Kyle A. Smith

A case series of dural venous sinus stenting in idiopathic intracranial hypertension: association of outcomes with optical coherence tomography.

Purpose/Aim: Pseudotumor cerebri or idiopathic intracranial hypertension (IIH) is characterized by increased intracranial pressure of unknown etiology. A subset of patients has shown benefit from endovascular dural venous sinus stenting (DVSS). We sought to identify a population of IIH patients who underwent DVSS to assess outcomes. Materials and Methods: A retrospective study was performed to identify IIH patients with dural sinus stenosis treated with DVSS. Outcome measures included dural sinus pressure gradients, peripapillary retinal nerve fiber layer (RNFL) thickness using optical coherence tomography and improvement in symptoms. Results: Seventeen patients underwent DVSS. Average pre- and post-intervention pressure gradients were 23.06 and 1.18 mmHg, respectively (p < 0.0001). Sixteen (94%) noted improvement in headache, fourteen (82%) had visual improvement and all (100%) patients had improved main symptom. Of 11 patients with optical coherence tomography, 8 showed decreased RNFL thickness and 3 remained stable; furthermore, these 11 patients had improved vision with improved papilledema in 8, lack of pre-existing papilledema in 2 and stable, mild edema in 1 patient. Conclusions: Our series of patients with dural sinus stenosis demonstrated improvement in vision and reduction in RNFL thickness. DVSS appears to be a useful treatment for IIH patients with dural sinus stenosis.

Spontaneous intracranial hypotension: Targeted or blind blood patch

The aim of this review is to determine the efficacy and optimal strategy for epidural blood patch placement in the treatment of spontaneous intracranial hypotension. We present a 37-year-old man who developed a 4 week duration postural headache without sustaining significant trauma. The diagnosis of spontaneous intracranial hypotension with associated subdural hygromas was confirmed with lumbar puncture and radiologic imaging. Spontaneous intracranial hypotension is generally due to cerebrospinal fluid leak from the thecal sac or nerve root sleeves, although the cause of leakage is unknown. In our patient, the site of leakage was identified at cervical C1-C2 level in the spine on myelography. Conservative management with repeated epidural blood patches was successful in symptom relief and complete resolution of cerebrospinal fluid leak and subdural hygromas. We reviewed the literature for efficacy of blood patches delivered directly to the site of leakage (targeted) or to the lumbar or thoracic spine away from the site of leakage or where the site cannot be determined (blind). No clear evidence exists on comparative efficacy due to paucity of randomized trials. However, epidural blood patches in general result in positive outcomes with overall efficacy near 90%. Some trials have suggested greater efficacy for targeted rather than blind epidural blood patches, but randomized studies and long-term prognosis remain to be evaluated.

Predicting Consistency of Meningioma by Magnetic Resonance Imaging.

Objective Meningioma consistency is important because it affects the difficulty of surgery. To predict preoperative consistency, several methods have been proposed; however, they lack objectivity and reproducibility. We propose a new method for prediction based on tumor to cerebellar peduncle T2-weighted imaging intensity (TCTI) ratios. Design The magnetic resonance (MR) images of 20 consecutive patients were evaluated preoperatively. An intraoperative consistency scale was applied to these lesions prospectively by the operating surgeon based on Cavitron Ultrasonic Surgical Aspirator (Valleylab, Boulder, Colorado, United States) intensity. Tumors were classified as A, very soft; B, soft/intermediate; or C, fibrous. Using T2-weighted MR sequence, the TCTI ratio was calculated. Tumor consistency grades and TCTI ratios were then correlated. Results Of the 20 tumors evaluated prospectively, 7 were classified as very soft, 9 as soft/intermediate, and 4 as fibrous. TCTI ratios for fibrous tumors were all ≤ 1; very soft tumors were ≥ 1.8, except for one outlier of 1.66; and soft/intermediate tumors were > 1 to < 1.8. Conclusion We propose a method using quantifiable region-of-interest TCTIs as a uniform and reproducible way to predict tumor consistency. The intraoperative consistency was graded in an objective and clinically significant way and could lead to more efficient tumor resection.

Intracerebral laser interstitial thermal therapy followed by tumor resection to minimize cerebral edema

OBJECTIVE Laser interstitial thermal therapy (LITT) is used in numerous neurosurgical applications including lesions that are difficult to resect. Its rising popularity can be attributed to its minimally invasive approach, improved accuracy with real-time MRI guidance and thermography, and enhanced control of the laser. One of its drawbacks is the possible development of significant edema, which contributes to extended hospital stays and often necessitates hyperosmolar or steroid therapy. Here, the authors discuss the use of minimally invasive craniotomy to resect tissue ablated with LITT in attempt to minimize cerebral edema. METHODS Five patients with glioblastoma multiforme prospectively underwent LITT followed by resection. The LITT was performed with the aid of an MR-compatible skull-mounted frame in the MRI suite. Ablated tumor was then resected via small craniotomy by using the NICO Myriad system or cavitron ultrasonic surgical aspirator. Postoperative management involved dexamethasone administration slowly tapered over several weeks. RESULTS The use of resection following LITT, as compared with open resection or LITT alone, did not extend the hospital stay except in 1 patient who required 3-day inpatient management of edema with a trapped ventricle. No new neurological deficits were encountered, although 1 patient developed seizures postoperatively. No increase in infection rates was identified. CONCLUSIONS Resection of ablated tumor is a viable option to reduce the incidence of neurological deficits due to edema following LITT. This approach appears to mitigate cerebral edema by increasing available volume for mass effect and reducing the tissue burden that may promote an inflammatory response.

Prediction of Consistency of Pituitary Adenomas by Magnetic Resonance Imaging

Objective Pituitary adenomas are typically soft. The prevalence of fibrous adenomas is ∼ 5 to 13%. Firm tumors are difficult to remove by curettage or suction. Predicting fibrous adenomas by magnetic resonance (MR) imaging is typically difficult and unreliable. We propose a new prediction method based on MR T2-sequence intensity. Methods The MRIs of 36 consecutive patients with nonsecreting macroadenomas were evaluated preoperatively by a blinded radiologist. Using an MR T2-weighted sequence, regions of interest were sampled from the adenoma and cerebellar peduncle, and the ratio was calculated. Intraoperatively, tumors were graded prospectively for their consistency by the operating surgeon. Results There were 28 soft and 6 fibrous tumors. Unpaired t test for these ratios was found to be statistically significant (p < 0.0240; 95% confidence interval, -0.8229 to -0.06207). Mean values for soft tumors were found to be 1.918 (standard error of the mean [SEM] = 0.08212); firm tumors, 1.475 (SEM = 0.1179). Soft tumors were associated with ratios > 1.5 (sensitivity 100%; specificity 66.7%); firm tumors were associated with ratios < 1.8 (sensitivity 100%; specificity 42.9%). Conclusion Fibrous adenomas are typically diagnosed intraoperatively. However, their resection can be technically challenging. Using T2 intensity ratios on routine preoperative MRI allows identification of these challenging cases. The surgeon can then be better prepared for the surgical resection.

Meningioma consistency prediction utilizing tumor to cerebellar peduncle intensity on T2-weighted magnetic resonance imaging sequences: TCTI ratio

OBJECTIVE Meningioma consistency, firmness or softness as it relates to resectability, affects the difficulty of surgery and, to some degree, the extent of resection. Preoperative knowledge of tumor consistency would affect preoperative planning and instrumentation. Several methods of prediction have been proposed, but the majority lack objectivity and reproducibility or generalizability to other surgeons. In a previous pilot study of 20 patients the authors proposed a new method of prediction based on tumor/cerebellar peduncle T2-weighted imaging intensity (TCTI) ratios in comparison with objective intraoperative findings. In the present study they sought validation of this method. METHODS Magnetic resonance images from 100 consecutive patients undergoing craniotomy for meningioma resection were evaluated preoperatively. During surgery a consistency grade was prospectively applied to lesions by the operating surgeon, as determined by suction and/or cavitron ultrasonic surgical aspirator (CUSA) intensity. Consistency grades were A, soft; B, intermediate; and C, fibrous. Using T2-weighted MRI sequences, TCTI ratios were calculated. Analysis of the TCTI ratios and intraoperative tumor consistency was completed with ANOVA and receiver operating characteristic curves. RESULTS Of the 100 tumors evaluated, 50 were classified as soft, 29 as intermediate, and 21 as firm. The median TCTI ratio for firm tumors was 0.88; for intermediate tumors, 1.5; and for soft tumors, 1.84. One-way ANOVA comparing TCTI ratios for these groups was statistically significant (p < 0.0001). A single cutoff TCTI value of 1.41 for soft versus firm tumors was found to be 81.9% sensitive and 84.8% specific. CONCLUSIONS The authors propose this T2-based method of tumor consistency prediction with correlation to objective intraoperative consistency. This method is quantifiable and reproducible, which expands its usability. Additionally, it places tumor consistency on a graded continuum in a clinically meaningful way that could affect preoperative surgical planning.

National Rates, Causes, Risk Factors, and Outcomes Associated With 30-Day and 90-Day Readmissions Following Degenerative Posterior Cervical Spine Surgery Utilizing the Nationwide Readmissions Database

BACKGROUND: Hospital readmissions have profound financial and clinical impacts. Analyses of 30‐day readmissions following spine surgery have been previously reported utilizing administrative databases. However, time periods outside the initial 30 days have not been well studied. Furthermore, these databases have limitations regarding coding and institutional crossover. OBJECTIVE: The authors sought to analyze 30‐day and 90‐day readmission rates and risk factors using the Nationwide Readmissions Database (NRD) in a retrospective cohort receiving elective, posterior cervical spine surgery for degenerative conditions. METHODS: NRD is a new source containing approximately 50% of US hospitalizations, with patient‐linkage numbers to longitudinally track patients. Patients 18 years of age or older were identified. Preoperative characteristics, demographics, and surgical characteristics were chosen for predictor variables. Thirty‐day and 90‐day readmission rates were calculated. Statistical analysis was completed using SPSS v.23 software via univariate and multivariate analyses. RESULTS: Between January and September 2013, a total of 29 990 patients were identified. Readmission rates for 30‐ and 90‐days were 5.4% and 10.0%, respectively. The most common reason for readmission during 30‐day and 90‐day periods was complications of surgical and/or medical care (31.0% vs 21.9%, respectively). The strongest risk factors for 30‐day readmission included wound dehiscence, weekend admission at index hospitalization, coagulopathy, and incidental durotomy. The strongest risk factors for 90‐day readmission included thromboembolic complications, postoperative hemorrhage, and comorbidities. CONCLUSION: Identification of predictors of readmission is important to allow for changes in perioperative management to potentially reduce readmissions and improve outcomes. Additionally, knowledge about readmission risk factors allows for preoperative counseling.

Neuroendoscopic treatment of symptomatic giant Virchow-Robin spaces.

Background: Virchow–Robin spaces (VRS) or perivascular spaces are interstitial cystic spaces surrounding the vasculature of brain parenchyma and course from the subarachnoid space. Small VRS (<2 mm) appear in all age groups, but can enlarge and be confused with other lesions like cystic neoplasms. These enlarged VRS are termed giant tumefactive perivascular spaces (GRPVS). Case Description: We present the case of a 50-year-old male who presents with right eye pain, blurred vision, headache, and gait imbalance. He was diagnosed with GRPVS and underwent an endoscopic third ventriculostomy and cyst fenestration. Postoperative imaging showed a decrease in size of the ventricular system with evidence of flow through the aqueduct and ventriculostomy. Brainstem VRS cysts decreased in size. Conclusion: Unlike the other small number of case reports, this patient is unique in his age of presentation and successful endoscopic method of treatment. The endoscopic approach provided great exposure and adequate access to the lesions. Clinically, symptoms improved, cyst size decreased, and need for permanent shunt placement was averted.

Subarachnoid Hemorrhage and Readmissions: National Rates, Causes, Risk Factors, and Outcomes in 16,001 Hospitalized Patients

INTRODUCTION The acute complications of aneurysmal subarachnoid hemorrhage (aSAH) often lead to readmissions, which are linked to hospital reimbursement. The national rates, causes, risk factors, and outcomes associated with 30-day and 90-day readmission after aSAH have not previously been reported. METHODS The Nationwide Readmissions Database was queried from January to September 2013 for all patients (age ≥18 years) with a diagnosis of aSAH. Data points included demographics, comorbidities, complications, and discharge outcomes. Causes and risk factors for 30-day and 90-day readmission were identified in univariate and multivariable analysis. RESULTS In 12,777 patients discharged alive after hospitalization for aSAH, 962 (7.5%) were readmitted within 30 days and 2153 (16.7%) within 90 days. Common causes of readmission included stroke, hydrocephalus, septicemia, and headache. At 30-day and 90-day readmission, 39.7% and 51.2% of patients with diagnosis of hydrocephalus underwent ventriculoperitoneal shunt placement, respectively. In multivariable analysis, cannabis use and diabetes were predictors of both 30-day and 90-day readmission and older patients were uniquely susceptible to 30-day readmissions. Risk factors for 90-day readmission included Medicare insurance, hypothyroidism, initial discharge to skilled nursing facility, and several index complications including bowel obstruction, gastrostomy, acute lung injury, and cerebral edema. Average cost and length of stay were calculated at 30-day (

Cervical Total Disc Replacement and Anterior Cervical Discectomy and Fusion: Reoperation Rates, Complications, and Hospital Resource Utilization in 72 688 Patients in the United States

16.647, 7.1 days) and 90-day readmission (