The Inter-Mammary Sticky Roll: A Novel Technique for Securing a Doppler Ultrasonic Probe to the Precordium for Venous Air Embolism Detection.

Venous air embolism is a devastating and potentially life-threatening complication that can occur during neurosurgical procedures. We report the development and use of the "inter-mammary sticky roll," a technique to reliably secure a precordial Doppler ultrasonic probe to the chest wall during neurosurgical cases that require lateral decubitus positioning. We have found that this noninvasive technique is safe, and effectively facilitates a constant Doppler signal with no additional risk to the patient

Updates in Mechanical Thrombectomy

Strokes are a major source of morbidity and mortality worldwide. The long-standing gold standard in stroke therapy, intravenous administration of tissue plasminogen activator (tPA), is limited by strict timing parameters and modest efficacy in large strokes caused by thrombi in the proximal cerebral vasculature. Multiple recent randomized controlled trials have demonstrated the efficacy of mechanical thrombectomy for patients with large vessel occlusions (LVOs). Recent clinical guidelines have been updated to include mechanical thrombectomy as a standard of care in properly selected stroke patients, with ongoing and future studies working to refine the optimal clinical and technical variables of this approach

Surgical Management of Intracerebral Hemorrhage

Intracerebral hemorrhage (ICH), defined as bleeding within the brain parenchyma, remains a challenging and controversial neurosurgical entity to treat. ICH has a broad range of etiology—stemming from complications associated with traumatic head injury to complications of hemorrhagic stroke. The role of medical management lies in optimizing blood pressure and intracerebral pressure, preventing secondary injury from complications of the hematoma such as seizures, and correcting coagulopathy. Given the mass effect of a hematoma and the possibility of expansion, surgical interventions attempt to evacuate the clot to restore normal intracerebral pressure and prevent worsening neurologic injury. This chapter reviews the recent controversy associated with surgical evacuation of intracerebral hemorrhage placing particular emphasis on the size and location of the hemorrhage and the methods used to evacuate the expanding ICH. Moreover, this chapter reviews considerations and therapeutic goals of the preoperative and postoperative window to minimize complications and optimize patient care

Treatment of pediatric intracranial aneurysms: institutional case series and systematic literature review.

INTRODUCTION: Pediatric intracranial aneurysms (IAs) are rare and have distinct clinical profiles compared to adult IAs. They differ in location, size, morphology, presentation, and treatment strategies. We present our experience with pediatric IAs over an 18-year period using surgical and endovascular treatments and review the literature to identify commonalities in epidemiology, treatment, and outcomes. METHODS: We identified all patients < 20 years old who underwent treatment for IAs at our institution between 2005 and 2020. Medical records and imaging were examined for demographic, clinical, and operative data. A systematic review was performed to identify studies reporting primary outcomes of surgical and endovascular treatment of pediatric IAs. Demographic information, aneurysm characteristics, treatment strategies, and outcomes were collected. RESULTS: Thirty-three patients underwent treatment for 37 aneurysms over 18 years. The mean age was 11.4 years, ranging from one month to 19 years. There were 21 males (63.6%) and 12 females (36.4%), yielding a male: female ratio of 1.75:1. Twenty-six (70.3%) aneurysms arose from the anterior circulation and 11 (29.7%) arose from the posterior circulation. Aneurysmal rupture occurred in 19 (57.5%) patients, of which 8 (24.2%) were categorized as Hunt-Hess grades IV or V. Aneurysm recurrence or rerupture occurred in five (15.2%) patients, and 5 patients (15.2%) died due to sequelae of their aneurysms. Twenty-one patients (63.6%) had a good outcome (modified Rankin Scale score 0-2) on last follow up. The systematic literature review yielded 48 studies which included 1,482 total aneurysms (611 with endovascular treatment; 656 treated surgically; 215 treated conservatively). Mean aneurysm recurrence rates in the literature were 12.7% and 3.9% for endovascular and surgical treatment, respectively. CONCLUSIONS: Our study provides data on the natural history and longitudinal outcomes for children treated for IAs at a single institution, in addition to our treatment strategies for various aneurysmal morphologies. Despite the high proportion of patients presenting with rupture, good functional outcomes can be achieved for most patients

Toward standardized brain tumor tissue processing protocols in neuro-oncology: a perspective for gliomas and beyond.

Implementation of standardized protocols in neurooncology during the surgical resection of brain tumors is needed to advance the clinical treatment paradigms that use tissue for diagnosis, prognosis, bio-banking, and treatment. Currently recommendations on intraoperative tissue procurement only exist for diffuse gliomas but management of other brain tumor subtypes can also benefit from these protocols. Fresh tissue from surgical resection can now be used for intraoperative diagnostics and functional precision medicine assays. A multidisciplinary neuro-oncology perspective is critical to develop the best avenues for practical standardization. This perspective from the multidisciplinary Oncology Tissue Advisory Board (OTAB) discusses current advances, future directions, and the imperative of adopting standardized protocols for diverse brain tumor entities. There is a growing need for consistent operating room practices to enhance patient care, streamline research efforts, and optimize outcomes

Radiographic and Clinical Outcomes With Particle or Liquid Embolic Agents for Middle Meningeal Artery Embolization of Nonacute Subdural Hematomas

BACKGROUND: Middle meningeal artery (MMA) embolization is an apparently efficacious minimally invasive treatment for nonacute subdural hematomas (NASHs), but how different embolisates affect outcomes remains unclear. Our objective was to compare radiographic and clinical outcomes after particle or liquid MMA embolization. METHODS: Patients who had MMA embolization for NASH were retrospectively identified from a multi-institution database. The primary radiographic and clinical outcomes-50% NASH thickness reduction and need for surgical retreatment within 90 days, respectively-were compared for liquid and particle embolizations in patients treated 1) without surgical intervention (upfront), 2) after recurrence, or 3) with concomitant surgery (prophylactic). RESULTS: The upfront, recurrent, and prophylactic subgroups included 133, 59, and 16 patients, respectively. The primary radiographic outcome was observed in 61.8%, 61%, and 72.7% of particle-embolized patients and 61.3%, 55.6%, and 20% of liquid-embolized patients, respectively (p = 0.457, 0.819, 0.755). Hazard ratios comparing time to reach radiographic outcome in the particle and liquid groups or upfront, recurrent, andprophylactic timing were 1.31 (95% CI 0.78-2.18; p = 0.310), 1.09 (95% CI 0.52-2.27; p = 0.822), and 1.5 (95% CI 0.14-16.54; p = 0.74), respectively. The primary clinical outcome occurred in 8.0%, 2.4%, and 0% of patients who underwent particle embolization in the upfront, recurrent, and prophylactic groups, respectively, compared with 0%, 5.6%, and 0% who underwent liquid embolization (p = 0.197, 0.521, 1.00). CONCLUSIONS: MMA embolization with particle and liquid embolisates appears to be equally effective in treatment of NASHs as determined by the percentage who reach, and the time to reach, 50% NASH thickness reduction and the incidence of surgical reintervention within 90 days

Medical management of ankylosing spondylitis

In the following literature review the authors consider the available evidence for the medical management of patients with ankylosing spondylitis (AS), and they critically assess current treatment guidelines. Medical therapy for axial disease in AS emphasizes improvement in patients' pain and overall function. First-line treatments include individualized physical therapy and nonsteroidal antiinflammatory drugs (NSAIDs) in conjunction with gastroprotective therapy. After an adequate trial of therapy with two NSAIDs exceeding 3 months or limited by medication toxicity, the patient may undergo tumor necrosis factor-alpha blockade therapy. Response should occur within 6-12 weeks, and patients must undergo tuberculosis screening. Evidence does not currently support the use of disease modifying antirheumatic drugs, corticosteroids, or radiotherapy in AS

Neurosurgery and quantum dots: Part I – State of the art

This article represents the first of a 2-part exploration of quantum dots (Qdots) and their application to neurological surgery. Spanning from materials science to immunology, this initial review traces the marriage of imaging physics to biochemical specificity. Qdot science now stands poised to dramatically advance the diagnosis and therapy of neurosurgical conditions. Qdot research efforts currently involve several disciplines; this comprehensive review therefore considers multiple fields of inquiry. This first installment discusses 1) Qdot physical properties, 2) established biological and in vivo properties, 3) magnetic resonance imaging applications, and ( 4) existing cardiovascular and oncologic research. Finally, this review establishes the existing bounds of Qdot possibilities. The second concept article details future endovascular diagnostic and therapeutic methods derived from these seminal advances