Initial Single Surgeon Evaluation Comparing A Prospective, Multicenter Initial Evaluation of the C-Arm Fluoroscopy with the Cirq Robotic Assistance Device for Instrumentation of the Thoracolumbar Spine

Objective: To compare our experience with pedicle screw insertion of the thoracolumbar spine utilizing the Cirq robot assistance device compared with traditional paradigm using fluoroscopy. Methods: We prospectively collected data of patients undergoing pedicle screw instrumentation in the thoracolumbar spine performed by a single surgeon at three different centers. One center took delivery of the Cirq robotic assistance device. Remaining two centers used C-arm fluoroscopy. Demographic information, diagnosis, total OR time, intraoperative complications, unexpected return to the operating room, and hospital readmissions within ninety days was compared between the two cohorts. Results: A total of 66 screws were placed during the study period. Forty percent were placed using the Cirq. Two thirds the patients had traumatic diagnoses with remaining degenerative spine disease. There were no misplaced pedicle screws in either group. While total OR time was longer in the Cirq cohort by 123 minutes (p=0.04), actual procedural time was not statistically different (p=0.11). Nonetheless there were also more hospital readmissions in the Cirq cohort compared with the C arm group (p=0.04). Conclusions: Thoracolumbar screws inserted using C-Arm fluoroscopy utilize less total operating room time with similar accuracy compared with the Cirq robotic assistance device. Further studies are warranted

Isolated Central Nervous System Metastasis From Neuroendocrine Carcinoma of the Cervix Without Pulmonary Metastasis

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

Intradural Extramedullary Primary Central Nervous System Melanoma of the Craniovertebral Junction during Pregnancy: Observations and Outcomes

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

Diagnosing a rare thoracic intramedullary spinal dermoid cyst using DWI with ADC mapping: Case report

Introduction Dermoid cysts are rare lesions generally associated with embryological errors that occur during neural tube closure. Intramedullary lesions are extremely rare, especially within the upper thoracic spinal cord. Case presentation We report a case of a 19-year-old male who had an intramedullary thoracic dermoid cyst presenting with progressive ataxia, lower limb weakness, and hyperreflexia. MRI demonstrated a 1.2 × 1.8-cm intramedullary thoracic dermoid cyst causing significant spinal cord compression, which was successfully removed via full resection. The patient had an uncomplicated postoperative course, with improvement in preoperative deficits. Discussion This is a unique case documenting a thoracic spinal cord intramedullary dermoid cyst not associated with trauma or congenital abnormality of the spinal cord. Conclusion We highlight the importance of future inclusion of diffusion-weighted magnetic resonance (MR) imaging (DWI) with apparent diffusion coefficient (ADC), an imaging modality that detects differences in cellularity of spinal cord lesions, for earlier diagnosis of dermoid cyst

Primary Middle Meningeal Artery Embolization for a Chronic Subdural Hematoma After Non-Accidental Trauma in a Child: A Case Report

Chronic subdural hematoma in children can be pathognomonic of abusive head trauma. Treatment options for these range from observation to surgical evacuation depending on clinical circumstance and presenting features, which can include mental status changes, headaches, focal neurologic deficits, or asymptomatic presentation. Standalone endovascular treatments represent an area of growing interest in the adult population as an effective treatment modality. However, embolization as a singular treatment approach has not been reported in the pediatric population. We report the first case of stand-alone middle meningeal artery (MMA) embolization of a chronic subdural hematoma as a sequela of abusive head trauma in a two-year-old child, resulting in complete resolution on non-contrast CT head at six months post embolization

Frequency of ICU Specific Interventions After Middle Meningeal Artery

Background: Middle meningeal artery embolization (MMAE) is increasingly performed for the treatment of chronic subdural hematomas. Some authors have described managing minimally symptomatic patients with MMAE in the outpatient setting. Our practice, however, has been to routinely admit patients after MMAE to the neuro-intensive care setting. Objective of this research is to analyze the frequency of ICU level interventions after MMAE in the neuro-intensive care unit. Methods: A consecutive series of MMA embolizations for cSDH were retrospectively reviewed from 2020 to 2022 at Valley Baptist Medical Center in Harlingen, TX, USA. Frequency of ICU specific interventions such as need for post procedural mechanical ventilation, need for intravenous vasopressor or antihypertensive medications was recorded. Results: A total of 50 MMA embolizations were performed during the study period. The average age of patients included in the study was 63 years old +/- 16 years with 30% being female. 34% patients did not receive any sort of ICU level intervention at all. Among the remaining who did, 32% required mechanical ventilation post procedurally. 14% needed a vasopressor and 48% required intravenous antihypertensives to maintain systolic blood pressure within goal parameters. Conclusions: 34% of patients who underwent MMAE did not require any ICU level interventions afterwards. The most common reason for an ICU intervention after MMAE was for correction of blood pressure to maintain within specified goal. Further investigation is warranted but it suggests that liberalizing blood pressure parameters could reduce the need for ICU utilization after MMAE

An artificial intelligence (AI)-based approach to clinical trial recruitment: The impact of Viz RECRUIT on enrollment in the EMBOLISE trial

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). Viz RECRUIT SDH is an artificial intelligence (AI)-based software platform that can automatically detect SDH in noncontrast computed tomography (NCHCT) images and report the volume, maximum thickness, and midline shift. We hypothesized that the mobile recruitment platform would aid enrollment and coordinate communication and image sharing among the entire research team. Materials and methods Patient enrollment in EMBOLISE prior to and after implementation of Viz RECRUIT SDH at a large comprehensive stroke center was compared along with the performance of the software platform. The EMBOLISE trial was activated on May 5, 2021, and Viz RECRUIT SDH was activated on October 6, 2021. The pre-AI cohort consisted of all patients from EMBOLISE to AI activation (153 days), and the post-AI cohort consisted of all patients from AI activation until August 18, 2022 (316 days). All alerts for suspected SDH candidates were manually reviewed to determine the positive predictive value (PPV) of the algorithm. Results Prior to AI-software implementation, there were 5 patients enrolled (0.99 patients/month) and one screen failure. After the implementation of the software, enrollment increased by 36% to 1.35 patients/month (14 total enrolled), and there were no screen failures. Over the entire post-AI period, a total of 6244 NCHCTs were processed by the system with 207 total SDH detections (3% prevalence). 35% of all alerts for suspected SDH were viewed within 10 min, and 50% were viewed within an hour. The PPV of the algorithm was 81.4 (CI [75.3, 86.7]). Conclusion The implementation of an AI-based software for the automatic screening of SDH patients increased the enrollment rate in the EMBOLISE trial, and the software performed well in a real-world, clinical trial setting

Thrombectomy for Large‐Vessel Occlusion With Pretreatment Intracranial Hemorrhage

Background Many patients treated with endovascular thrombectomy (EVT) in clinical practice would not have qualified for inclusion in the initial clinical trials demonstrating benefit for EVT, yet likely will benefit from reperfusion. One such subset for which data are sparse is patients with emergent large‐vessel occlusion and concomitant intracranial hemorrhage (ICH). The objective of this report is to document patients who underwent thrombectomy for large‐vessel occlusion in the presence of concomitant ICH and evaluate their clinical characteristics and outcomes. Methods We retrospectively reviewed prospectively collected patient records at 4 comprehensive stroke centers from 2012 to 2019. Patients were identified who had pre‐EVT ICH. Data collected included baseline patient demographics and laboratory values, stroke characteristics, ICH radiographic variables, antiplatelet/anticoagulant/thrombolytic medication use, and procedural factors. The primary safety outcome was any worsening of ICH on neuroimaging obtained 24 hours after EVT. Results Eight patients were identified who underwent thrombectomy with concomitant ICH. The mean age was 71.9 years (range, 37–90). Median National Institutes of Health Stroke Scale score was 25 (interquartile range, 16.5–28.8), and 5 (63%) received tissue plasminogen activator. All patients underwent EVT and had mTICI2B or greater reperfusion. In 7 patients (88%), the initial ICH remained stable on postprocedure imaging. In 1 patient who received intravenous antiplatelet agents during thrombectomy, the hemorrhagic transformation was radiographically increased but without clinical correlate or mass effect. Conclusions In a multi‐institution evaluation of 8 patients with ICH at the time of thrombectomy, 1 patient had radiographic worsening of hemorrhage, and no patient experienced clinical worsening related to hemorrhage progression. These findings suggest that thrombectomy may be safe in this population

Abstract Number ‐ 247: Multimodal imaging approach for the diagnosis of (ICAD): basic principles, current and future perspectives

Introduction Symptomatic intracranial atherosclerotic disease is among the most common causes of acute ischemic stroke. The imaging tools utilized for the diagnostic of ICAD have significantly evolved over the past few decades. This paper is a 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

Abstract Number ‐ 101: Blood Pressure Interventions Are Most Common Reason for ICU Admission After MMA Embolization

Introduction Middle meningeal artery embolization (MMAE) is a minimally invasive technique that is increasingly performed for the treatment of chronic subdural hematomas. In comparison to prior surgical interventions, which often resulted in complications such as insufficient drainage or recurrence of rebleeding, MMAE has greatly reduced the need for multiple inpatient hospitalizations. Some authors have described managing minimally symptomatic patients with MMAE in the outpatient setting. Our practice, however, has been routinely admitting patients to the neuro‐intensive care setting after MMAE. The objective of this research is to analyze the frequency of ICU level interventions that were administered to patients after MMAE in the neuro‐intensive care unit in order to gain a better understanding of postoperative management and assess the potential for future management in the outpatient setting. Methods A consecutive series of MMA embolizations for cSDH were retrospectively reviewed from 2020 to 2022 at Valley Baptist Medical Center in Harlingen, TX, USA. Frequency of ICU specific interventions such as need for post procedural mechanical ventilation, need for intravenous vasopressor or antihypertensive medications was recorded. Additional data collected included patient clinical presentations, indications for treatment, additional neurosurgical intervention, length of ICU stay, and blood pressure parameters. Results A total of 50 MMA embolizations were performed during the study period. The average age of patients included in the study was 63 years old +/‐ 16 years with 30% being female. 34% patients did not receive any sort of ICU level intervention at all. Among the remaining who did, 32% required mechanical ventilation post procedurally. 14% needed a vasopressor and 48% required intravenous antihypertensives to maintain systolic blood pressure within goal parameters. Conclusions The most common reason for an ICU intervention after MMAE was for correction of blood pressure to maintain within specified goal. 34% of patients who underwent MMAE did not require any ICU level interventions afterwards. Further investigation is warranted, but current data suggests that liberalizing blood pressure parameters could potentially reduce the need for ICU utilization after MMAE. Assessment of various components of ICU level interventions administered to patients post‐MMAE allows for a better understanding on preventive measures that can be taken in the future to reduce length of inpatient stay post procedurally, which would reduce risk of iatrogenic complications, minimize spread of nosocomial infections, andoverall increase patient comfort