BACKGROUND Middle meningeal artery (MMA) embolization has emerged as a promising treatment for chronic subdural hematoma (cSDH). OBJECTIVE To determine the safety and efficacy of MMA embolization. METHODS Consecutive patients who underwent MMA embolization for cSDH (primary treatment or recurrence after conventional surgery) at 15 centers were included. Clinical details and follow-up were collected prospectively. Primary clinical and radiographic outcomes were the proportion of patients requiring additional surgical treatment within 90 d after index treatment and proportion with > 50% cSDH thickness reduction on follow-up computed tomography imaging within 90 d. National Institute of Health Stroke Scale and modified Rankin Scale were also clinical outcomes. RESULTS A total of 138 patients were included (mean age: 69.8, 29% female). A total of 15 patients underwent bilateral interventions for 154 total embolizations (66.7% primary treatment). At presentation, 30.4% and 23.9% of patients were on antiplatelet and anticoagulation therapy, respectively. Median admission cSDH thickness was 14 mm. A total of 46.1% of embolizations were performed under general anesthesia, and 97.4% of procedures were successfully completed. A total of 70.2% of embolizations used particles, and 25.3% used liquid embolics with no significant outcome difference between embolization materials (P > .05). On last follow-up (mean 94.9 d), median cSDH thickness was 4 mm (71% median thickness reduction). A total of 70.8% of patients had >50% improvement on imaging (31.9% improved clinically), and 9 patients (6.5%) required further cSDH treatment. There were 16 complications with 9 (6.5%) because of continued hematoma expansion. Mortality rate was 4.4%, mostly unrelated to the index procedure but because of underlying comorbidities. CONCLUSION MMA embolization may provide a safe and efficacious minimally invasive alternative to conventional surgical techniques.

OBJECTIVEThe Pipeline embolization device (PED) is a routine choice for the endovascular treatment of select intracranial aneurysms. Its success is based on the high rates of aneurysm occlusion, followed by near-zero recanalization probability once occlusion has occurred. Therefore, identification of patient factors predictive of incomplete occlusion on the last angiographic follow-up is critical to its success.METHODSA multicenter retrospective cohort analysis was conducted on consecutive patients treated with a PED for unruptured aneurysms in 3 academic institutions in the US. Patients with angiographic follow-up were selected to identify the factors associated with incomplete occlusion.RESULTSAmong all 3 participating institutions a total of 523 PED placement procedures were identified. There were 284 procedures for 316 aneurysms, which had radiographic follow-up and were included in this analysis (median age 58 years; female-to-male ratio 4.2:1). Complete occlusion (100% occlusion) was noted in 76.6% of aneurysms, whereas incomplete occlusion (≤ 99% occlusion) at last follow-up was identified in 23.4%. After accounting for factor collinearity and confounding, multivariable analysis identified older age (> 70 years; OR 4.46, 95% CI 2.30–8.65, p < 0.001); higher maximal diameter (≥ 15 mm; OR 3.29, 95% CI 1.43–7.55, p = 0.005); and fusiform morphology (OR 2.89, 95% CI 1.06–7.85, p = 0.038) to be independently associated with higher rates of incomplete occlusion at last follow-up. Thromboembolic complications were noted in 1.4% and hemorrhagic complications were found in 0.7% of procedures.CONCLUSIONSIncomplete aneurysm occlusion following placement of a PED was independently associated with age > 70 years, aneurysm diameter ≥ 15 mm, and fusiform morphology. Such predictive factors can be used to guide individualized treatment selection and counseling in patients undergoing cerebrovascular neurosurgery.

BACKGROUND Pediatric epilepsy surgery is a treatment modality appropriate for select patients with debilitating medication-resistant seizures. Previous publications have studied seizure freedom as the main outcome of epilepsy surgery. However, there has been no systematic assessment of the postoperative life quality for these children. OBJECTIVE To estimate the quality of life (QOL) long-term outcomes after surgery for intractable epilepsy in pediatric patients. METHODS A systematic search of the PubMed and Cochrane databases was performed. Studies reporting questionnaire-assessed QOL at least 12 months postoperatively were included. QOL means and standard deviations were compared between surgically and medically managed patients, between the preoperative and postoperative state of each patient, and were further stratified into patients achieving seizure freedom, and those who did not. Meta-analysis was performed using fixed effects models for weighted mean differences (WMD), 95% confidence intervals (CI) and sensitivity analyses. Funnel plots and Begg's tests were utilized to detect publication bias. RESULTS The search yielded 18 retrospective studies, reporting 890 surgical patients. Following epilepsy surgery, children had significant QOL improvement compared to their preoperative state (WMD: 16.71, 95% CI: 12.19-21.22, P < .001) and better QOL than matched medically treated controls (WMD: 12.42, 95% CI: 6.25-18.58, P < .001). Patients achieving total seizure freedom after surgery had significant postoperative QOL improvement (WMD: 16.12, 95% CI: 7.98-24.25, P < .001), but patients not achieving seizure freedom did not achieve statistical significance (P = .79). CONCLUSION Epilepsy surgery can effectively improve QOL in children with medication-resistant seizures, through seizure freedom, which was associated with the greatest improvement in life quality.

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In spinal surgery, outcomes are directly related both to patient and procedure selection, as well as the accuracy and precision of instrumentation placed. Poorly placed instrumentation can lead to spinal cord, nerve root or vascular injury. Traditionally, spine surgery was performed by open methods and placement of instrumentation under direct visualization. However, minimally invasive surgery (MIS) has seen substantial advances in spine, with an ever-increasing range of indications and procedures. For these reasons, novel methods to visualize anatomy and precisely guide surgery, such as intraoperative navigation, are extremely useful in this field. In this review, we present the recent advances and innovations utilizing simulation methods in spine surgery. The application of these techniques is still relatively new, however quickly being integrated in and outside the operating room. These include virtual reality (VR) (where the entire simulation is virtual), mixed reality (MR) (a combination of virtual and physical components), and augmented reality (AR) (the superimposition of a virtual component onto physical reality). VR and MR have primarily found applications in a teaching and preparatory role, while AR is mainly applied in hands-on surgical settings. The present review attempts to provide an overview of the latest advances and applications of these methods in the neurosurgical spine setting.

Stroke in pregnant women has a mortality rate of 1.4 deaths per 100,000 deliveries. Vascular malformations are the most common cause of hemorrhagic stroke in this population; preeclampsia and other risk factors have been identified. However, nearly a quarter of strokes have an undeterminable cause. Spontaneous intracranial hemorrhage (ICH) is less frequent but results in significant morbidity. The main objective of this study is to review the literature on pregnant patients who had a spontaneous ICH. A systematic review of the literature was conducted on PubMed and the Cochrane library from January 1992 to September 2016 following the PRISMA guidelines. Studies reporting pregnant patients with spontaneous intraparenchymal hemorrhage (IPH), subarachnoid hemorrhage (SAH), and subdural hemorrhage (SDH) were selected and included if patients had non-structural ICH during pregnancy or up to 6 weeks postpartum confirmed by imaging. Twenty studies were included, and 43 patients identified. Twenty-two patients (51.3%) presented with IPH, 15 patients (34.8%) with SAH, and five patients (11.6%) with SDH. The most common neurosurgical management was clinical in 76.7% of patients, and cesarean section was the most common obstetrical management in 28% of patients. The most common maternal outcome was death (48.8%), and fetal outcomes were evenly distributed among term delivery, preterm delivery, and fetal or neonatal death. Spontaneous ICH carries a high maternal mortality with IPH being the most common type, most frequently presenting in the third trimester. Diagnosis and management do not differ for the parturient compared to the non-pregnant woman.

Background The ISAT (International Subarachnoid Aneurysm Trial) has generated a paradigm shift towards endovascular treatment for intracranial aneurysms but remains unclear if this has led to a true reduction in the risk for aneurysmal subarachnoid hemorrhage (aSAH). We sought to study the association between the treatment burden of unruptured and ruptured aneurysms in the post‐ISAT era. Methods and Results Admissions data from the National Inpatient Sample (2004–2014) were extracted, including patients with a primary diagnosis of aSAH or unruptured intracranial aneurysms treated by clipping or coiling. Within each year, this combined group was randomly matched to non‐aneurysmal control group, based on age, sex, and Elixhauser comorbidity index. Multinomial regression was performed to calculate the relative risk ratio of undergoing treatment for either ruptured or unruptured aneurysms in comparison with the reference control group, adjusted for time. After adjusting for National Inpatient Sample sampling effects, 243 754 patients with aneurysm were identified, 174 580 (71.6%) were women; mean age, 55.4±13.2 years. A total of 121 882 (50.01%) patients were treated for unruptured aneurysms, 79 627 (65.3%) endovascularly and 42 256 (34.7%) surgically. A total of 121 872 (49.99%) patients underwent procedures for aSAH, 68 921 (56.6%) endovascular, and 52 951 (43.5%) surgically. Multinomial regression revealed a significant year‐to‐year decrease in aSAH procedures compared with the control group of non‐aneurysmal hospitalizations (relative risk ratio, 0.963 per year; P <0.001), while there was no statistical significance for unruptured aneurysms procedures (relative risk ratio, 1.012 per year; P =0.35). Conclusions With each passing year, there is a significant decrease in relative risk ratio of undergoing treatment for aSAH, concomitant with a stable annual risk of undergoing treatment for unruptured intracranial aneurysms.

MMD may coincide with pregnancy, but there is paucity of high-quality data. It appears that MMD is not a contraindication to pregnancy, if blood pressure and ventilation are properly managed. There is no clear evidence that bypass surgery before pregnancy or cesarean mode of delivery improve outcomes.