198)=0.19, p =.849] overall during the first month of the U.S. pandemic. There were significant decreases in enhancement [ t (201)=4.55, p <.001], social [ t (201)=9.39, p <.001] and conformity [ t (201)=3.58, p <.001] motives, but a significant increase in coping motives [ t (201)=-3.71, p <.001]. Regression analyses showed that increases in enhancement [ β =0.46, p <.001] and coping [ β =0.27, p =.004] motives were significantly related to increases in drinking frequency, and increases in coping motives [ β =0.32, p =.002] were related to increases in drinking quantity. Riskier drinking prior to the pandemic was significantly related to greater increase in drinking quantity in the first month of the U.S. pandemic [ β =0.31, p <.001]. Conclusion: Results of this study provide initial support that changes in drinking motives were important predictors for changes in alcohol use during the first month of the U.S. pandemic. Contrary to anecdotal reports, drinking decreased overall during the first month of the U.S. pandemic; however, those with existing risky patterns of drinking prior to the start of the U.S. pandemic were at greatest risk for drinking escalation during this time.

Anterior and lateral approaches to the lumbar spine are commonly used today for a variety of indications. These approaches can ultimately be traced back to early attempts to treat Pott's disease. Evidence of Mycobacterium tuberculosis infection of the spine dates as far back as 2400 BCE, with ancient Egyptian mummies exhibiting lesions consistent with Pott's disease. For many centuries, Pott's disease was treated conservatively, and surgery came to be used when conservative therapy was ineffective, as medical therapy had yet to become available. In 1779, Percivall Pott recommended that peripheral paraspinal tuberculous abscesses be drained after noticing that patients' lower limb function improved after the formation of spontaneous draining sinuses. Building on Pott's ideas, Ménard described the first lateral approach to the spine via a costotransversectomy approximately 1 century after Pott's theory. Most importantly, the surge in understanding anatomy with respect to developing safe corridors to the deeper structures of the human body brought together advances in technology, instrumentation, and visualization. Surgeons were thus emboldened to explore more complex anterior approaches to the spine. In 1906, Müller reported the first successful anterior approach to the spine in a patient with Pott's disease. Over the next several decades, the efforts of surgeons such as Ito, Capener, Burns, and Mercer would lead to the development of the anterior lumbar interbody fusion. The costotransversectomy later evolved into the lateral rhachotomy and lateral extracavitary approach, which along with advances in the anterior lumbar interbody fusion paved the way for the oblique lumbar interbody fusion and lateral lumbar interbody fusion., (Copyright © 2020 Elsevier Inc. All rights reserved.)

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

Objective: Blunt cerebrovascular injury (BCVI) is associated with high rates of neurological morbidity and mortality. The detection and management of BCVI has improved with advances in imaging and sensitive screening protocols. Few studies have explored how these injuries specifically affect the geriatric population. The purpose of this retrospective analysis was to investigate the presentation and prognosis of BCVI in the elderly population and to assess its clinical implications in the management of these patients., Methods: All patients presenting to the University of Cincinnati (UC) level I trauma center between February 2017 and December 2019 were screened for BCVI and entered into the prospectively maintained UC Neurotrauma Registry. Patients with BCVI confirmed by CT angiography underwent retrospective chart reviews to collect information regarding demographics, positive screening criteria, cause of injury, antithrombotic agent, injury location, Denver Grading Scale, hospital and ICU length of stay, and discharge disposition. Patients were divided into geriatric (age ≥ 65 years) and adult (age < 65 years) subgroups. Continuous variables were analyzed using the Student t-test and categorical variables with the Pearson chi-square test., Results: Of 124 patients with BCVI, stratification by age yielded 23 geriatric and 101 adult patients. Injury in the geriatric group was associated with significantly higher mortality (p = 0.0194). The most common cause of injury in the elderly was falls (74%, 17/23; p < 0.0001), whereas motor vehicle accidents were most common in the adult group (38%, 38/100; p = 0.0642). With respect to the location of injury, carotid (p = 0.1171) and vertebral artery (p = 0.6981) injuries did not differ significantly for the geriatric group. The adult population presented more often with Denver grade I injuries (p < 0.0001), whereas the geriatric population presented with grade IV injuries (p = 0.0247). Elderly patients were more likely to be discharged to skilled nursing facilities (p = 0.0403) and adults to home or self-care (p = 0.0148)., Conclusions: This study is the first to characterize BCVI to all cervical and intracranial vessels in the geriatric population. Older age at presentation is significantly associated with greater severity, morbidity, and mortality from injury, with no preference for the particular artery injured. These findings carry important clinical implications for adapting practice in an aging population.

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