Andrew S. Little

Ventriculoperitoneal shunting after aneurysmal subarachnoid hemorrhage: Analysis of the indications, complications, and outcome with a focus on patients with borderline ventriculomegaly - Commentary

OBJECTIVEThe goals of this study were to investigate the risk factors, indications, complications, and outcome for patients with ventriculoperitoneal shunts (VPSs) after subarachnoid hemorrhage and to define a subgroup eligible for future prospective studies designed to clarify indications for placement of a VPS. METHODSClinical characteristics of 236 prospectively evaluated patients with subarachnoid hemorrhage and 6 months of follow-up were analyzed. Hydrocephalus was estimated by the relative bicaudate index (RBCI) measured on computed tomographic scans at the time of shunting. Patients were divided into three groups by ventricle size: Group 1 included 121 patients with small ventricles (RBCI <1.0), Group 2 included 88 patients with borderline ventricle size (RBCI 1.0–1.4), and Group 3 included 27 patients with markedly enlarged ventricles (RBCI >1.4). RESULTSInitially, 86 patients (36%) underwent ventriculoperitoneal shunting: 19 in Group 1 (16%), 43 in Group 2 (49%), and 24 in Group 3 (90%). Indications for placement of a VPS, risk factors, and outcome differed markedly by group. Four patients (3% of those not initially shunted) developed delayed hydrocephalus requiring a VPS, including one in Group 2 (2%). The 6-month shunt complication rate was 13%. Evaluation of patients in Group 2 indicated that functional status was an important factor in selecting candidates for shunting, and that patients receiving shunts and shunt-free patients demonstrated improvement in functional status during follow-up. CONCLUSIONAlthough we currently use a proactive shunting paradigm for posthemorrhagic hydrocephalus, this report demonstrates that a conservative approach to patients with borderline ventricle size (i.e., RBCI of 1.0–1.4) and normal intracranial pressure should be evaluated in a prospective randomized trial.

The management of completely resected childhood intracranial ependymoma: the argument for observation only

IntroductionThe management of children with completely resected intracranial ependymomas is controversial. We favor deferring adjuvant radiotherapy in low-risk patients, whereas others recommend radiotherapy.ReviewThis article reviews the available evidence for and against deferring radiotherapy in children with low-risk completely resected childhood ependymomas.

Short-duration, single-agent antibiotic prophylaxis for meningitis in trans-sphenoidal surgery

Perioperative bacterial meningitis after trans-sphenoidal surgery for pituitary and parasellar lesions is an uncommon but serious complication. Little evidence guides the choice of chemoprophylaxis in this setting. To begin to address this deficiency, we investigated the incidence of perioperative meningitis in 442 patients who underwent trans-sphenoidal surgery and received a short chemoprophylaxis regimen with a single agent and did not require lumbar drainage. In 2005 we instituted a standardized antibiotic prophylaxis protocol for trans-sphenoidal surgery that utilized intravenous cefuroxime, a second-generation cephalosporin with broad coverage and excellent spinal fluid penetration, administered 30xa0min before surgery and 8xa0h later. The primary endpoint was the incidence of perioperative (within 30xa0days of surgery) bacterial meningitis. Data from The Barrow Pituitary Outcomes Project, a prospectively maintained patient research database, were supplemented with review of medical records and hospital discharge codes. There were no cases of perioperative meningitis. Three patients developed delayed meningitis associated with persistent or recurrent spinal fluid leakage 2–8xa0months after surgery. Perioperatively, seven patients received additional antibiotics for urinary tract infections. A single-agent, short-duration chemoprophylaxis regimen for trans-sphenoidal surgery is effective at preventing perioperative meningitis in patients who do not require lumbar drainage after surgery. The results of this regimen compare favorably to historical rates achieved with longer regimens that use two antibiotics. Future studies will investigate the role prophylactic antibiotics play in nasal mucosa healing and sinusitis.

Supraorbital Eyebrow Approach

The supraorbital eyebrow craniotomy is an anterolateral approach that allows the surgeon to address diverse pathology of the anterior cranial fossa, parasellar region, proximal sylvian fissure, ipsilateral circle of Willis, basal frontal lobe, and ventral brainstem. When supplemented with intracranial endoscopy, lesions of the lateral cavernous sinus, pituitary fossa, contralateral circle of Willis, and ipsilateral retroorbital space may be addressed. The goals of the approach are to treat neurosurgical lesions using a less-invasive technique, limit brain retraction and tissue trauma by exploiting anatomic corridors, offer comparable safety and efficacy relative to standard approaches, and yield a good cosmetic result.

Two Years Since the BRAIN Initiative: Update on Current Scientific and Technological Neuroscience Advancements

On April 2, 2013, President Obama announced the commencement of the BRAIN (Brain Research through Advancing Innovative Neurotechnologies) Initiative, as part of a presidential focus on further understanding the human brain . Many neurosciences view this as a long-awaited relief, as funding rates for research grants reached an all-time nadir. The focus of the initiative was aimed at accelerating both the development and application of technology in the field of neuroscience, with an ultimate goal of providing new methods to diagnose, treat, and prevent neurologic disorders. The charge of the BRAIN Initiative, as summarized by National Institutes of Health (NIH) Director Francis Collins, M.D., Ph.D., is “to accelerate the development and application of innovative technologies to construct a dynamic picture of brain function that integrates neuronal and circuit activity over time and space .” One of the most substantial changes has been the announcement of dozens of leading technological firms, academic institutions, scientists, and other key contributors to the field of neuroscience, who have made commitments to advancing the initiative, with a 12-year research strategy for NIH to achieve the goals of the BRAIN Initiative . The gaps in knowledge that will be the target of the BRAIN Initiative include: “forming a comprehensive, rigorous inventory of different brain cell types, developing the technology to map circuits of the brain, improving methods for large-scale mapping of neural activity, developing and applying interventional tools that can change neural circuit dynamics to link brain activity to behavior, identifying new tools to understand the biological basis of mental processes, and finally discover how dynamic patterns of neural activity are transformed into cognition, emotion, perception and action in health and disease .” Two years since the launch of the BRAIN Initiative, there has been some early progress in the development of novel technologies. Published in the May 2015 issue of Neuron, scientists have described a new method to turn behaviors both on and off in rodents. Using a technique known as DREADDs (designer receptors exclusively activated by designer drugs), Bryan Roth et al. were able to control neuronal circuitry and behavior in rodents , selectively turning them both on and off. This is in contrast to the field of optogenetics, which is a bulky, labor-intensive technique that allows scientists to label neurons with a light-sensitive protein (e.g., channelrhodopsin-2, then use pulses of light to turn genes on and off) . They developed a new DREADD (Designer Receptors Exclusively Activated by Designer Drugs) using the kopioid receptor (KOR), which is activated by the inert ligand SALB (salvinorin B), then expressed KORD in several neuronal contexts (including cells in the substantia nigra [SN], ventral tegmental area [VTA], arcuate nucleus [ARC], and paraventricular hypothalamus [PVH]) to selectively modify distinct neuronal populations and their respective circuits. By silencing via KORD of VTA/SN neurons, they were able to

Patient out-of-pocket spending in cranial neurosurgery: single-institution analysis of 6569 consecutive cases and literature review

OBJECTIVE With drastic changes to the health insurance market, patient cost sharing has significantly increased in recent years. However, the patient financial burden, or out-of-pocket (OOP) costs, for surgical procedures is poorly understood. The goal of this study was to analyze patient OOP spending in cranial neurosurgery and identify drivers of OOP spending growth. METHODS For 6569 consecutive patients who underwent cranial neurosurgery from 2013 to 2016 at the authors institution, the authors created univariate and multivariate mixed-effects models to investigate the effect of patient demographic and clinical factors on patient OOP spending. The authors examined OOP payments stratified into 10 subsets of case categories and created a generalized linear model to study the growth of OOP spending over time. RESULTS In the multivariate model, case categories (craniotomy for pain, tumor, and vascular lesions), commercial insurance, and out-of-network plans were significant predictors of higher OOP payments for patients (all p < 0.05). Patient spending varied substantially across procedure types, with patients undergoing craniotomy for pain (

Cost Transparency in Neurosurgery: A Single-Institution Analysis of Patient Out-of-Pocket Spending in 13 673 Consecutive Neurosurgery Cases

1151 ±

The Minimal Clinically Important Difference of the Anterior Skull Base Nasal Inventory-12

209) having the highest mean OOP payments. On average, commercially insured patients spent nearly twice as much in OOP payments as the overall population. From 2013 to 2016, the mean patient OOP spending increased 17%, from

The pterygoclival ligament: a novel landmark for localization of the internal carotid artery during the endoscopic endonasal approach

598 to

Targeting the Cohesive Cluster Phenotype in Chordoma via β1 Integrin Increases Ionizing Radiation Efficacy

698 per patient encounter. Commercially insured patients experienced more significant growth in OOP spending, with a cumulative rate of growth of 42% (