BACKGROUND:Guidelines recommend aneurysm securement within 24 h from arrival for aneurysmal subarachnoid hemorrhage (aSAH) but the optimal treatment window within this timeframe remains unclear. We examined the association between arrival-to-treatment (AtT) timing and outcomes in patients undergoing endovascular securement for aSAH. METHODS:We retrospectively analyzed a prospectively collected cohort of patients with aSAH treated at a single academic center between 2015-2023. Multivariate logistic regressions (MLR) and multivariate generalized additive models (MGAM) evaluated the relationships between AtT time and outcomes including poor functional outcome at 3 months (modified Rankin scale [mRS] 3-6), primary outcome) and unfavorable discharge disposition (secondary outcome). Subgroup analyses were performed for patients with Hunt and Hess (HH) grades ≥ 3. We also analyzed AtT time in relation to preprocedural aneurysmal rebleeding. RESULTS:Of 434 patients with aSAH reviewed, 351 underwent endovascular treatment (mean age, 57.7 ± 13.7; 64.1% female; 94.3% treated within 24 h). For the overall cohort, AtT time was not significantly associated with poor functional outcome (MLR: OR 0.67, 95%CI [0.44, 1.05], p = 0.08; MGAM: edf = 1, p = 0.06). Among high HH-grade patients, longer AtT time was associated with improved outcomes (MLR: OR 0.54, 95%CI [0.32, 0.91], p = 0.024; MGAM: edf = 1, p = 0.02). Longer AtT was not associated with increased preprocedural rebleeding (MLR: OR 1.37, 95%CI [0.66, 3.15] p = 0.4). CONCLUSIONS:In high-grade aSAH, modest variation in arrival-to-treatment time within the AHA-recommended 24-hour window was not associated with worse outcomes and was associated with improved functional recovery. However, this finding is likely influenced by clinician triage patterns, survival bias, and residual confounding rather than a causal benefit of delayed intervention. These results reinforce the safety of early aneurysm treatment within established guidelines while highlighting the complex interplay between patient stability, procedural timing, and institutional workflow. Larger prospective multicenter studies are needed to clarify optimal timing across diverse practice settings.

BACKGROUND Mycotic aneurysms (MAs) typically present with intracranial hemorrhage but are a rare cause of subdural hematoma (SDH). Although infective endocarditis is the most common etiology, MAs may also result from bacteremia associated with intravenous drug use, meningitis, or poor dentition. Patients with ventriculoatrial shunts (VASs) are at increased risk for shunt-related bacteremia compared to those with ventriculoperitoneal shunts, potentially predisposing them to MA formation. OBSERVATIONS This is the case of a 61-year-old female with a fusiform distal left middle cerebral artery MA presenting as an acute-on-chronic SDH without endocarditis, but with positive blood cultures and CSF cultures for Cutibacterium acnes from a long-term VAS. LESSONS MAs can rarely present as SDHs and should be considered in the differential diagnosis for patients with a long-standing VAS due to the risk of subacute bloodstream infections. https//thejns.org/doi/10.3171/CASE25625

Objective:Carotid endarterectomy (CEA) is a standard treatment for atherosclerotic carotid stenosis. Perioperative symptomatic restenosis or reocclusion of the carotid artery following CEA is a rare but serious complication that typically necessitates intervention. The efficacy and safety profile of emergent endovascular therapy (EVT) as an alternative to repeat CEA in the treatment of acute perioperative neurological decline remain unknown. Methods:All patients undergoing CEA in the Department of Neurosurgery at a single comprehensive stroke center from 2015 to 2024 were reviewed. Patients who underwent EVT for acute perioperative neurological deficits were included in our series. A systematic literature review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines to identify articles relevant to the endovascular management of acute neurological deficits following CEA. Results:Four patients from our institutional cohort met the inclusion criteria. An additional 39 patients were identified from the literature review in 11 source articles, which yielded a total of 43 patients. CEA was performed for symptomatic lesions in 28 (28/32, 87.5%) patients. Abnormal angiographic findings were reported for all patients. Thrombus accumulation in or distal to the operated internal carotid artery (ICA) (26/43, 60.5%) and dissection flaps (15/43, 34.9%) were the most common findings. Five (11.6%) patients had tandem cervical ICA and intracranial occlusions, of which thrombectomy of the intracranial lesion was successfully performed on 3 patients. All patients except for 1 (42/43, 97.6%) underwent technically successful endovascular stenting. Following EVT, 76.7% (33/43) of patients had no persisting neurological deficits. Nine (20.9%) patients were found to have new cerebral infarcts on post-EVT imaging. In-hospital mortality was reported for 6 patients (14%), 4 of whom were found to have tandem cervical ICA and intracranial occlusions. Conclusion:EVT is likely a technically viable alternative treatment for patients with perioperative acute neurologic deficits after CEA. However, most of the literature available comes from case series, thereby limiting the quality of evidence. Improved reporting of standard stroke outcome measures may help to inform the implementation of EVT and repeat CEA for acute ischemic symptoms after CEA.

INTRODUCTION: Large language models (LLMs) have shown promising performance on medical licensing exams, but their ability to excel in subspecialty domains and their robustness under adversarial conditions remain unclear. METHODS: AtlasGPT was built using GPT-4 with retrieval-augmented generation from expert-verified neurosurgical knowledge sources. Its performance was compared to GPT-4 and Gemini Advanced on a 149-question neurosurgery exam. Adversarial testing assessed robustness to misinformation. Answer explanations were rated by 15 independent neurosurgeons and compared to the question bank. RESULTS: Across all 149 questions, AtlasGPT achieved 90.6% accuracy, outperforming GPT-4 (80.5%, P=0.020) and Gemini Advanced (80.5%, P=0.020). On text-only questions, AtlasGPT, Gemini Advanced and GPT-4 achieved 95.6%, 92.9% and 87.8% accuracy, respectively. In adversarial testing, AtlasGPT was fooled 14% of the time, compared to 44% for GPT-4 and 68% for Gemini Advanced. Neurosurgeons rated AtlasGPT's answer explanations as significantly more comprehensive, relevant, and better-referenced than the question bank's explanations (P<0.001). CONCLUSIONS: AtlasGPT demonstrates the potential of subspecialty-focused LLMs to outperform general models, exhibit robustness to misinformation, and generate high-quality explanations. Domain-specific LLMs may improve medical knowledge, decision-making, and educational materials in complex fields like neurosurgery.

BACKGROUND Unilateral cranial nerve (CN) VI, or abducens nerve, palsy is rare in children and has not been reported in association with Chiari malformation type 1 (CM1) in the absence of other classic CM1 symptoms. OBSERVATIONS A 3-year-old male presented with acute incomitant esotropia consistent with a unilateral, left CN VI palsy and no additional neurological symptoms. Imaging demonstrated CM1 without hydrocephalus or papilledema, as well as an anterior inferior cerebellar artery (AICA) vessel loop in the immediate vicinity of the left abducens nerve. Given the high risk of a skull base approach for direct microvascular decompression of the abducens nerve and the absence of other classic Chiari symptoms, the patient was initially observed. However, as his palsy progressed, he underwent posterior fossa decompression with duraplasty (PFDD), with the aim of restoring global cerebrospinal fluid dynamics and decreasing possible AICA compression of the left abducens nerve. Postoperatively, his symptoms completely resolved. LESSONS In this first reported case of CM1 presenting as a unilateral abducens palsy in a young child, possibly caused by neurovascular compression, the patient’s symptoms resolved after indirect surgical decompression via PFDD.

BACKGROUND AND OBJECTIVES: Glucagon-like peptide-1 receptor agonists (GLP-1 RAs) have gained increasing popularity since the approval of semaglutide by the United States Food and Drug Administration for chronic weight management. Significant benefits have been noted in glycemic control and cardiovascular health. However, as increasing numbers of patients are started on these medications, it is important for neurosurgeons to have knowledge of any perioperative considerations and side effects related to this class of drugs. METHODS: We performed a qualitative literature review using the PubMed and Embase databases, using the following key words: GLP-1 RAs adverse events; GLP-1 RAs and anesthesia; substance use disorders; and addiction, functional neurosurgery, nervous system rehabilitation, and spinal cord injury. Articles of relevance to perioperative management of these medications and specific benefits in the neurosurgical field were discussed. RESULTS: Recent guidance from the American Society of Anesthesiologists demonstrates the importance of tailored management of GLP-RA drugs for surgical patients. In addition, certain positive effects have been noted with relation to substance use disorders, neural protection and rehabilitation, and neurodegenerative disorders such as Alzheimer's disease. CONCLUSION: In this article, we review what the neurosurgeon needs to know about the perioperative management of GLP-1 RAs and discuss existing literature in clinical and preclinical studies for potential indications and benefits of these medications, which can influence the management of conditions treated by neurosurgeons.

Rubber bullets have long been known to cause, on rare occasions, traumatic brain injury (TBI). However, neurosurgical literature on this occurrence is limited, and no focused review of this injury pattern has been conducted. The authors present the case of a 28-year-old male struck by a rubber bullet in the left periorbital region, causing TBI in addition to complete left visual loss and complex facial fractures. After developing a cerebrospinal fluid (CSF) leak, the patient was taken to the operating room for combined neurosurgical-craniofacial intervention. Utilizing frameless intraoperative computation tomography navigation assistance, a successful repair was made of both the patient's CSF leak and complex craniofacial injuries. TBI due to a rubber bullet is a rare but severe occurrence. Unfortunately, much of the limited literature on this topic is bereft of demographic, clinical course, injury pattern, and imaging data. Presented here is the first operative case report of TBI due to a rubber bullet. Volume rendered imaging is provided to demonstrate the extent of trauma incurred. Additionally, a methodology for frameless intraoperative computation tomography navigation assistance is shared for consideration, as it served as a helpful adjunct for a combined intracranial-craniofacial surgical repair. The experience of treating the patient's traumatic CSF leak in the context of severe craniofacial and ophthalmologic injuries highlights the need for a multidisciplinary surgical approach that may arise when treating patients with TBI due to a rubber bullet.

BACKGROUND:To evaluate the feasibility of awake transforaminal endoscopic surgery in the management of symptomatic spinal metastases.METHODS:Transforaminal endoscopic spine procedures were performed by 1 surgeon in 325 patients over a period of 4 years from 2014 to 2018. Four of these patients suffered from radicular pain secondary to nerve compression from metastatic spine disease and are the basis of our analysis. Data was evaluated retrospectively in these patients with a minimum follow up of 1 year.RESULTS:All 4 patients treated with transforaminal endoscopic spine surgery for decompression of their metastatic spine disease had successful resolution of their symptoms without any perioperative complications and only brief recovery periods required.CONCLUSIONS:Awake endoscopic surgery for the treatment of symptomatic metastatic spine disease is an effective outpatient surgical option for the treatment of patients suffering from radicular pain due to nerve compression from metastatic spine disease.

BACKGROUND Platelet transfusion has been utilized to reverse platelet dysfunction in patients on preinjury antiplatelets who have sustained a traumatic intracranial hemorrhage (tICH); however, there is little evidence to substantiate this practice. The objective of this study was to perform a systematic review on the impact of platelet transfusion on survival, hemorrhage progression and need for neurosurgical intervention in patients with tICH on prehospital antiplatelet medication. METHODS Controlled, observational and randomized, prospective and retrospective studies describing tICH, preinjury antiplatelet use, and platelet transfusion reported in PubMed, Embase, Cochrane Reviews, Cochrane Trials and Cochrane DARE databases between January 1987 and March 2019 were included. Investigations of concomitant anticoagulant use were excluded. Risk of bias was assessed using the Newcastle-Ottawa scale. We calculated pooled estimates of relative effect of platelet transfusion on the risk of death, hemorrhage progression and need for neurosurgical intervention using the methods of Dersimonian-Laird random-effects meta-analysis. Sensitivity analysis established whether study size contributed to heterogeneity. Subgroup analyses determined whether antiplatelet type, additional blood products/reversal agents, or platelet function assays impacted effect size using meta-regression. RESULTS Twelve of 18,609 screened references were applicable to our questions and were qualitatively and quantitatively analyzed. We found no association between platelet transfusion and the risk of death in patients with tICH taking prehospital antiplatelets (odds ratio [OR], 1.29; 95% confidence interval [CI], 0.76–2.18; p = 0.346; I 2 = 32.5%). There was no significant reduction in hemorrhage progression (OR, 0.88; 95% CI, 0.34–2.28; p = 0.788; I 2 = 78.1%). There was no significant reduction in the need for neurosurgical intervention (OR, 1.00; 95% CI, 0.53–1.90, p = 0.996; I 2 = 59.1%; p = 0.032). CONCLUSION Current evidence does not support the use of platelet transfusion in patients with tICH on prehospital antiplatelets, highlighting the need for a prospective evaluation of this practice. LEVEL OF EVIDENCE Systematic Reviews and Meta-Analyses, Level III.

BACKGROUND:Foot drop that results from compression of the exiting L5 nerve as a result of far lateral disc herniation (FLDH) at L5-S1 poses a significant surgical challenge to the minimally-invasive spine surgeon given the narrow corridor for an extraforaminal approach because of the high iliac crest.OBJECTIVES:Here we describe our experience with transforaminal endoscopic decompression for the treatment of foot drop secondary to FLDH at L5-S1.STUDY DESIGN:Retrospective case review.SETTING:This study took place in a single-center, academic hospital.METHODS:A technique for the transforaminal endoscopic treatment of foot drop secondary to L5-S1 FLDH is presented in a series of 5 consecutive patients treated over a period of 3 years. Preoperative and postoperative clinical data with 1-year follow-up are presented.RESULTS:A consecutive series of 211 patients who underwent transforaminal endoscopic treatment for lumbar radiculopathy between 2011 and 2014 are presented. Seventy-seven patients had L5-S1 discectomies and 5 of those patients presented with foot drop and FLDH. The mean visual analog scale score for radicular pain improved from an average pain score before surgery of 7.2 to 0.8 one year after surgery, and the mean motor score for anterior tibialis strength improved from an average motor score before surgery of 2.6 to 4.8 one year after surgery.LIMITATIONS:Small case series evaluated retrospectively with one year follow-up.CONCLUSIONS:Transforaminal endoscopic surgical access to FLDH pathology may be a unique approach to the treatment of foot drop because it allows for neural decompression of disc and foraminal pathology without requiring significant destabilizing bone removal.KEY WORDS:Endoscopic spine surgery, minimally-invasive, transforaminal, foot drop, far lateral disc herniation.

OBJECTIVE: Perineural cysts are a benign spine pathology but, when they become symptomatic and require surgical treatment, represent a significant challenge to the spine surgeon. Here we describe our experience with a novel endoscopic approach to the biopsy, drainage, resection of the cyst wall, and direct cyst fenestration to the subarachnoid space. METHODS: A transforaminal endoscopic approach to a lumbar 2-3 perineural cyst is presented here in a 25-year-old patient. A step-by-step technique for the biopsy, drainage, and resection of the cyst wall is presented. RESULTS: The patient underwent cyst resection and fenestration into the subarachnoid space without complication, with immediate relief of his preoperative symptoms and after 1 year remains symptom-free. CONCLUSIONS: Surgical treatment of perineural cysts in the spine represent a significant challenge to the surgeon, principally due to the risk of spinal fluid leak in the post-operative period. Transforaminal endoscopic surgical access to this disease pathology is a novel minimally invasive surgical approach presented here that allows diagnosis and treatment of a perineural cyst and can be performed in an awake patient.

OBJECTIVE Traumatic intracranial hemorrhage (tICH) is a significant source of morbidity and mortality in trauma patients. While prognostic models for tICH outcomes may assist in alerting clinicians to high-risk patients, previously developed models face limitations, including low accuracy, poor generalizability, and the use of more prognostic variables than is practical. This study aimed to construct a simpler and more accurate method of risk stratification for all tICH patients. METHODS The authors retrospectively identified a consecutive series of 4110 patients admitted to their institution's level 1 trauma center between 2003 and 2013. For each admission, they collected the patient's sex, age, systolic blood pressure, blood alcohol concentration, antiplatelet/anticoagulant use, Glasgow Coma Scale (GCS) score, Injury Severity Score, presence of epidural hemorrhage, presence of subdural hemorrhage, presence of subarachnoid hemorrhage, and presence of intraparenchymal hemorrhage. The final study population comprised 3564 patients following exclusion of records with missing data. The dependent variable under study was patient death. A k-fold cross-validation was carried out with the best models selected via the Akaike Information Criterion. These models risk stratified the study partitions into grade I (< 1% predicted mortality), grade II (1%-10% predicted mortality), grade III (10%-40% predicted mortality), or grade IV (> 40% predicted mortality) tICH. Predicted mortalities were compared with actual mortalities within grades to assess calibration. Concordance was also evaluated. A final model was constructed using the entire data set. Subgroup analysis was conducted for each hemorrhage type. RESULTS Cross-validation demonstrated good calibration (p < 0.001 for all grades) with a mean concordance of 0.881 (95% CI 0.865-0.898). In the authors' final model, older age, lower blood alcohol concentration, antiplatelet/anticoagulant use, lower GCS score, and higher Injury Severity Score were all associated with greater mortality. Subgroup analysis showed successful stratification for subarachnoid, intraparenchymal, grade II-IV subdural, and grade I epidural hemorrhages. CONCLUSIONS The authors developed a risk stratification model for tICH of any GCS score with concordance comparable to prior models and excellent calibration. These findings are applicable to multiple hemorrhage subtypes and can assist in identifying low-risk patients for more efficient resource allocation, facilitate family conversations regarding goals of care, and stratify patients for research purposes. Future work will include testing of more variables, validation of this model across institutions, as well as creation of a simplified model whose outputs can be calculated mentally.

Doberstein, Cody A.; Powers, Andrew Y.; Pinto, Mauricio B.; Tang, Oliver Y.; Chen, Jia-Shu ScB Candidate; Asaad, Wael F. MD, PhD Author Information

Here, the authors examined the factors involved in the volumetric progression of traumatic brain contusions. The variables significant in this progression are identified, and the expansion rate of a brain bleed can now effectively be predicted given the presenting characteristics of the patient.

Powers, Andrew Y. BA; Pinto, Mauricio B.; Tang, Oliver Y.; Chen, Jia-Shu; Candidate, ScB.; Doberstein, Cody A. BS; Asaad, Wael F. MD, PhD Author Information

PURPOSE:Traumatic subdural hemorrhage (SDH) is associated with high mortality, yet many patients are not managed surgically. We sought to understand what factors might be associated with SDH enlargement to contribute to the triage of these conservatively managed patients.MATERIALS AND METHODS:A consecutive series of 117 patients admitted to our institution's level 1 trauma center for SDH between January 1, 2010 and December 31, 2010 were evaluated. Volumetric measurement of SDHs was performed on initial and follow-up head computed tomography (CT) scans with recording of initial midline shift and classification by location. Multimodel analysis quantified associations with change in SDH volume.RESULTS:Systolic blood pressure, presence of subarachnoid hemorrhage, and initial SDH volume demonstrated positive associations with change in SDH volume, while initial midline shift and transfusion of platelets demonstrated negative associations. Initial convexity SDH volume demonstrated positive association with change in convexity SDH volume, while initial midline shift and transfusion of platelets demonstrated negative associations. Anticoagulant/antiplatelet use demonstrated positive association with change in tentorial SDH volume, while time between CT scans demonstrated negative association.CONCLUSIONS:Platelet transfusion, anticoagulation, and hypertension have significant associations with expansion in non-surgical cases of SDH. Monitoring these factors may assist triaging these patients.

Type 1 Chiari malformations (CMs) are a group of congenital or acquired disorders which include the abnormal presence of the cerebellar tonsils in the upper spinal canal, rather than the posterior fossa. The resulting anatomic abnormality causes crowding of the structures at the craniocervical junction and can impair the normal flow of cerebral spinal fluid (CSF) in this region. This impairment in CSF flow dynamics can led to the development of syringomyelia or hydrocephalus. Type 1 CMs have been associated with a wide array of symptoms resulting from either cerebellar and brainstem compression and distortion or disturbances in CSF dynamics, and can affect both children and adults. The clinical diagnosis may be difficult. Age usually matters in the clinical presentation, and in symptomatic patients, surgical intervention is usually required. [Full article available at http://rimed.org/rimedicaljournal-2017-06.asp].

There have been infrequent reports of isolated central nervous system blastomycosis. We report a case of intracranial epidural abscess secondary to Blastomyces dermatitidis in a patient residing in Rhode Island with a history of remote travel to an endemic area. The clinical, radiographic, and pathologic features of this unique case are reviewed.

The International Headache Society Guidelines define glossopharyngeal neuralgia as a “severe transient stabbing pain experienced in the ear, base of the tongue, tonsillar fossa, or beneath the angle of the jaw” [25]. The glossopharyngeal nerve serves autonomic, motor, and sensory functions; compromise of this nerve along its course can cause neuralgia. Compression by blood vessels and tumors are known to cause this condition. Glossopharyngeal neuralgia affects adults and can be mistakenly diagnosed as trigeminal neuralgia, but tests can be used to differentiate these conditions. Treatment consists mainly of pharmacologic management, but surgical procedures can be used to treat medically refractory cases.

Stroke is a major cause of death and disability in the United States and rapid evaluation and treatment of stroke patients are critical to good outcomes. Effective surgical treatments aim to restore adequate cerebral blood flow, prevent secondary brain injury, or reduce the likelihood of recurrent stroke. Patient evaluation in centers with a comprehensive stroke program and a dedicated neuro- vascular team is recommended. [Full article available at http://rimed.org/rimedicaljournal-2017-06.asp].