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Background: EMBOLISE (NCT 04402632) is an ongoing randomized controlled trial investigating the safety and efficacy of middle meningeal artery embolization for the treatment of subacute or chronic subdural hematoma (SDH). We hypothesized that the implementation Viz RECRUIT SDH, an artificial-intelligence (AI)-based mobile recruitment platform, would aid enrollment by automatically pre-screening suspected candidates for SDH and coordinating communication and image sharing among the entire research team. Methods: Patient enrollment in EMBOLISE prior to and after implementation of Viz RECRUIT SDH at a primary (PSC) and comprehensive stroke center (CSC) was compared. Viz RECRUIT SDH automatically detects SDH in head non-contrast computed tomography (NCCT) images and reports the volume, maximum thickness, and midline shift. The EMBOLISE trial was activated on May 5, 2021, and Viz RECRUIT SDH was activated on October 6, 2021; therefore, the pre-Viz cohort consisted of all patients from EMBOLISE to Viz activation (131 days), and the post-Viz cohort consisted of all patients from Viz activation until August 18, 2022 (316 days). For the post-Viz cohort, additional data is presented on AI-based screening metrics. Results: Prior to implementation of the AI-based software, there were 5 patients enrolled (0.99 patients/month). After implementation of the software for trial screening, enrollment increased by 36% to 1.35 patients/month (14 total enrolled), and there were no screen failures. Over the entire post-Viz period, a total of 6804 NCCTs were prescreened by Viz with 208 total SDH detections (3% prevalence). A total of 50 detections were made at the PSC and 158 came from the CSC. 79% of all alerts for suspected SDH were viewed, and 48% of all viewed alerts occurred within 10 minutes. Conclusions: The implementation of an AI-based software for the automatic screening of SDH patients increased the enrollment rate in the EMBOLISE trial. Moreover, in a busy research institution with 13 active studies in 2022, the automatic alerts of all potential patients keep our attention on EMBOLISE with coordinated screening and communication in a single mobile application.

Background: Prior studies have shown rescue intracranial angioplasty and/or stenting (PTAS) is safe and efficacious in acute large vessel occlusion (LVO) of the anterior circulation with underlying intracranial atherosclerotic disease (ICAD). We investigated the safety and efficacy of acute intracranial angioplasty and/or stenting in patients with posterior circulation intracranial atherosclerosis-related occlusion (ICAS-O). Methods: Through the utilization of a prospectively collected endovascular database at a comprehensive stroke center between January 2016- May 2022, variables such as demographics, co-morbid conditions, symptomatic intracerebral hemorrhage (ICH), the mortality rate at discharge, and recanalization rate and favorable clinical outcome, modified thrombolysis in cerebral infarction score (mTICI) and favorable clinical outcome (modified Rankin Scale (mRS), were examined. The outcomes between acute PTAS + MT in the anterior and posterior circulation were compared. Results: There were a total of 75 acute ischemic stroke (AIS) patients who underwent rescue PTAS, of which 15 (20.0 %) were posterior circulation ICAS-O group. Baseline characteristics were similar between the groups except for gender (6.7 % vs 45.0) and atrial fibrillation (21.7% vs 0.0%). There was no statistical difference in discharge NIH Stroke Scale (mean, 18 vs 23%, P = 0.860) or favorable outcome (modified Rankin Scale ≤ 2) at 90 days (46.7% vs 38.7 %, P = 0.477) between the posterior and anterior ICAS-O groups respectively. Symptomatic ICH rate tended to be higher in the anterior group (11.7 vs 6.7%, P = 0.495). Conclusions: Rescue angioplasty and/or stenting seem safe treatment options for posterior circulation ICAS-related LVO. Further larger multicenter prospective studies are required to corroborate the results of our study.

Purpose To review the different imaging modalities utilized in the diagnosis of Intracranial Atherosclerotic Disease (ICAD) including their latest development and relevance in management of ICAD. Methods A review of the literature was conducted through a search in google scholar, PubMed/Medline, EMBASE, Scopus, clinical trials.gov and the Cochrane Library. Search terms included, “imaging modalities in ICAD,” “ICAD diagnostic,” “Neuroimaging of ICAD,” “Evaluation of ICAD”. A summary and comparison of each modality's basic principles, advantages and disadvantages were included. Results A total of 144 articles were identified and reviewed. The most common imaging used in ICAD diagnoses were DSA, CTA, MRA and TCD. They all had proven accuracy, their own benefits, and limitations. Newer modalities such as VWI, IVUS, OCT, PWI and CFD provide more detailed information regarding the vessel walls, plaque characteristics, and flow dynamics, which play a tremendous role in treatment guidance. In certain clinical scenarios, using more than one modality has been shown to be helpful in ICAD identification. The rapidly evolving software related to imaging studies, such as virtual histology, are very promising for the diagnostic and management of ICAD. Conclusions ICAD is a common cause of recurrent ischemic stroke. Its management can be both medical and/or procedural. Many different imaging modalities are used in its diagnosis. In certain clinical scenario, a combination of two more modalities can be critical in the management of ICAD. We expect that continuous development of imaging technique will lead to individualized and less invasive management with adequate outcome.

Background Remote tele-proctoring has been conducted in neuro-endovascular surgery, however, evidence to support its use in the fellowship training is limited. We demonstrate a novel augmented reality tele-proctoring platform to enable a remote attending to guide a fellow. Methods A consecutive series of neuro-endovascular cases were performed by a neuro-endovascular fellow with remote guidance from an attending surgeon. The fellow and attending were connected using a commercially available cloud-based platform designed to capture and stream up to four live video feeds from a clinical environment to a remote user. In this setting, two video streams were obtained directly from the anteroposterior and lateral cameras on the biplane. Additional video of the operator from a telescopic camera was streamed live to the remote attending surgeon. The attending could provide immediate vocal feedback and also deploy the platform's augmented reality tools to communicate with the fellow in the angiography suite. Results A total of 10 cases were performed on eight patients utilizing the cloud-based tele-proctoring platform to facilitate instruction. The series included diagnostic angiograms and interventions such as intracranial balloon angioplasty, carotid stenting, and intracranial stenting. All cases were a technical success. No complications or deaths occurred. When compared to similar cohort of 10 cases prior to these which utilized a traditional instruction paradigm; we saw no differences in contrast use ( p = 0.38), fluoroscopy time ( p = 0.85), or technical success. Conclusions This study demonstrates successful use of an augmented reality tele-proctoring platform to guide a neuro-endovascular fellow through complex neuro-interventional procedures from a remote setting.

OBJECTIVE Ruptured blister, dissecting, and iatrogenic pseudoaneurysms are rare pathologies that pose significant challenges from a treatment standpoint. Endovascular treatment via flow diversion represents an increasingly popular option; however, drawbacks include the requirement for dual antiplatelet therapy and the potential for thromboembolic complications, particularly acute complications in the ruptured setting. The Pipeline Flex embolization device with Shield Technology (PED-Shield) offers reduced material thrombogenicity, which may aid in the treatment of ruptured internal carotid artery pseudoaneurysms. METHODS The authors conducted a multi-institution, retrospective case series to determine the safety and efficacy of PED-Shield for the treatment of ruptured blister, dissecting, and iatrogenic pseudoaneurysms of the internal carotid artery. Clinical, radiographic, treatment, and outcomes data were collected. RESULTS Thirty-three patients were included in the final analysis. Seventeen underwent placement of a single device, and 16 underwent placement of two devices. No thromboembolic complications occurred. Four patients were maintained on aspirin alone, and all others were treated with long-term dual antiplatelet therapy. Among patients with 3-month follow-up, 93.8% had a modified Rankin Scale score of 0–2. Complete occlusion at follow-up was observed in 82.6% of patients. CONCLUSIONS PED-Shield represents a new option for the treatment of ruptured blister, dissecting, and iatrogenic pseudoaneurysms of the internal carotid artery. The reduced material thrombogenicity appeared to improve the safety of the PED-Shield device, as this series demonstrated no thromboembolic complications even among patients treated with only single antiplatelet therapy. The efficacy of PED-Shield reported in this series, particularly with placement of two devices, demonstrates its potential as a first-line treatment option for these pathologies.

Background and Purpose Angioplasty and stenting is a treatment option for patients with medically refractory symptomatic intracranial atherosclerotic disease (sICAD). Currently the Wingspan Stent System (WSS) is the only FDA approved device for this indication. We find the Resolute (R) Onyx Stent, a drug-eluting balloon mounted stent (DES), a better alternative to the WSS for treatment of sICAD. Herein, we present our findings comparing the two stents based on our single center experience. Methods A prospectively maintained neuro-endovascular databased was queried for patients between January 2013 to June 2021. Inclusion criteria for patients included sICAD with failed medical management, and intracranial stenting with either R-Onyx DES or WSS, including patients treated within 7 days of their last stroke. Primary outcomes were assessed via the occurrence of ischemic or hemorrhagic stroke or death within 72 h of the procedure. Secondary outcomes consisted of recurrent stroke or significant in-stent restenosis evaluated by a clinical or angiographic follow-up at 6 months. Results A total of 184 patients, average age 61.26 (SD = 12.53) (44% women), were eligible for analysis with 58 having R-onyx DES and 126 having WSS. Within 72 h, the primary outcome was observed in 1.7% (n = 1) of patients in the R-onyx DES group and 6.3% (n = 8) of patients in the WSS group (p = 0.089). Among 41 angiographic and clinical follow-ups in the R-onyx DES group, none had a recurrent stroke, while among 101 patients who had follow-up in the WSS group, 8.9% (n = 9) had a stroke (p = 0.024). At a 6-month angiographic follow-up, there was a significantly lower rate of symptomatic in-stent restenosis among the R-onyx DES group with 1.7% (n = 1) compared with 21.4% (n = 27) in the WSS group (p = 0.0003). Conclusion R-onyx DES is more effective than WSS in treating sICAD with low rates of periprocedural complications and long-term strokes and symptomatic in-stent restenosis. Future prospective randomized multicenter trials are needed.

Background and Purpose: Angioplasty and stenting is a treatment option for patients with medically refractory symptomatic intracranial atherosclerotic disease (sICAD). Currently the Wingspan Stent System (WSS) is the only FDA approved device for that indication. Nonetheless, our group has shown the Resolute (R) Onyx Stent, a drug-eluting balloon mounted stent (DES), can be feasibly used to treat lesions in this population at lower cost. Herein, we compare the two stents based on our single center experience. Methods: A prospectively maintained neuro-endovascular databased was queried for patients between January 2013 to June 2021. Inclusion criteria for patients included sICAD (≥70% stenosis) with failed medical management, and intracranial stenting with either the R-onyx DES or WSS, including patients treated within 7 days of last stroke. Primary outcomes were assessed via the occurrence of ischemic or hemorrhagic stroke or death within 72 h of the procedure while secondary outcomes consisted of stroke or angiographic reoccurrence (in-stent restenosis) evaluated by a clinical or angiographic follow-up at 6 months. Results: A total of 184 patients, average age 61.26 (SD=12.53) ( 44% women), were eligible for analysis with 58 having R-onyx DES and 126 having WSS. There was no significant difference in age or premorbid risk factors between the two groups. Within 72 h, 1.7% (n=1) of patients had a primary event of ischemic or hemorrhagic stroke or death in the R-onyx DES group while 6.3% (n=8) of patients had those indications in the WSS group (p = 0.089). Among 41 angiographic and clinical follow-ups in the R-onyx DES group, none had a stroke, while among 101 of those follow-ups in the WSS group, 8.9% (n=9) had a stroke (p=0.024). In terms of 6-month angiographic follow-ups, there was a significantly lower rate of symptomatic in-stent restenosis among the R-onyx DES group with 1.7% (n=1) experiencing symptomatic in-stent restenosis, and 21.4% (n=27) in the WSS group having that indication (p=0.0003). Conclusion: Our experience has been that R-onyx DES is more effective at treating sICAD with low rates of periprocedural complications within 72 h, long-term strokes, and symptomatic in-stent restenosis. Future prospective randomized multicenter trials are needed.

Background and Purpose: Angioplasty and stenting is a therapeutic option for patients with medically refractory intracranial atherosclerotic disease (ICAD). We previously demonstrated the feasibility of using Resolute (R) Onyx Stent, a drug-eluting balloon mounted coronary stent (DES), for ICAD patients. WEAVE (Wingspan Stent System Post Market Surveillance) trial assessed the periprocedural safety of Wingspan Stents in ICAD patients. We present our on-going experience with R-Onyx in ICAD patients integrating WEAVE styled methodology to assess outcomes in our cohort. Methods: A prospectively maintained neuro-endovascular database was queried for intracranial angioplasty and stenting cases from October 2019 to June 2021. Patients with symptomatic ICAD despite maximum medical management with >70% stenosis who were treated with R-Onyx DES were included. Primary outcomes were assessed according to WEAVE trial criteria (ischemic or hemorrhagic stroke or death within 72 h of the procedure). Secondary outcomes were assessed by occurrence of stroke and/or in-stent restenosis evaluated 30 days post-procedure clinically or angiographically. Results: A total of 58 patients were eligible for analysis with a mean age of 63.66 years, and 63.8% (n=37) were males. A total of 42 patients had an indication for treatment consisting of recurrent stroke while 16 had recurrent transient ischemic attacks. A total of 62 R-onyx DES stents were used to treat 58 patients with symptomatic lesions with an average stenosis of 84.7%. All procedures were completed successfully with Conclusion: Our study reinforces the feasibility of R-Onyx DES for treatment of ICAD refractory to maximal medical management by reporting low periprocedural complication rates (1.7%) according to WEAVE methodology, which itself had a periprocedural complication rate of 2.6%, and low long-term frequencies of indications such as strokes and restenosis. These findings perhaps warrant randomized comparative studies between the stents.

BackgroundWe report the largest multicenter experience to date of utilizing the Comaneci device for endovascular treatment of refractory intracranial vasospasm.MethodsConsecutive patients undergoing Comaneci mechanical dilatation for vasospasm were extracted from prospectively maintained registries in 11 North American centers (2020–2022). Intra-arterial vasodilators (IAV) were allowed, with the Comaneci device utilized after absence of vessel dilation post-infusion. Pre- and post-vasospasm treatment scores were recorded for each segment, with primary radiological outcome of score improvement post-treatment. Primary clinical outcome was safety/device-related complications, with secondary endpoints of functional outcomes at last follow-up.ResultsA total of 129 vessels in 40 patients (median age 52 years; 67.5% females) received mechanical dilation, 109 of which (84.5%) exhibited pre-treatment severe-to-critical vasospasm (ie, score 3/4). Aneurysmal subarachnoid hemorrhage was the most common etiology of vasospasm (85%), with 65% of procedures utilizing Comaneci-17 (92.5% of patients received IAV). The most treated segments were anterior cerebral artery (34.9%) and middle cerebral artery (31%). Significant vasospasm drop (pre-treatment score (3–4) to post-treatment (0–2)) was achieved in 89.9% of vessels (96.1% of vessels experienced ≥1-point drop in score post-treatment). There were no major procedural/post-procedural device-related complications. Primary failure (ie, vessel unresponsive) was encountered in one vessel (1 patient) (1/129; 0.8%) while secondary failure (ie, recurrence in previously treated segment requiring retreatment in another procedure) occurred in 16 vessels (7 patients) (16/129; 12.4%), with median time-to-retreatment of 2 days. Favorable clinical outcome (modified Rankin Scale 0–2) was noted in 51.5% of patients (median follow-up 6 months).ConclusionsThe Comaneci device provides a complementary strategy for treatment of refractory vasospasm with reasonable efficacy/favorable safety. Future prospective trials are warranted.

Introduction: Mechanical thrombectomy (MT) results in a marked improvement in outcomes of acute ischemic stroke (AIS) patients. First pass effect (FPE), which is defined as the achievement of complete recanalization (mTICI 3) from a single pass, appears to be associated with higher rates of good outcome. We seek to determine if dimensions of stentreivers such as length and diameter have influence on FPE, and other safety outcomes including hemorrhagic transformation, symptomatic intracerebral hemorrhage (sICH), masseffect, and mortality. Methodology: Patients who underwent MT between 2012 and 2020 were identified from a prospectively maintained database at a comprehensive stroke center. Then, these patients were stratified based on dimensions of stentrievers into: "4x20", "4x40", "6x30", and “6x40". Stentrievers used during the study period included Trevo and Solitare. Results: This study included 320 AIS patients. The mean (SD) age of the included patients was 70.7 (13.5), and 54.1% of them were males. 79 (24.7%) of the stentrievers were 4x20, 47 (14.7%) were 4x40, 66 (20.6%) were 6x30, while 128 (40%) were 6x40. There was no difference among the four stentreivers in FPE rates (64.6% vs 68.1%, 66.7%, 67.2%, p=0.98), hemorrhagic transformation (10.1% vs 14.9%, 12.1%, 14.8%, p=0.88), mass effect (3.8% vs 6.4%, 9.1%, 11.7%, p=0.134), and mortality rates (17.7% vs 23.7%, 19.7%, 20.3%, p=0.86). Noteworthy, sICH was significantly different among the groups with the lowest rates reported for 4x40 (4.3%) and 6x40 (5.5%), followed by 4x20 (10.1%), and 6x30 (16.7%), respectively (p=0.04). Conclusions: Stentriever dimensions do not appear to significantly influence FPE rates. We found that 4x40 and 6x40 stentrievers were significantly associated with lower rates of sICH.

Neuroendocrine carcinoma of the cervix (NECC) accounts for 2% of all cervical cancers. Brain metastasis is rare, with few cases described in the literature, and is usually associated with preceding pulmonary metastasis. We describe an additional case of isolated brain metastasis without pulmonary metastasis from NECC and reflect on unique management. A 37-year-old woman with a history of NECC presented with severe headache post-total hysterectomy with pelvic lymph node dissection. The computed tomography (CT) scan demonstrated obstructive hydrocephalus with several intra-axial lesions located in the pineal region, left cerebellar hemisphere, and left frontal operculum. A right frontal ventriculostomy was initially placed to relieve the hydrocephalus. CSF was sent for cytology but was unrevealing. Due to the degree of brainstem compression and the need to obtain a pathologic diagnosis, a posterior fossa craniotomy for the removal of the lesion was performed. Histopathology demonstrated small blue cell tumors positive for neuroendocrine markers consistent with neuroendocrine carcinoma of the cervix. Resection of additional metastasis was not recommended. An endoscopic third ventriculostomy (ETV) was then performed in order to remove the ventriculostomy with success. The patient was then referred to radiation oncology and received whole-brain radiotherapy (WBRT) for a total of 30 Grays (3000 cGy) over 10 fractions. Interval imaging demonstrated complete resolution of the pineal and left frontal lesions. The patient was symptom-free for approximately three months. She then presented with paraplegia consistent with follow-up imaging of her neuraxis, demonstrating drop metastasis in her cervical, thoracic, and lumbar spine. Spinal radiation was given with partial recovery in upper extremity function, however, lower extremity function did not recover. The patient was then transferred to palliative care. There are no guidelines on NECC brain metastasis management. Brain metastasis is associated with reduced longevity. NECC has a propensity for early dissemination and treatment failure. ETV is preferred over ventriculoperitoneal shunting in cases with obstructive hydrocephalus, as it may reduce the risk of tumor seeding. Retrospectively, our patient may have benefitted from upfront craniospinal radiation.

Background: Primary central nervous system (CNS) melanoma is a rare lesion derived from neural crest precursors. While its management is analogous to metastatic spinal melanoma, the literature does not describe this entity clearly in pregnant patients and the unique implications it presents. Here, we describe the case of a pregnant patient who presented with primary CNS melanoma of the cervical spine. Case Description: A 27-year-old pregnant patient presented with a 3-month history of neck and interscapular pain. MRI of the cervical spine demonstrated a ventral intradural extramedullary mass adjacent to the C2-C3 vertebral bodies causing severe cord compression. The patient was induced at 31 weeks and shortly thereafter developed quadriparesis and became obtunded. The patient underwent emergent right-sided C1 hemilaminectomy, complete C2-C4 laminectomy, and right-sided intradural division of the dentate ligaments for removal of the ventral intradural mass. Full neurological recovery was achieved before discharge. At follow-up, the infant was found to be negative for transplacental metastasis. We performed fractionated radiotherapy 4 weeks after index surgery. Nine months following index surgery, she presented with severe axial neck pain. Radiographs of the cervical spine demonstrated postlaminectomy kyphosis. The patient later underwent a posterior cervical fusion. She was recurrence-free 9 months follow-up. Conclusion: The differential for intradural extramedullary spinal lesions should include schwannoma, neurofibroma, meningioma, metastasis, and melanoma. Physicians caring for pregnant patients with melanoma should be aware of the potential for transplacental metastasis and perform follow-up for fetal complications.

Two unlike metals near one another can break down as they move toward electrochemical equilibrium resulting in galvanic corrosion. We describe a case of electrochemical corrosion resulting in pseudarthrosis, followed by instrumentation failure leading to subarachnoid hemorrhage. A 53-year-old female with a history of cervical instability and two separate prior cervical fusion surgery with sublaminar cables presented with new onset severe neck pain. Restricted range of motion in her neck and bilateral Hoffman's was noted. X-ray of her cervical spine was negative. A noncontrast CT scan of her head and neck showed subarachnoid hemorrhage in the prepontine and cervicomedullary cisterns. Neurosurgical intervention involved removal of prior stainless steel and titanium cables, repair of cerebrospinal fluid leak, and nonsegmental C1–C3 instrumented fusion. She tolerated the surgery well and followed up without complication. Galvanic corrosion of the Brook's fusion secondary to current flow between dissimilar metal alloys resulted in catastrophic instrumentation failure and subarachnoid hemorrhage.

OBJECT The authors have previously reported on their early experience with sublaminar polyester bands in spine surgery. In this paper, the authors describe the use of sublaminar polyester bands in long-segment posterior instrumented spinal fusions from the upper thoracic spine to the ilium in 21 children and transitional adults with progressive neuromuscular scoliosis. Transitional adults were patients older than 18 years of age with a spinal disorder of pediatric onset, such as spina bifida. This dedicated study represents the first reported use of polyester bands in spine surgery for neuromuscular scoliosis in this patient population in the US. METHODS The authors retrospectively reviewed the demographics and procedural data of patients who underwent posterior instrumented fusion using sublaminar polyester bands for neuromuscular scoliosis. RESULTS Twenty-one pediatric and adult transitional patients, ranging in age from 10 to 20 years (mean 14 years), underwent posterior instrumented fusion for progressive neuromuscular scoliosis. The average coronal Cobb angle measured 66° before surgery (range 37°–125°). Immediately after surgery, the mean coronal Cobb angle was 40° (range 13°–85°). At last follow-up, the average coronal Cobb angle was maintained at 42° (range 5°–112°). Regarding sagittal parameters, thoracic kyphosis was restored by 8%, and lumbar lordosis improved by 20% after surgery. Mean follow-up duration was 17 months (range 2–54 months). One patient with an aborted procedure due to loss of intraoperative evoked potentials was excluded from the analysis of radiographic outcomes. Mean surgical time was 7 hours 43 minutes (range 3 hours 59 minutes to 10 hours 23 minutes). All patients received either a 12- or 24-mg dose of recombinant human bone morphogenetic protein–2. Average estimated blood loss was 976 ml (range 300–2700 ml). Complications directly related to the use of sublaminar instrumentation included transient proprioceptive deficit (1 patient) and prolonged paraparesis (1 patient). Other complications noted in this series included disengagement of the rod from an iliac screw (1 patient), proximal junctional kyphosis (1 patient), noninfected wound drainage (2 patients), and perioperative death (1 patient). The lessons learned from these complications are discussed. CONCLUSIONS Pedicle screws, laminar/pedicle/transverse process hooks, and sublaminar metal wires have been incorporated into posterior spinal constructs and widely reported and used in the thoracic and lumbar spines and sacrum with varying success. This report demonstrates the satisfactory radiological outcomes of hybrid posterior spinal constructs in pediatric and adult neuromuscular scoliosis that include sublaminar polyester bands that promise the technical ease of passing sublaminar instrumentation with the immediate biomechanical rigidity of pedicle screws and hooks. However, the high neurological complication rate associated with this technique (2/21, or 10%) tempers the acceptable radiographic outcomes.

This study aimed to determine if partial removal of the occipital condyle provides a significant increase in visibility and "angle of attack" for treating lesions with extension ventral to the brainstem in children using CT morphometric data. Morphometric analysis was performed in 199 children using CT scans. Angle of attack was measured for both the paracondylar and transcondylar far lateral approach. Statistical analysis was performed using paired or unpaired Student's t-tests (p

Surgical resection is the current standard of therapy for the treatment of arteriovenous malformation (AVM). Endovascular embolization is commonly used as an adjunct prior to surgical resection because it is believed to reduce the risk of intraoperative bleeding. Embolization has been associated with other complications including visual deficits, vessel perforation, and catheter adhesion. Catheter adhesion in which retained segments are contained within the embolization cast are not necessarily cause for concern, but retention of larger portions may confer an increased risk of thrombus formation. Such cases warrant the removal of the retained segments or the patient may suffer serious complications including death related to cerebrovascular events. In this case report, we describe a unique case of catheter adhesion in which the extension of the feeding catheter and the length of the introducer was left in its entirety down to the entry portion at the level of the groin and later retrieved in its entirety by craniotomy.

This study explores the usefulness of virtual simulation training for learning to place pedicle screws in the lumbar spine.Twenty-six senior medical students anonymously participated and were randomized into two groups (A = no simulation; B = simulation). Both groups were given 15 minutes to place two pedicle screws in a sawbones model. Students in Group A underwent traditional visual/verbal instruction whereas students in Group B underwent training on pedicle screw placement in the ImmersiveTouch simulator. The students in both groups then placed two pedicle screws each in a lumbar sawbones models that underwent triplanar thin slice computerized tomography and subsequent analysis based on coronal entry point, axial and sagittal deviations, length error, and pedicle breach. The average number of errors per screw was calculated for each group. Semi-parametric regression analysis for clustered data was used with generalized estimating equations accommodating a negative binomial distribution to determine any statistical difference of significance.A total of 52 pedicle screws were analyzed. The reduction in the average number of errors per screw after a single session of simulation training was 53.7% (P = 0.0067). The average number of errors per screw in the simulation group was 0.96 versus 2.08 in the non-simulation group. The simulation group outperformed the non-simulation group in all variables measured. The three most benefited measured variables were length error (86.7%), coronal error (71.4%), and pedicle breach (66.7%).Computer-based simulation appears to be a valuable teaching tool for non-experts in a highly technical procedural task such as pedicle screw placement that involves sequential learning, depth perception, and understanding triplanar anatomy.

BACKGROUND:The effort required to introduce simulation in neurosurgery academic programs and the benefits perceived by residents have not been systematically assessed.OBJECTIVE:To create a neurosurgery simulation curriculum encompassing basic and advanced skills, cadaveric dissection, cranial and sp

Object Isolated cervical canal stenosis at the level of the atlas (C-1) is a rare cause of cervical myelopathy in the pediatric population. It has been associated with several genetic disorders including spondyloepiphysial dysplasia congenita, Down syndrome, and Klippel-Feil syndrome. The purpose of this study is to highlight the authors' experience with 4 additional pediatric cases, review the literature, and report a new association of this disease with Williams syndrome. Methods The medical records and radiological imaging studies of 4 patients treated at Texas Children's Hospital for symptomatic hypoplasia of the atlas were retrospectively reviewed. Pertinent patient demographic data, clinical presentation, imaging findings, and outcomes after surgery were recorded. A thorough literature review was performed, allowing the authors to compare and contrast their 4 cases to surgical cases already published in the literature. Results There were 11 boys and 1 girl in the aggregate series. The average age of the patients was 7 years (range 13 months–14 years), and the duration of symptoms prior to presentation was 6 months (range 0–36 months). The mean sagittal diameter of the spinal canal at the level of the atlas measured from the posterior aspect of the dens to the anterior aspect of the arch of C-1 was 11.9 mm (range 8.3–16 mm) in the aggregate series. In 2 new pediatric patients with hypoplasia of the atlas the disease was associated with Williams syndrome, which has not been previously described. Patients in the aggregate series were followed for an average of 18 months (range 3–50 months). Laminectomy of C-1 provided neurological improvement in all patients who presented. Conclusions Isolated cervical spinal canal stenosis at the level of the atlas is a rare cause of cervical myelopathy. The authors hope that this report will prompt clinicians to consider it when searching for the origin of signs and symptoms of cervical myelopathy, especially in children.

The authors describe rare cases of congenital hypoplasia of the L-5 pedicles and the congenital absence of the left S-1 pedicle in 2 young girls, respectively, including the presentation, diagnosis, and treatment. Moreover, they review the literature on this clinical entity. The patients presented with intractable chronic low-back pain. Plain radiographs and 2D CT scanning revealed the presence of the aforementioned anomalies. Degenerative changes to adjacent level and contralateral facet joints were thought to be the result of overload and instability and seemed to have led to spondylolisthesis, micromotion at L-5 and S-1, and subsequent low-back pain. The pediatric patients were treated with posterior instrumented fusion with good functional outcomes at a minimum 3-month follow-up. To the best of the authors' knowledge, these are the first reports of intractable low-back pain and spondylolisthesis accompanied by hypoplastic-aplastic pedicles at the lumbosacral junction in children.

Aims: Lateral transtemporal approaches are useful for addressing lesions located ventral to the brainstem, especially when the pathologic diagnosis of the tumor dictates that a gross or near total resection improves outcomes. One approach, the presigmoid approach receives little attention in the pediatric population thus far. We sought to characterize morphometric changes, particularly the clival depth and the petroclival Cobb angle, that occur in the temporal bones of children and draw implications about doing a presigmoid approach in children. Settings and Design: This study was a retrospective study performed at John Sealy Hospital, a level-one trauma center that takes care of pediatric injuries as well. Subjects and Methods: We performed a morphometric analysis of noncontrast computed tomography head studies in 96 boys and 67 girls. Central clival depth and petroclival angle were obtained in the axial plane at the level of the internal auditory meatus using the method described by Abdel Aziz et al. Statistical Analysis Used: Descriptive statistics and Student's t-test to compare groups were calculated using Microsoft Excel. Results: We found no gender difference in mean central clival depth or petroclival angle (P = 0.98 and P = 0.61, respectively). However, when we broke our cohort by age into those younger than 9 years of age and those 10 years or older, we found the petroclival angle decreased by 6.2° which was statistically significant (P < 0.000000006). Conclusions: These findings suggest that a presigmoid retrolabyrinthine approach is useful for children 9 years of age and younger as the petroclival angle appears to decrease resulting in a shallower clival depression in these patients.

The authors present a unique case of a patient with communicating hydrocephalus and repeated ventriculoperitoneal shunt obstructions resulting from mucin-secreting enterogenous cell deposits at the cervicomedullary junction. Pathological examinations revealed that these cellular deposits lacked characteristic cystic architecture and the patient had no history of previous cyst with dissemination. Because of the repeated shunt obstructions and inability to surgically resect the lesion in its entirety, the authors elected radiation therapy to the cervicomedullary junction, encompassing the radiological abnormality. As of this writing, the patient has remained at neurological baseline and has not required further shunt revisions for obstruction.

We read the experience of Alurkar et al1 with balloon-expandable stents for treatment of intracranial atherosclerosis with interest. They have demonstrated a 30-day stroke rate of 5.64% (11/195 lesions) and total complication rate of 9.74% (19/195 lesions). We congratulate the authors’ success in accruing a large series with relatively low procedural morbidity. Nonetheless, we disagree that optimal medical therapy for patients with symptomatic …

Spinal arthrodesis was the first successful treatment for scoliosis, performed by Dr. Russell A. Hibbs in 1911 and later by Dr. Fred H. Albee for tuberculosis. In 1914, Dr. H.P.H. Galloway and Dr. Hibbs began using the method to treat neuromuscular scoliosis in patients with poliomyelitis. However, this treatment approach was plagued by loss of deformity correction over time and high pseudarthrosis rates. The turning point in the operative management of spinal deformities began in 1947 with Dr. Paul Randall Harrington when he started a decade-long process to revolutionize surgical treatment of spinal deformities culminating in the advent of the Harrington Rod, the first successful implantable spinal instrumentation system. During the epoch that he was in practice, Dr. Harrington's achievement influenced the technology and art of spine surgery for his contemporaries and the coming generations of spine surgeons. The purpose of this article is to review the life of Dr. Harrington, and how he has arguably come to be known as “Father of the Modern Treatment of Scoliosis.”

CT angiography (CTA) is increasingly being utilized in the initial diagnosis of subarachnoid hemorrhage. While active bleeding from an intracranial aneurysm has been demonstrated on conventional angiography, CT angiogram findings of active aneurysmal hemorrhage are not well described. We present a case of an actively bleeding anterior communicating artery aneurysm demonstrated by CT angiography. The initial CTA demonstrated the extravasation of contrast from the anterior communicating artery. A second CT scan less than 1 h later confirmed the ongoing hemorrhage, with extension of hemorrhage into the subarachnoid cisterns and the ventricular system. Recognition of active aneurismal hemorrhage by CTA may modify plan of treatment and follow-up imaging.

We report two unusual cases of a 17-month-old boy with a previously undiagnosed lumbar dermal sinus tract terminating in an intradural dermoid cyst and holocord edema or syrinx, presenting with paraparesis and sphincter dysfunction secondary to an intramedullary abscess and a 26-month-old boy with a previously undiagnosed lumbar dermal sinus tract terminating in an infected dermoid cyst and intramedullary abscess, presenting with recurrent episodes of meningitis and hydrocephalus. Pre-operative magnetic resonance imaging (MRI) studies in these patients were initially confused for an intramedullary spinal cord tumor; however, the presence of an associated dermal sinus tract made this diagnosis of neoplasm less likely. Total excision of the dermal sinus tract, debulking of the dermoid cyst and drainage of the intramedullary abscess through an L1-L5 osteoplastic laminoplasty and midline myelotomy, followed by long-term antibiotic therapy resulted in a good functional recovery. Post-operative MRI of the spine showed removal of the dermoid cyst, decreased inflammatory granulation tissue and resolution of the holocord edema or syrinx. We also performed a literature review to determine the cumulative experience of management of intramedullary abscess in this rare clinical setting.