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Background: Rectus gyrus hematoma (RGH) is a localized intracerebral hemorrhage involving the most medial part of the orbital surface of the frontal lobe. It can be an imaging finding in the setting of a ruptured anterior communicating artery aneurysm; however, other differentials are rarely reported in the literature. In this paper, we opt to present for the 1st time an overview of RGH regarding its history, anatomical correlation, and related neuroimaging with particular emphasis on the potential differential diagnosis for underlying pathologies. Methods: A literature review was conducted in PubMed, Medline, and Google scholar databases to review the existing literature highlighting the history, pertinent anatomy, and clinical characteristics of RGH. Results: The literature review yielded papers targeting the RGH neither as a radiological sign nor as a surgical correlate to the cerebrovascular lesion. We used the available indirectly related articles to formulate an overview to serve the aim of this paper and to highlight the potential value of studying the RGH. Conclusion: The RGH may represent an overlooked radiological finding that has potential significance through its relation to a set of vascular lesions affecting the brain. Further studies into the topic are needed to expand the utility of this sign.

Background: Flow diverters are becoming one of the main endovascular procedures used to treat aneurysms. Flow diverter devices (FDDs) have multiple types approved for endovascular procedure use. Although their indications are not well described, they are usually used for large or giant, wide-necked, and recurrent aneurysms. Multiple FDDs can be deployed to treat giant aneurysms to ensure and accelerate aneurysm occlusion and mitigate complications. We report a case of endovascular treatment of an intracranial aneurysm using three silk FDDs complicated by a delayed migration of the stents along the parent artery, along with a literature review of the related cases. Methods: We conducted a PubMed Medline database search by the following combined formula of subjects headings: ((((((intracranial aneurysm[MeSH Terms]) AND (endovascular procedure[MeSH Terms])) OR (endovascular technique[MeSH Terms])) AND (endovascular[Title/Abstract]) AND (Flow diverter[Title/ Abstract])) OR (flow diversion[Title/Abstract])) OR (Pipeline[Title/Abstract])) AND (Multiple[Title/Abstract]). Results: The result was eight cases of endovascular treatment of intracranial aneurysms with multiple FDD. The male-to-female ratio in these cases was 5:3, and there is a wide age range from 22 months to 69 years old. The cases differed in the type and number of FDDs used, yet, they all had similar results with aneurysm occlusion and recovery of the patient with no observed complications. Conclusion: Tandem flow diverter deployment has technical challenges and complications such as complete obstruction can occur. Planning and learning from experience with those new technologies are the typical way to overcome such complications in the future.

Introduction The petroclival region is an integral part of the skull base. It can harbor different pathologies and provides access to the petroclival junction and cerebellopontine angle. We present the results of the morphometric analysis of the posterior fossa and a prediction model to enable skull base surgeons to choose an optimal surgical corridor considering patient's bony anatomy. Methods Ninety patients (14 to assess interobserver reliability) with temporal bone computed tomography were selected. Exclusion criteria included patients Results The average age was 49.5 years (55%) for males. The mean clival length and surface areas were 44.2 mm (standard deviation [SD] ± 4.1) and 8.1 cm2 (SD ± 1.3). The mean petrous apex and translabyrinthine corridors volumes were 2.2 cm3 (SD ± 0.6) and 10.1 cm3 (SD ± 3.7). The mean petroclival angle at the internal auditory canal (IAC) was 154.9 degrees (SD ± 9). The clival length correlated positively with clival surface area (rho = 0.6, p Conclusion The petroclival region is complex and with high variability of surgical significance. The use of preoperative measurements of the clival length and petroclival angle as part of surgical planning that could help the surgeon to choose an optimal surgical corridor by overcoming the anatomical variability elements.

To identify factors impacting long-term complications, reoperations, readmission rates, and health care utilization in patients with osteoporosis (OP) following lumbar fusions.We used International Classification of Disease, Ninth Revision, International Classification of Disease, Tenth Revision , and Current Procedural Terminology codes to extract data from MarketScan (2000-2016). Patients undergoing lumbar spine fusion were divided into 2 groups based on preoperative diagnosis: OP or non-OP. We used multivariable generalized linear regression models to analyze outcomes of interest (reoperation rates, readmissions, complications, health care utilization) at 1, 6, 12, and 24 months after discharge.MarketScan identified 116,749 patients who underwent lumbar fusion with ≥24 months of follow-up; 6% had OP. OP patients had a higher incidence of complications (14% vs. 9%); were less likely to be discharged home (77% vs. 86%, P0.05); had more new fusions or refusions at 6 months (2.9% vs. 2.1%), 12 months (5% vs. 3.8%), and 24 months (8.5% vs. 7.4%); incurred more outpatient services at 12 months (80 vs. 61) and 24 months (148 vs. 115); and incurred higher overall costs at 12 months ($22,932 vs. $17,017) and 24 months ($48,379 vs. $35,888). Elderly OP patients (65 years old) who underwent multilevel lumbar fusions had longer hospitalization, had higher complication rates, and incurred lower costs at 6, 12, and 24 months compared with young non-OP patients who underwent single-level lumbar fusion.Patients of all ages with OP had higher complication rates and required revision surgeries at 6, 12, and 24 months compared with non-OP patients. Elderly OP patients having multilevel lumbar fusions were twice as likely to have complications and lower health care utilization compared with younger non-OP patients who underwent single-level fusion.

Background: Accurate assessment and evaluation of health interventions are crucial to evidence-based care. The use of outcome measures in neurosurgery grew with the introduction of the Glasgow Coma Scale. Since then, various outcome measures have appeared, some of which are disease-specific and others more generally. This article aims to address the most widely used outcome measures in three major neurosurgery subspecialties, “vascular, traumatic, and oncologic,” focusing on the potential, advantages, and drawbacks of a unified approach to these outcome measures. Methods: A literature review search was conducted by using PubMed MEDLINE and Google scholar Databases. Data for the three most common outcome measures, The Modified Rankin Scale (mRS), The Glasgow Outcome Scale (GOS), and The Karnofsky Performance Scale (KPS), were extracted and analyzed. Results: The original objective of establishing a standardized, common language for the accurate categorization, quantification, and evaluation of patients’ outcomes has been eroded. The KPS, in particular, may provide a common ground for initiating a unified approach to outcome measures. With clinical testing and modification, it may offer a simple, internationally standardized approach to outcome measures in neurosurgery and elsewhere. Based on our analysis, Karnofsky’s Performance Scale may provide a basis of reaching a unified global outcome measure. Conclusion: Outcome measures in neurosurgery, including mRS, GOS, and KPS, are widely utilized assessment tools for patients’ outcomes in various neurosurgical specialties. A unified global measure may offer solutions with ease of use and application; however, there are limitations.

Background Idiopathic intracranial hypertension (IIH) is a common neurosurgical condition, and the exact pathophysiology remains elusive. Cerebral sinovenous stenosis (CSS) and the resultant decreased venous outflow have been labelled as a potential contributors to the pathophysiology of IIH. We describe the effect of cerebrospinal fluid (CSF) drainage on sinovenous pressure in a patient with IIH and a radiographic evidence of CSS. Case description A patient in their 40s with a diagnoses of IIH and imaging finding of focal stenosis of the distal left transverse sinus. To assess the nature of the stenosis, we performed venous sinus pressure monitoring with concurrent CSF drainage (5 ml at one minute intervals) through a lumbar drain with continuous mean sinovenous pressures recording. We observed a progressive decline in the pressure recording while draining CSF, after draining 40 ml of CSF, the final pressure gradient recording of the TS-SS trans-stenotic was (7 mm Hg from 27 mm Hg), mean SSS pressure (37 mm Hg from 60 mm Hg), and mean TS pressure (35 mm Hg from 56 mm Hg). The mean SS pressure remained relatively unperturbed. Conclusion Our findings indicate that the cerebral sinovenous pressure response to CSF removal generally conforms to a monophasic exponential decay model.

Introduction To compare the healthcare utilization in patients who presented with no pseudomeningocele (PSM) following vestibular schwannoma (VS) surgery (nd-PSM), PSM following VS surgery and required surgical repair (s-PSM) and those who presented with PSM and did not require surgical repair (ns-PSM). Methods MarketScan database was queried using the International Classification of Diseases, ninth and tenth revisions, and current procedural terminology four, from 2000 to 2018. We included patients

Background A significant proportion of transfemoral cerebral angiography complications are related to the access site, with no clear consensus concerning the optimal closure technique. In this study, we examined the usefulness of a shortened closure protocol for transfemoral diagnostic cerebral angiography. Methods We performed a retrospective review of patients who underwent transfemoral (4Fr sheath) diagnostic cerebral angiography procedures at our institution. We included patients > 18 years old who underwent the shortened closure protocol to achieve hemostasis at the access site. The shortened protocol entailed the use of nonocclusive manual compression for 15 min followed by 2 h of bed rest, with additional 10–15 min of compression for new hematoma. We collected and analyzed the patients’ demographics, use of antiplatelet and anticoagulation medications, sheath size, and others. Results The study cohort comprised 119 patients with a mean age was 54 years with (88%) females. Forty-one patients (34%) were on antiplatelet medications, with 12 (10%) on dual antiplatelet therapy (DAPT). Four patients (3%) (two on DAPT, one on Aspirin alone, and one was not on any antiplatelet medication) had access site hematoma that required additional compression. Subgroup analysis showed that within the DAPT, Aspirin alone, and no antiplatelet medications groups, (17%), (3%), and (1%) of patients developed access site hematoma, respectively. Conclusion This pilot study demonstrates that our closure protocol for transfemoral angiograms is safe and effective. There was a trend toward higher access-site complications in patients on DAPT. Further studies are required to expand on and validate our results.

Aneurysms of the distal anterior inferior cerebellar artery (AICA) are uncommon. They can present with subarachnoid hemorrhage (SAH), cerebellopontine angle syndrome, or a combination of the two. We describe the technique and nuances of microsurgical clipping of a ruptured distal AICA aneurysm using a retrosigmoid approach. After performing the craniotomy, the AICA was exposed in a distal to proximal fashion and the aneurysm and the proximal parent vessel were identified. After establishing proximal control, a clip was placed across the neck of the aneurysm to obliterate it while maintaining flow within the parent vessel. Finally, the flow within the parent vessel was confirmed and the final clip position was checked to ensure that it was not compressing any of the cranial nerves in the vicinity. The aneurysm was completely obliterated, and the parent vessel remained patent. Distal AICA aneurysms are rare and challenging to treat. The retrosigmoid approach is commonly used to treat these aneurysms. Careful planning, which includes studying the vascular anatomy and the aneurysm characteristics, and proficient execution of the procedure can increase the safety and improve outcomes of surgical clipping of these aneurysms.

A persistent stapedial artery originates from the petrous segment of the internal carotid artery due to failure of the regression of the embryonic stapedial artery. During embryologic development, the stapedial artery supplies the middle meningeal artery through the ventral pharyngeal artery. The presence of a persistent stapedial artery can result in direct communication between the basilar and middle meningeal arteries. We present a cerebral angiogram image of an adult patient that shows a right-sided persistent stapedial artery with communication between the right middle meningeal and basilar arteries. It is important to recognize such rare anatomic variants during endovascular interventions to avoid catastrophic complications such as nontarget embolization of the posterior circulation.

Background: Intramedullary cervical cystic lesions are typically attributed to tumors, infection, or trauma. Here, a patient newly presented with quadriparesis due to a chronic cervical intramedullary hematoma attributed to a cervical epidural steroid injection (CESI) performed 4 years earlier. Case Description: A 38-year-old patient had a CESI in 2014. Resulting in a transient quadriparesis attributed to an inadvertent intramedullary cord injection. Now, at age 42, she presented with a recurrent cervical myelopathy due to an MR-documented C3-C6 intramedullary cystic lesion that at surgery proved to be a chronic liquified hematoma rather than a syrinx. Conclusion: CESI can result in inadvertent intramedullary hemorrhages and spinal cord injuries. Here, a 42-year-old female presented with recurrent myelopathy due to a chronic intramedullary C3-C6 cervical hematoma attributed a prior intramedullary CESI injection performed 4 years previously.

Background Intracranial mycotic aneurysms are uncommon. They can occur due to extravascular extension or intravascular seeding of the vessel wall. They often result in subarachnoid hemorrhage with poor prognosis. We present a rare case of subarachnoid hemorrhage due to vertebral artery dissection with aproximal anterior inferior cerebellar artery (AICA)−posterior inferior cerebellar artery common trunk mycotic aneurysm after an episode of bacterial meningitis. Case Description A 66-year-old male with history of 2 episodes of culture-negative bacterial meningitis presented with a Hunt and Hess grade II, Fisher grade III subarachnoid hemorrhage. Catheter angiography showed a right-sided intracranial vertebral artery (VA) dissection and a fusiform AICA−posterior inferior cerebellar artery trunk aneurysm. The patient underwent an endovascular occlusion of the VA dissecting aneurysm followed by an occipital artery to AICA bypass with trapping of the aneurysm. The patient developed a left-sided numbness and weakness after the coiling procedure due to anteromedian medullary stroke (occlusion of the right anterior spinal artery). The patient's magnetic resonance imaging 3 weeks before the aneurysm rupture and during the second episode of meningitis showed new enhancement of both vertebral arteries with a mild reduction in the right VA caliber. At 6 weeks' follow-up the patient was off the ventilator but had a modified Rankin Scale score of 5. Conclusions Bacterial meningitis can lead to inflammatory injury of the intracranial vessels with resultant aneurysm formation. New enhancement of the vessel wall indicates that patients are at risk of developing mycotic aneurysms; therefore close observation with repeated vascular imaging is necessary.

Objective Intracranial meningiomas are the most common primary brain tumor. Treatment paradigms have evolved over time. There are limited number of population-based studies that examine this modern evolution. Here, we describe the trends of management of intracranial meningiomas using a national database. Methods The data were obtained from the National Cancer Database for the years 2004 to 2015, the collected variables included: patients' age, gender, insurance type, income, comorbidity score, the tumor size and grade, and treatment modality (observation, surgery, radiotherapy, or combination therapy). We performed statistical analyses to detect association between unique variables and outcomes. In addition, we performed mortality analyses for various treatment modalities. Results A total of 199,096 patients with a diagnosis of intracranial meningioma were included, the majority of patients were white females, mean age of 61 years, and half of the tumors were ≤ 3 cm. Observation was the most commonly used management modality followed by surgical resection, radiotherapy, and combination therapy. For the entire time period, there was an increased use of observation as a primary management method. Predictors of mortality included increased age, larger tumor size, higher tumor grade, treatment at a community hospital, and higher comorbidity scores. Conclusion Population-based studies of intracranial meningiomas are uncommon; our study is one of the few reports that examine the changes in the modern management paradigms of meningioma in the United States over time. Additionally, we shed light on the factors that affected survival of patients with this condition.

Objective/Background High-grade spondylolisthesis (HGS) is a complex clinical problem that poses significant challenges to the treating physician. Contentious debate has continued regarding the most optimal surgical approach for these patients. A variety of transsacral and transvertebral techniques have been described in reported studies. Methods and Results We present 2 cases of low back pain and radicular symptoms. Our 2 patients were a 35-year-old woman and a 26-year-old white woman. The computed tomography and magnetic resonance imaging scans revealed progressive HGS (grade III) that had not been relieved by conservative measures. Both patients underwent transsacral fixation using the reverse Bohlman technique (RBT) at L5-S1 and L4-L5 anterior lumbar interbody fusion combined with posterolateral fusion. At the 9- and 10-month follow-up visits, the patients reported minimal back pain with no radicular symptoms, and the imaging studies showed satisfactory fusion in both patients. Conclusions To the best of our knowledge, this is the first report to demonstrate the utility of the sacroiliac joint fusion cage using RBT in patients with HGS with successful clinical outcome. The RBT is safe, feasible, and effective in carefully selected patients.

OBJECTIVE Cranioplasty is a technically simple procedure, although one with potentially high rates of complications. The ideal timing of cranioplasty should minimize the risk of complications, but research investigating cranioplasty timing and risk of complications has generated diverse findings. Previous studies have included mixed populations of patients undergoing cranioplasty following decompression for traumatic, vascular, and other cerebral insults, making results challenging to interpret. The objective of the current study was to examine rates of complications associated with cranioplasty, specifically for patients with traumatic brain injury (TBI) receiving this procedure at the authors’ high-volume level 1 trauma center over a 25-year time period. METHODS A single-institution retrospective review was conducted of patients undergoing cranioplasty after decompression for trauma. Patients were identified and clinical and demographic variables obtained from 2 neurotrauma databases. Patients were categorized into 3 groups based on timing of cranioplasty: early (≤ 90 days after craniectomy), intermediate (91–180 days after craniectomy), and late (> 180 days after craniectomy). In addition, a subgroup analysis of complications in patients with TBI associated with ultra-early cranioplasty (< 42 days, or 6 weeks, after craniectomy) was performed. RESULTS Of 435 patients identified, 141 patients underwent early cranioplasty, 187 patients received intermediate cranioplasty, and 107 patients underwent late cranioplasty. A total of 54 patients underwent ultra-early cranioplasty. Among the total cohort, the mean rate of postoperative hydrocephalus was 2.8%, the rate of seizure was 4.6%, the rate of postoperative hematoma was 3.4%, and the rate of infection was 6.0%. The total complication rate for the entire population was 16.8%. There was no significant difference in complications between any of the 3 groups. No significant differences in postoperative complications were found comparing the ultra-early cranioplasty group with all other patients combined. CONCLUSIONS In this cohort of patients with TBI, early cranioplasty, including ultra-early procedures, was not associated with higher rates of complications. Early cranioplasty may confer benefits such as shorter or fewer hospitalizations, decreased financial burden, and overall improved recovery, and should be considered based on patient-specific factors.

Objective To review our experience with punctate midline myelotomy (PMM) for malignant and benign visceral pain with an emphasis on detailed side-effect profiles and efficacy. Methods Thirteen adults (5 men) underwent microsurgical transverse-crush PMM. Results Median follow-up for the benign pain group (n = 6) was 17.5 months (10–72) and for the malignant group (n = 7) was 8 months (0.5–31). Five of seven patients in the malignant pain group obtained excellent, lasting relief. Two had initial relief followed by worsening pain with disease progression. In the benign pain group, two patients with endodermal-origin pain (gastrointestinal tract, bladder) had complete, long-lasting relief. Three patients with mesodermal-origin pain (ureter) had excellent relief for 2–3 months, followed by recurrence in two and partial (40%) recurrence in the third. One man with pre-existing cervical myelopathy underwent PMM for benign testicular-region pain from which he had long-term relief but only transient relief of coexisting low-back and leg pain. There were no motor deficits in either group, and all patients remained ambulatory and continent. The most common side effect was transient numbness of the medial leg and foot. Two patients (both with pre-existing spinal pathology) reported persistent moderate reduction of bowel, bladder, and sexual sensation. Conclusions PMM offers substantial pain relief for carefully selected patients with intractable visceral pain. Relief from primarily endoderm-derived structures was most complete and long-lasting. Relief from mesoderm-derived structures was typically transient or incomplete. There was essentially no relief from pain of ectoderm-derived structures. Detailed preoperative counseling is important, especially for those with pre-existing neurologic deficits.

Micro-neurosurgery and since it emerged in the 1960s has been performed by a single neurosurgeon. More recently, the concept of the two-surgeon, four-hand technique has been introduced into the fie...

Background: Aneurysms of the cortical branches of the middle cerebral artery (MCA) are rare. They usually are secondary to traumatic or infectious etiologies and are rarely idiopathic. The specific characteristics of idiopathic aneurysms in such location are not well defined in the literature. The authors report a rare case of a ruptured giant idiopathic cortical MCA aneurysm with review of the available literature on this clinical entity. Case Description: A 24-year-old female presented with headache, disturbed level of consciousness, and right-sided weakness. Imaging studies showed a left frontoparietal intracerebral hematoma and a giant saccular aneurysm in the posterior parietal cortical branch of the MCA. The patient had no history of head trauma or active infection; therefore, the aneurysm was considered idiopathic. A microsurgical clipping of the aneurysm with evacuation of the hematoma was performed. There were no surgical complications, and the patient achieved a good outcome modified Rankin Scale of 1 with no neurological deficits. Conclusion: Idiopathic aneurysms of the cortical branches of the MCA are rare, and usually present with intraparenchymal hemorrhage due to rupture. There is no clear consensus regarding the optimal management strategy. This case shows that timely management can lead to good outcomes.

Introduction The transcribriform and transclival corridors are endoscopic endonasal approaches used to treat pathologies of the skull base. We present a predictive model that uses the clival length and ethmoidal width to predict the size and surgical freedom (SF) of these corridors. Methods Adult facial computed tomography scans were reviewed. Exclusion criteria included patients Results A total of 103 patients were included with an average age of 44.9 years and 47% males. Females had a smaller clival surface area (8 vs. 9.2 cm2, p = 0.001). For transclival corridor, clival length correlated positively with SF in the sagittal plane (rho = 0.44, p Conclusion A significant variability of the bony anatomy of the anterior and central skull base was found. The use of clival length and ethmoidal width as part of preoperative surgical planning might help to overcome the anatomical variability which could affect the adequacy of surgical corridors.