BACKGROUND: Current Brain Injury Guidelines (BIG) characterize patients with intracranial hemorrhage taking antiplatelet or anticoagulant agents as BIG 3 (the most severe category) regardless of trauma severity. This study assessed the risk of in-hospital mortality or need for neurosurgery in patients taking low-dose aspirin who otherwise would be classified as BIG 1. METHODS: This was a retrospective study at an academic level 1 trauma center. Patients were included if they were admitted with traumatic intracerebral hemorrhage and were evaluated by the BIG criteria. Exclusion criteria included indeterminate BIG status or patients with missing primary outcomes documentation. Patients were categorized as BIG 1, BIG 2, BIG 3, or BIG 1 on aspirin (patients with BIG 1 features taking low-dose aspirin). The primary endpoint was a composite of neurosurgical intervention and all-cause in-hospital mortality. Key secondary endpoints include rate of intracranial hemorrhage progression, and intensive care unit- and hospital-free days. RESULTS: A total of 1,520 patients met the inclusion criteria. Median initial Glasgow Coma Scale was 14 (interquartile range [IQR], 12-15), Injury Severity Scale score was 17 (IQR, 10-25), and Abbreviated Injury Scale subscore head and neck (AIS(Head)) was 3 (IQR, 3-4). The rate of the primary outcome for BIG 1, BIG 1 on aspirin, BIG 2, and BIG 3 was 1%, 2.2%, 1%, and 27%, respectively; the difference between BIG 1 on aspirin and BIG 3 was significant (p < 0.001). CONCLUSION: Patients taking low-dose aspirin with otherwise BIG 1-grade injuries experienced mortality and required neurosurgery significantly less often than other patients categorized as BIG 3. Inclusion of low-dose aspirin in the BIG criteria should be reevaluated.

BACKGROUND:Steroids are used ubiquitously in the preoperative management of patients with brain tumor. The rate of improvement in focal deficits with steroids and the prognostic value of such a response are not known. OBJECTIVE:To determine the rate at which focal neurological deficits respond to preoperative corticosteroids in patients with brain metastases and whether such an improvement could predict long-term recovery of neurological function after surgery. METHODS:Patients with brain metastases and related deficits in language, visual field, or motor domains who received corticosteroids before surgery were identified. Characteristics between steroid responders and nonresponders were compared. RESULTS:Ninety six patients demonstrated a visual field (13 patients), language (19), or motor (64) deficit and received dexamethasone in the week before surgery (average cumulative dose 43 mg; average duration 2.7 days). 38.5% of patients' deficits improved with steroids before surgery, while 82.3% of patients improved by follow-up. Motor deficits were more likely to improve both preoperatively ( P = .014) and postoperatively ( P = .010). All 37 responders remained improved at follow-up whereas 42 of 59 (71%) of nonresponders ultimately improved ( P < .001). All other clinical characteristics, including dose and duration, were similar between groups. CONCLUSION:A response to steroids before surgery is highly predictive of long-term improvement postoperatively in brain metastasis patients with focal neurological deficits. Lack of a response portends a somewhat less favorable prognosis. Duration and intensity of therapy do not seem to affect the likelihood of response.

INTRODUCTION: Idiopathic intracranial hypertension (IIH) is a debilitating disease that can present with severe vision loss. Although medical management is the first-line treatment, these cases commonly require intervention by either ventriculoperitoneal/pleural shunting (VPS) or, more recently, by venous sinus stenting (VSS). Unfortunately, this chronic disease can lead to multiple clinical encounters which increases financial burden. Therefore, identifying ways to effectively treat IIH definitively while limiting healthcare costs are of great interest. METHODS: This is a retrospective study of IIH patients diagnosed via modified Dandy criteria who received VPS (n=27) or VSS (n=27) from May 2008–May 2019. Visual outcomes were reported by a neuro-ophthalmologist at approximately 1-month post-procedure. Costs of emergency department as well as and outpatient/inpatient encounters for neurosurgery and ophthalmology were obtained from the index procedure to 3 years post-procedure. RESULTS: VSS patients had higher pre-intervention ophthalmology evaluation rates (stents: n = 22, 88.9%; shunts: n = 7, 23.1%; p < 0.0001). Papilledema was present in most patients (VSS 82.6% vs VPS 66.7%, p = 0.60) and all patients had stable/improved papilledema at follow-up. Two VSS patients (4.9%) required a second stent. Four VSS patients (9.8%) had a VPS placed. No VPS patients received a VSS. Encounter cost for VSS placement were more expensive than primary VPS placement ($10,749 vs $13,648; p = 0.002). However, at 1.5 years after index procedure, cumulative VPS cost surpassed VSS and persisted at 3 years ($22,674 vs $17,441, p = 0.039). CONCLUSIONS: VPS and VSS have similar visual outcomes with all cases having stable or improved papilledema. The upfront cost of VSS is greater than VPS; however, VPS quickly surpasses VSS in cost by 1.5 years after index procedure and continues to study endpoint at 3 years. These results may help guide multi-disciplinary care for patients with IIH.

Background There is evidence that frailty is an independent predictor of worse outcomes after stroke. Similarly, although obesity is associated with a higher risk for stroke, there are multiple reports describing improved mortality and functional outcomes in higher body mass index (BMI) patients in a phenomenon known as the obesity paradox. We investigated the effect of low BMI on outcomes after mechanical thrombectomy (MT).Methods We conducted a retrospective analysis of 231 stroke patients who underwent MT at an academic medical center between 2020-2022. The patients' BMI data were collected from admission records and coded based on the Centers for Disease Control and Prevention (CDC) obesity guidelines. Recursive partitioning analysis (RPA) in R software was employed to automatically detect a BMI threshold associated with a significant survival benefit. Frailty was quantified using the Modified Frailty Index 5 and 11.Results In our dataset, by CDC classification, 2.6% of patients were underweight, 27.3% were normal BMI, 30.7% were overweight, 19.9% were class I obese, 9.5% were class II obese, and 10% were class III obese. There were no significant differences between these groups. RPA identified a clinically significant BMI threshold of 23.62 kg/m(2). Independent of frailty, patients with a BMI <= 23.62 kg/m(2) had significantly worse overall survival (P<0.001) and 90-day modified Rankin Scale (P=0.027) than patients above the threshold.Conclusions Underweight patients had worse survival and functional outcomes after MT. Further research should focus on the pathophysiology underlying poor prognosis in underweight MT patients, and whether optimizing nutritional status confers any neuroprotective benefit.

BACKGROUND:Sellar masses within the pars intermedius, bordered anteriorly by normal pituitary gland/stalk, and/or with ectatic cavernous carotid anatomy are challenging and high risk when approached through the endonasal standard direct/anterior sellar approach. This approach portends itself to a higher risk of pituitary gland/stalk injury and subtotal resection with the aforementioned anatomic variants.OBJECTIVE:To describe the indirect clival recess corridor approach to sellar lesions. This corridor is a "silent" point of access to lesions in this region endoscopically. While skull base teams may have used this approach to some degree, it has not yet been described in the literature to our knowledge.METHODS:We defined the clival recess surgical corridor with skull base craniometric measurements and use a case example with aberrant anatomy to illustrate the approach. We cross-sectionally reviewed 42 patients with sellar and suprasellar masses. To describe the approach's anatomy, we devised and defined the terms dorsum sella plumb line, anatomic corridor, angle of osseous, and operative corridor.RESULTS:Created novel clival aeration grade informing surgical planning. Classified clival aeration as Grade 1 (100%-75% aeration), Grade 2 (75%-50% aeration), Grade 3 (50%-25% aeration), and Grade 4 (25%-0% aeration). This classification system determines extent of drilling of the clivus required to optimize the clival recess corridor approach and its limitations.CONCLUSION:The clival recess surgical corridor is effective for accessing pituitary lesions within the sella. Consider the indirect approach when a standard direct/anterior sellar approach has high risk for vascular injury and/or endocrinological dysfunction.

BACKGROUND:Increasing evidence supports the effectiveness of venous sinus stenting (VSS) with favorable outcomes, safety, and expenses compared with shunting for idiopathic intracranial hypertension. Yet, no evidence is available regarding optimal postoperative recovery, which has increasing importance with the burdens on health care imposed by the coronavirus disease 2019 pandemic. We examined adverse events and costs after VSS and propose an optimal recovery pathway to maximize patient safety and reduce stress on health care resources. METHODS:A retrospective review was undertaken of elective VSS operations performed from May 2008 to August 2021 at a single institution. Primary data included hospital length of stay, intensive care unit (ICU) length of stay, adverse events, need for ICU interventions, and hospital costs. RESULTS:Fifty-three patients (98.1% female) met the inclusion criteria. Of these patients, 51 (96.2%) were discharged on postoperative day (POD) 1 and 2 patients were discharged on POD 2. Both patients discharged on POD 2 remained because of groin hematomas from femoral artery access. There were no major complications or care that required an ICU. Eight patients (15.1%) were lateralized to other ICUs or remained in a postanesthesia care unit because the neurosciences ICU was above capacity. Total estimated cost for initial recovery day in a neurosciences ICU room was $2361 versus $882 for a neurosurgery/neurology ward room. In our cohort, ward convalescence would save an estimated $79,866 for bed placement alone and increase ICU bed availability. CONCLUSIONS:Our findings reaffirm the safety of VSS. These patients should recover on a neurosurgery/neurology ward, which would save health care costs and increase ICU bed availability.

Abstract Purpose: To determine the rate at which focal neurologic deficits respond to pre-operative corticosteroids in patients with brain metastases and whether such an improvement is predictive of long-term improvement in neurologic function following surgery. Methods: Patients with pathology-proven brain metastases who underwent open surgical resection between 2010 and 2019 were identified. Charts were reviewed to identify patients with deficits in language, visual field, or motor domains who received corticosteroids prior to surgery. Descriptive analysis compared characteristics between steroid responders and non-responders. Dosage and duration were binned into deciles and plotted against their corresponding response rates. Results: 96 patients demonstrated a visual field (13 patients), language (19), or motor (64) deficit and received dexamethasone in the week prior to surgery (average cumulative dose 42.66 mg; average duration 64.5 hours). 38.5% of patients’ deficits improved on neurologic exam prior to surgery. 82.3% of patients improved by follow-up. Motor deficits were most likely to improve (46.9%; p = 0.024). All 37 responders demonstrated durable improvement at follow-up whereas 42 of 59 (71%) of non-responders ultimately improved (p < 0.001). Average dosage and duration prior to response were 17.33 mg and 23.94 hours, respectively. All other clinical characteristics were similar between responders and non-responders. Conclusions: A response to steroids prior to surgery predicts long-term improvement for focal neurologic deficits related to brain metastases. Lack of such a response portends a somewhat less favorable prognosis. There is no obvious association between duration or intensity of therapy and response.

Microvascular decompression (MVD) is a common surgical technique used for treatment of trigeminal neuralgia (TN) caused by direct vascular compression of the nerve at the brainstem entry zone (BEZ). Here we report a case of a patient (status postcraniotomy for microsurgical clip obliteration of a ruptured mid-basilar artery aneurysm) who developed right-sided TN 6 years after the procedure. During MVD surgery the clip head was found to be compressing the trigeminal nerve at the BEZ, causing Type 1 TN in V3 distribution. This is consistent with the commonly held theory that a pulsatile stimulus is needed to cause TN. To our knowledge there are no previous reports in the literature of an instrument causing TN.

Corticosteroids reduce vasogenic cerebral edema and are thought to improve related neurologic deficits or symptoms of increased intracranial pressure. Brain metastases are typically associated with a large amount of edema and, consequently, come with a disproportionate degree of mass effect that may cause such deficits. There remains no standard approach to pre-operative corticosteroid therapy, nor is it understood what clinical characteristics are associated with a neurologic response to pre-operative steroids. We examined characteristics of steroid responders versus non-responders and, further, evaluated whether a response to preoperative steroids is predictive of durable improvement in neurologic function. Patients with pathology-proven brain metastases who underwent open surgical resection between 2009 and 2019 were identified from departmental records. Charts were reviewed to identify patients with motor dysfunction who received corticosteroids prior to surgery. Multiple patient and clinical characteristics were extracted and compared using student t-, chi-square, and Fisher’s exact tests. 90 patients exhibited pre-operative motor deficits, 69 of whom received corticosteroids prior to surgery (dose 2 – 112 mg; median 25 mg). 34 patients neurologic function improved prior to surgery, whereas 35 patients had no demonstrable improvement. All 34 patients (100%) whose motor function improved pre-operatively with steroids had sustained improvement at follow-up, whereas 27 of 35 (77%) patients who did not improve pre-operatively were better at follow-up (p = 0.005). All other clinical characteristics were similar between responders and non-responders. All motor deficits related to brain metastases that responded to steroids prior to surgery demonstrated durable improvement at follow-up, suggesting such an improvement portends a favorable long-term functional outcome. Conversely, a failure to improve with steroid therapy confers a more guarded prognosis.

CNS lymphoma often presents with atypical imaging characteristics leading to delay in diagnosis and initiation of treatment. Among the most rarely reported of these is entirely nonenhancing CNS lymphoma, which is estimated at an incidence of about 1%. Here, we present three cases of nonenhancing CNS lymphoma in immune competent patients at both initial presentation and recurrence and in primary as well as secondary CNS lymphoma. Diffusion- and perfusion-weighted imaging was found helpful in diagnosis in some cases.

BACKGROUND: Unusual vascular anatomy can present treatment challenges as traditional approaches may be unfeasible. CASE DESCRIPTION: In this case we describe a patient who presented with subarachnoid hemorrhage due to a ruptured basilar apex aneurysm, with an occluded left vertebral artery and severely stenotic right vertebral artery. Coil embolization was performed via catheterization of an ascending cervical artery, with a successful clinical and radiographic outcome. CONCLUSIONS: This demonstrates novel use of an endovascular technique in the setting of multiple vascular pathologies.

Purpose: High dose corticosteroids are an effective tool for rapidly alleviating neurologic symptoms caused by intracranial mass lesions. However, there is concern that preoperative corticosteroids limit the ability to obtain a definitive pathologic diagnosis, particularly if imaging features suggest primary central nervous system lymphoma (PCNSL). Methods: To explore the impact of preoperative corticosteroids in newly diagnosed PCNSL patients, from 2009 to 2018 treated at our institution. Results: We identified 54 patients; 18 had received corticosteroids prior to biopsy or resection. Only in one case did the patient have a prior non-diagnostic biopsy, requiring a second procedure. The cumulative doses of preoperative dexamethasone ranged from 4 mg to 120 mg (mean 32 mg, median 24 mg), given over 1-14 days (mean 2 days, median 1 day), and the majority had received corticosteroids for only 1-2 days. There was a trend for a larger diameter of lesional T1 contrast enhancement for patients who received steroids (39 mm vs. 34 mm, p = 0.11). In this series of cases with pathologically and clinically proven PCNSL, preoperative corticosteroids had been given in a third of cases, suggesting that they may be given for symptomatic relief without compromising pathologic diagnosis. Conclusions: Despite the commonly held tenet that preoperative corticosteroids can obscure the pathologic diagnosis in PCNSL, this is likely not the case in the majority of patients who receive a short course preoperatively. Obtaining a second stereotactic scan to confirm continued presence of the lesion prior to tissue sampling may also mitigate these concerns. (C) 2019 Elsevier Ltd. All rights reserved.