OBJECTIVE The field of neurosurgery is constantly undergoing improvements and advances, both in technique and technology. Cerebrovascular neurosurgery is no exception, with endovascular treatments changing the treatment paradigm. Clipping of aneurysms is still necessary, however, and advances are still being made to improve patient outcomes within the microsurgical treatment of aneurysms. Surgical rehearsal platforms are surgical simulators that offer the opportunity to rehearse a procedure prior to entering the operative suite. This study is designed to determine whether use of a surgical rehearsal platform in aneurysm surgery is helpful in decreasing aneurysm dissection time and clip manipulation of the aneurysm. METHODS The authors conducted a blinded, prospective, randomized study comparing key effort and time variables in aneurysm clip ligation surgery with and without preoperative use of the SuRgical Planner (SRP) surgical rehearsal platform. Initially, 40 patients were randomly assigned to either of two groups: one in which surgery was performed after use of the SRP (SRP group) and one in which surgery was performed without use of the SRP (control group). All operations were videotaped. After exclusion of 6 patients from the SRP group and 9 from the control group, a total of 25 surgical cases were analyzed by a reviewer blinded to group assignment. The videos were analyzed for total microsurgical time, number of clips used, and number of clip placement attempts. Means and standard deviations (SDs) were calculated and compared between groups. RESULTS The mean (± SD) amount of operative time per clip used was 920 ± 770 seconds in the SRP group and 1294 ± 678 seconds in the control group (p = 0.05). In addition, the mean values for the number of clip attempts, total operative time, ratio of clip attempts to clips used, and time per clip attempt were all lower in the SRP group, although the between-group differences were not statistically significant. CONCLUSIONS Preoperative rehearsal with SRP increased efficiency and safety in aneurysm microsurgery as demonstrated by the statistically significant improvement in time per clip used. Although the rest of the outcomes did not demonstrate statistically significant between-group differences, the fact that the SRP group showed improvement in mean values for all measures studied suggests that preoperative rehearsal may increase the efficiency and safety of aneurysm microsurgery. Future studies aimed at improving patient outcome and safety during surgical clipping of aneurysms will be needed to keep pace with the quickly advancing endovascular field.

Background En plaque meningiomas are a rare subtype of meningiomas that are frequently encountered in the spheno-orbital region. Characterized by a hyperostotic and dural invasive architecture, these tumors present unique diagnostic and treatment considerations. Objectives The authors conduct a narrative literature review of clinical reports of en plaque meningiomas to summarize the epidemiology, clinical presentation, diagnostic criteria, and treatment considerations in treating en plaque meningiomas. Additionally, the authors present a case from their own experience to illustrate its complexity and unique features. Methods A literature search was conducted using the MEDLINE database using the following terminology in various combinations: meningioma, meningeal neoplasms, en plaque, skull base, spheno-orbital, and sphenoid wing. Only literature published in English between 1938 and 2018 was reviewed. All case series were specifically reviewed for sufficient data on treatment outcomes, and all literature was analyzed for reports of misdiagnosed cases. Conclusion En plaque meningiomas may present with a variety of symptoms according to their location and degree of bone invasion, requiring a careful diagnostic and treatment approach. While early and aggressive surgical resection is generally accepted as the optimal goal of treatment, these lesions require an individualized approach, with further investigation needed regarding the role of new therapies.

Level 3.

Primary intradural malignant peripheral nerve sheath tumor (MPNST) is an extremely rare diagnosis and is associated with an extremely poor prognosis. A 77-year-old man diagnosed with an intradural MPNST, more than 40 years after radiation for a testicular seminoma, is reported. Intradural MPNSTs of the spine outside the setting of neurofibromatosis is extremely rare and can masquerade as common benign nerve sheath tumors, on imaging. An older age at presentation with short duration of symptoms and prior regional radiation treatment encompassing the spine in the treatment field regardless of remoteness should alert the oncologists and neurosurgeons to the possible existence of this rare and aggressive tumor, as the management, and overall prognosis of this tumor is distinctly different compared to the usual intradural spinal tumors.

We present case reports of 2 pediatric patients who were both found to have pial arteriovenous fistulas (AVFs) with subsequent genetic analysis revealing mutations in the RASA1 gene. Considering their family history of distinct cutaneous lesions, these mutations were likely inherited as opposed to de novo mutations. Patient 1 had large capillary malformations on the left side of the face and neck, associated with macrocephaly, and presented at the age of 32 months with speech delay, right-sided weakness, and focal seizures involving the right side of the body. Patient 2 presented with proptosis at the age of 9 months, but was otherwise neurologically intact. Given the chance for definitive single-stage control of vascular shunt (obviating chances for radiation exposure with endovascular treatment) and surgically accessible location of these intracranial lesions, both patients were treated with surgery with excellent clinical and radiological outcome. In general, given the high mortality secondary to severe congestive heart failure when treated conservatively, the goal of treatment in cortical AVF in young children, even when asymptomatic, is rapid control of the shunt. This was achieved successfully in our cases - both patients experienced significant symptomatic improvement following surgery and remained neurologically stable in the subsequent follow-up visits.

No abstract

OBJECTIVE Endovascular mechanical thrombectomy is safe and effective for the treatment of acute ischemic stroke (AIS) due to large-vessel occlusion (LVO). Still, despite high rates of procedural success, it is routine practice to uniformly admit postthrombectomy patients to an intensive care unit (ICU) for postoperative observation. Predictors of ICU criteria and care requirements in the postmechanical thrombectomy ischemic stroke patient population are lacking. The goal of the present study is to identify risk factors associated with requiring ICU-level intervention following mechanical thrombectomy. METHODS The authors retrospectively analyzed data from 245 patients undergoing thrombectomy for AIS from anterior circulation LVO at a comprehensive stroke and tertiary care center from January 2015 to March 2020. Clinical variables that predicted the need for critical care intervention were identified and compared. The performance of a binary classification test constructed from these predictive variables was also evaluated using a validation cohort. RESULTS Seventy-six patients (31%) required critical care interventions. A recanalization grade lower than modified Thrombolysis in Cerebral Infarction (mTICI) scale grade 2B (odds ratio [OR] 3.625, p = 0.001), Alberta Stroke Program Early Computed Tomography Score (ASPECTS) < 8 (OR 3.643, p < 0.001), and presence of hyperdensity on postprocedure cone-beam CT (OR 2.485, p = 0.005) were significantly associated with the need for postthrombectomy critical care intervention. When applied to a validation cohort, a clearance classification scheme using these three variables demonstrated high positive predictive value (0.88). CONCLUSIONS A recanalization grade lower than mTICI 2B, ASPECTS < 8, and postprocedure hyperdensity on cone-beam CT were shown to be independent predictors of requiring ICU-level care. Routine admission to ICU-level care can be costly and confer increased risk for hospital-acquired conditions. Safely and reliably identifying low-risk patients has the potential for cost savings, value-based care, and decreasing hospital-acquired conditions.

We would recommend the use of standing x-rays when considering surgical planning in all myelopathy patients. This manuscript was reviewed and approved by an institutional review board. Informed consent was not obtained because patient specific identifying information was not used. It was performed in accordance with the ethical standards laid down in the 1964 Declaration of Helsinki and its later amendments.