OBJECTIVE The role of the cerebellum in cognitive function and psychiatric symptoms is poorly understood and particularly understudied in patients with cerebellar pathologies such as Chiari malformation type I (CM-I). Additionally, it is unclear if interventions targeted toward the cerebellum might impact these life-altering symptoms. The authors sought to characterize pre- and postoperative cognitive and psychiatric function in CM-I patients as evidence for targeted cerebellar treatment for some cognitive and psychiatric conditions. METHODS This prospective study included surgical patients with CM-I who reported cognitive or psychiatric dysfunction. Patients completed a preoperative assessment and a parallel assessment 6 months following surgery. Neuropsychological evaluations included a 90-minute standardized assessment of cognitive function across multiple domains and a self-reported assessment of psychiatric symptoms. This clinical sample consisted of 54 patients (mean age 34.17 years, median 14.15 years). Any patient demonstrating preoperative performance below 3.5 SDs within any cognitive domain was excluded (n = 1). All patients underwent preoperative neuropsychological assessment comprising standard clinical tests of processing speed, attention, memory, executive function, and psychiatric symptoms. RESULTS Preoperatively, CM-I patients performed significantly worse than a representative normative sample on measures of executive function and visuospatial memory and reported more psychiatric symptoms across all domains. On postoperative assessment, 89% of patients showed clinically significant improvements (> 1 SD) in cognitive and/or psychiatric domains. CONCLUSIONS The authors demonstrate significant, often unrecognized, impairments in cognitive function and psychiatric symptoms in a cohort of CM-I patients. Following targeted surgical posterior fossa decompression, these symptoms improved, suggesting that at least in a subgroup of symptomatic CM-I patients, these symptoms may be treatable. This study highlights the potential role of the cerebellum in cognitive and psychiatric dysfunction.

Management of intracranial aneurysms (IAs) is determined by patient age, risk of rupture, and comorbid conditions. While endovascular and microsurgical interventions offer solutions to mitigate the risk of rupture, pharmacological management strategies may complement these approaches or serve as alternatives in appropriate cases. The pathophysiology of IAs allows for the targeting of inflammation to prevent the development and rupture of IAs. The aim of this review is to provide an updated summary of different pharmaceutical management strategies for IAs. Acetylsalicylic acid and renin-angiotensin-aldosterone system (RAAS) inhibitor antihypertensives have some evidence supporting their protective effect. Studies of selective cyclooxygenase-2 (COX-2) inhibitors, statins, ADP inhibitors, and other metabolism-affecting drugs have demonstrated inconclusive findings regarding their association with aneurysm growth or rupture. In this manuscript, we highlight the evidence supporting each drug’s effectiveness.

Cerebral aneurysms are a source of neurological morbidity and mortality, most often as a result of rupture. The most common approach for treating aneurysms involves endovascular embolization using nonbiodegradable medical devices, such as platinum coils. However, the need for retreatment due to the recanalization of coil-treated aneurysms highlights the importance of exploring alternative solutions. In this study, we propose an injectable extracellular matrix-derived embolic formed in situ by Michael addition of gelatin-thiol (Gel-SH) and hyaluronic acid vinyl sulfone (HA-VS) that may be delivered with a therapeutic agent (here, RADA-SP) to fill and remodel aneurysmal tissue without leaving behind permanent foreign bodies. The injectable embolic material demonstrated rapid gelation under physiological conditions, forming a highly porous structure and allowing for cellular infiltration. The injectable embolic exhibited thrombogenic behavior in vitro that was comparable to that of alginate injectables. Furthermore, in vivo studies in a murine carotid aneurysm model demonstrated the successful embolization of a saccular aneurysm and extensive cellular infiltration both with and without RADA-SP at 3 weeks, with some evidence of increased vascular or fibrosis markers with RADA-SP incorporation. The results indicate that the developed embolic has inherent potential for acutely filling cerebrovascular aneurysms and encouraging the cellular infiltration that would be necessary for stable, chronic remodeling.

Platelet aggregation is intimately associated with vascular inflammation and is commonly seen on routine histology studies of cerebral aneurysms. Platelets, when activated, have been shown to augment neutrophil response and the pro-inflammatory cascade. Platelet-neutrophil complexes have been found to aggravate atherosclerosis through a positive feedback loop. We hypothesized that targeting platelet aggregation and downstream inflammation could be used to prevent aneurysm formation and progression. First, we induced cerebral aneurysm formation in a previously described intracranial aneurysm model via carotid artery ligation, hypertension, and stereotactic elastase injection in C57BL/6 mice and analyzed vessels for lesion and thrombus formation. Raybiotech cytokine arrays were used to analyze 96 cytokines in induced murine aneurysms and 120 cytokines in human tissue samples. Cerebral aneurysm formation and inflammatory pathway were then studied in animals treated with IgG2 antibody (control), anti-GpIb antibody (platelet depletion), 1:10 DMSO:PBS (control), clopidogrel, anti-CXCR1/2 small molecule inhibitor, or anti-CXCL7 antibody. Bleeding assays and flow cytometry were used to evaluate platelet function in treated groups. CD31 + platelet aggregates are a common feature in human and mouse cerebral aneurysm specimens. Platelet ablation in mice prevents cerebral aneurysm formation (20

BACKGROUND AND OBJECTIVES: Neurosurgical management of idiopathic intracranial hypertension (IIH) can be challenging given high rates of revision associated with cerebrospinal fluid shunting. In this study, we present a technical report and early outcomes for lumbocaval shunt (LCS) placement in difficult-to-manage cases. METHODS: A literature search was performed for previous reports of LCS or lumboatrial shunt. Electronic medical records of patients who underwent placement of LCS for the treatment of IIH at a single institution were reviewed. Based on early experience and outcomes, our modified technique for LCS is described. RESULTS: Six patients (4 females, median age 36 years [IQR 31-43]) underwent placement of LCS between October 2023 and April 2024. LCS was completed in all cases without intraoperative complications. The median operative time was 88.5 minutes [IQR 79.5-158.8]. One patient developed low-pressure headaches that resolved after the addition of a shunt-assist device. Five of 6 patients reported improved headache at the last follow-up visit, with 4 of 5 patients reporting that their high-pressure headaches completely resolved (median time to the last follow-up of one month [IQR 1-2 months]). During the study period, one shunt revision was performed because of migration of the lumbar shunt into a suprafascial pocket. This led to modification of the surgical technique, specifically the inclusion of anchoring dips. CONCLUSION: LCS may represent an alternative shunting technique in difficult-to-manage patients with IIH. Further assessment of long-term outcomes is needed.

BACKGROUND:Central venous catheters (CVCs) play an indispensable role in clinical practice. Catheter malposition and tip migration can lead to severe complications. The authors present a case illustrating the endovascular management of inadvertent marginal sinus cannulation after an internal jugular vein (IJV) catheter tip migration.OBSERVATIONS:A triple-lumen CVC was inserted without complications into the right IJV of a patient undergoing a repeat sternotomy for aortic valve replacement. Two weeks postinsertion, it was discovered that the tip had migrated superiorly, terminating below the torcula in the posterior fossa. In the interventional suite, a three-dimensional venogram confirmed the inadvertent marginal sinus cannulation. The catheter was carefully retracted to the sigmoid sinus to preserve the option of catheter exchange if embolization became necessary. After a subsequent venogram, which displayed an absence of contrast extravasation, the entire catheter was safely removed. The patient tolerated the procedure well.LESSONS:Clinicians must be vigilant of catheter tip migration and malposition risks. Relying solely on postinsertion radiographs is insufficient. Once identified, prompt management of the malpositioned catheter is paramount in reducing morbidity and mortality and improving patient outcomes. Removing a malpositioned catheter constitutes a critical step, best performed by a specialized team under angiographic visualization.

Background Cranial nerve (CN) palsies are rare presenting symptoms of intracranial aneurysms. Our objectives were to report our institutional outcomes and study-level meta-analysis summarizing rates of improvement and identifying factors associated with recovery from CN symptoms after flow diversion. Methods We conducted a retrospective review of our institutional database for patients with intracranial aneurysms presenting with CN palsies who underwent treatment with flow diversion between 2015 and 2023. Systematic review of the literature was performed using Medline, EMBASE, Cochrane, as well as manual citation searches. Random effects meta-analysis was used. Results Thirteen of 136 studies were included in the meta-analysis and were combined with our institutional data. The pooled rate of improvement in any CN palsies following flow diversion was 71% (95%CI, 60%-82%, n=322). Patients presenting with CN II deficits were less likely to improve following treatment compared to other CN deficits (pooled OR [pOR] 0.32, 95%CI, 0.16-0.63, n=224). The pooled rate of clinical improvement was 53% in CNII deficits (95%CI, 42%-65%, n=80) and 80% in other CN deficits (95%CI, 71%-88%, n=106). An increased rate of improvement was associated with acute intervention (pOR 9.12, 95% CI, 2.26–36.73, n = 71) and radiographic aneurysm occlusion (pOR 5.29, 95%CI, 1.66-16.90, n=118). Conclusions Flow diversion improves CN palsy outcomes in patients with symptomatic intracranial aneurysms. The lower rate of improvement in visual acuity compared to other CN deficits may point to a different mechanism of injury or potential recoverability in these patients.

ObjectiveCerebral vasospasm and the resultant delayed cerebral infarction is a significant source of mortality following aneurysmal SAH. Vasospasm is currently detected using invasive or expensive imaging at regular intervals in patients following SAH, thus posing a risk of complications following the procedure and financial burden on these patients. Currently, there is no blood-based test to detect vasospasm.MethodsPubMed, Web of Science, and Embase databases were systematically searched to retrieve studies related to cerebral vasospasm, aneurysm rupture, and biomarkers. The study search dated from 1997 to 2022. Data from eligible studies was extracted and then summarized.ResultsOut of the 632 citations screened, only 217 abstracts were selected for further review. Out of those, only 59 full text articles met eligibility and another 13 were excluded.ConclusionsWe summarize the current literature on the mechanism of cerebral vasospasm and delayed cerebral ischemia, specifically studies relating to inflammation, and provide a rationale and commentary on a hypothetical future bloodbased test to detect vasospasm. Efforts should be focused on clinical-translational approaches to create such a test to improve treatment timing and prediction of vasospasm to reduce the incidence of delayed cerebral infarction.

Intracranial aneurysms are reported to affect 2–5

Background  Stereotactic radiosurgical rhizolysis of the trigeminal nerve is an established modality increasingly employed to alleviate the symptoms of refractory trigeminal neuralgia. This study analyzes the academic impact of the top 100 cited articles on the radiosurgical management of trigeminal neuralgia. Methods  The Scopus database was searched for articles containing "radiosurgery" and one or more of "trigeminal neuralgia," "trigeminus neuralgia," and "tic douloureux." The top 100 articles written in English were arranged in descending order by citation count. Documents were evaluated for authors, publication year, journal and impact factor, total citations, nationality, study type, radiosurgical modality, and the affiliated institution. Quantitative and qualitative analyses were performed on the data. Results  The most cited articles were published between 1971 and 2019. The average citation per year was 4.3. The most targeted anatomic area was the "root entry zone" or proximal portion of the cisternal segment of the trigeminal nerve. The most utilized modality was Gamma Knife radiosurgery. The country with the highest number of publications was the United States. Thirty-six percent of the articles were published in the Journal of Neurosurgery . Lunsford, Kondziolka, Flickinger, and Régis, respectively, were the most frequently listed co-authors. The most prolific institute was the University of Pittsburgh Medical Center. Conclusion  Stereotactic radiosurgery is an important modality in the management of medically or surgically refractory trigeminal neuralgia. This analysis assesses its contributions over the past five decades to identify trends in treatment practices for neurosurgeons and to highlight areas where further study is needed.

Maladaptive inflammation underlies the formation and rupture of human intracranial aneurysms. There is a growing body of evidence that anti-inflammatory pharmaceuticals may beneficially modulate this process. Clopidogrel (Plavix) is a commonly used irreversible P2Y12 receptor antagonist with anti-inflammatory activity. In this paper, we investigate whether clopidogrel is associated with the likelihood of aneurysm rupture in a multi-institutional propensity-matched cohort analysis. Patients presenting for endovascular treatment of their unruptured intracranial aneurysms and those presenting with aneurysm rupture between 2015 and 2019 were prospectively identified at two quaternary referral centers. Patient demographics, comorbidities, and medication usage at the time of presentation were collected. Patients taking clopidogrel or not taking clopidogrel were matched in a 1:1 fashion with respect to location, age, smoking status, aneurysm size, aspirin usage, and hypertension. A total of 1048 patients with electively treated aneurysms or subarachnoid hemorrhages were prospectively identified. Nine hundred twenty-one patients were confirmed to harbor aneurysms during catheter-based diagnostic angiography. A total of 172/921 (19%) patients were actively taking clopidogrel at the time of presentation. Three hundred thirty-two patients were matched in a 1:1 fashion. A smaller proportion of patients taking clopidogrel at presentation had ruptured aneurysms than those who were not taking clopidogrel (6.6% vs 23.5%, p < .0001). Estimated treatment effect analysis demonstrated that clopidogrel usage decreased aneurysm rupture risk by 15%. We present, to the best of our knowledge, the first large-scale multi-institutional analysis suggesting clopidogrel use is protective against intracranial aneurysm rupture. It is our hope that these data will guide future investigation, revealing the pathophysiologic underpinning of this association.

Abstract IMPORTANCE: Cerebral aneurysms are typically diagnosed incidentally or upon rupture. In this study we aimed to investigate cost-effectiveness of a hypothetical blood-based diagnostic test to detect cerebral aneurysm formation in the US healthcare model. DESIGN: Markov decision analytic models were created for four different case studies to simulate management of cerebral aneurysm diagnosis within the US healthcare system over 50 years. To assess robustness, we performed sensitivity analyses. Further analysis was performed for different risk factors, patient groups, and aneurysm size. INTERVENTIONS: Standard care, thrice-annually blood test monitoring, annual blood testing among high-risk groups. RESULTS: A blood based diagnostic test pathway is more cost effective in patients undergoing watchful-waiting and as a screening tool in patients at a higher-risk of developing an aneurysm when compared to the traditional pathway. Our analysis demonstrated a greater than three-fold reduction in mortality compared to the standard of care (SOC) (15.71% vs 53.10%, respectively). The cost of using a blood test per additional QALY gained was estimated to be $34,515.13 among the watchful-waiting cohort. The threshold price for cost-effectiveness of a blood test was determined to be $3,951. Among patients with one family member with an aneurysm and smokers, we observed a near tenfold reduction in mortality compared to the SOC (0.21% vs 2.35%, and 0.27% vs 3.30 %, respectively) with a threshold at $865.23 and $1,078.48. CONCLUSIONS: Introduction of a hypothetical blood-based diagnostic test to detect cerebral aneurysm formation would have a life-saving effect within the US healthcare system while remaining cost-effective.

Background Cerebral aneurysms are common, but there is no blood test for their diagnosis. Cerebral aneurysms are diagnosed incidentally or upon rupture. Current diagnostic tools either are invasive or place a large financial burden on the patient. Introduction of a blood test can reduce costs and allow for additional screening. Methods Markov decision analytic models were created for different case studies to simulate management within the US health care system. The model was run over 50 cycle‐years. Probabilities, costs, and outcomes were obtained from the literature and the National Inpatient Sample database. Quality‐adjusted life years were used to assess outcomes. Subgroup analysis was performed for different risk factors, patient groups, aneurysm size, and family members. Results A blood‐based diagnostic pathway is more cost effective in patients undergoing watchful waiting and as a screening tool in patients who may be at a higher risk. There was a 3‐fold reduction in death compared with the standard of care (15.71% versus 53.10%). The cost of using a blood test per additional quality‐adjusted life year gained was $34 515.13 among the watchful‐waiting cohort. The threshold price was $3951. Among patients with 1 family member with an aneurysm, we observed a 10‐fold reduction in death compared with the standard of care (0.21% versus 2.35%), with a threshold at $845.77. Among patients who smoke, we observed a 10‐fold reduction in death compared with the standard of care (0.27% versus 3.30%) with a threshold at $1054.24. Among patients with 2 family members with an aneurysm, there was a 10‐fold reduction in death compared with the standard of care (0.48% versus 5.85%) with a threshold at $1876.46. Conclusion Introduction of a blood‐based test for cerebral aneurysms would have a lifesaving effect within the US health care system while remaining cost effective.

BACKGROUND:Recent literature suggests that spinal infections are increasing in prevalence. Any compartment can be infected in the spine; however, multicompartmental infections are rare.OBSERVATIONS:To the authors' knowledge, this report is the only reported case of a tetra-compartmental spinal infection consisting of epidural, subdural, subarachnoid, and intramedullary components with a contiguous lumbar spondylodiscitis resulting in conus medullaris syndrome requiring surgical intervention.LESSONS:This case highlights the importance of surgical intervention in severe cases such as the one illustrated in this report. Second, magnetic resonance imaging with and without contrast is required to check for spreading of the infection as these findings may change the surgical approach. Last, the use of intraoperative ultrasound is paramount to evaluate the subdural and intramedullary compartments in severe cases.

Introduction: Gram-negative rod (GNR) bacterial ventriculitis is a rare complication of shunt-dependent hydrocephalus, often requiring an extended and invasive treatment course. Accumulation of purulent material, as well as empyema and septation formation, limits circulation of antibiotics and infection clearance. Supplementation of standard care with neuroendoscopic-guided intraventricular lavage with lactated Ringer solution and fenestration of septations may facilitate infection clearance and simplify the eventual shunt construct required. Here, the utility of serial lavage for ventriculitis is described in a population of shunt-dependent neonates and infants at high risk for morbidity and mortality. Methods: Five infants with shunt-dependent hydrocephalus and subsequent GNR ventriculitis were treated with standard care measures with the addition of serial neuroendoscopic lavage. A retrospective chart review was performed to collect patient characteristics, shunt dependency, and shunt revisions within a year of ventriculitis resolution. Results: Patients demonstrated a mean 74% decrease in cerebrospinal fluid (CSF) protein following each neuroendoscopic lavage and trended toward a shorter time to infection clearance in comparison to previously published literature. Patients required 0–2 shunt revisions at 1-year follow-up following hospitalization for shunt-related ventriculitis (mean 0.8 +/− 0.8). Conclusions: Serial neuroendoscopic lavage is an effective technique, used alone or in combination with fenestration of septations, to reduce the CSF protein and bacterial load in the treatment of ventriculitis, decreasing time until eradication of infection. Serial lavage may reduce the risk of future shunt malfunction, simplify the future shunt construct, and decrease duration of infection.

BACKGROUND:Establishing central venous access is important to provide fluid resuscitation or medications intravenously to patients.OBSERVATIONS:Although accidental cannulation of the internal carotid artery has been reported in the literature, to our knowledge this report is the first documented intraoperative ultrasound video demonstrating accidental and simultaneous common carotid artery and internal jugular cannulation during central line placement in the internal jugular vein.LESSONS:Ultrasound use minimizes accidental carotid cannulation during central line placement in the internal jugular vein. Carotid artery puncture can be managed by external application of pressure or surgical reexploration.

Cerebral aneurysm embolization is a therapeutic approach to prevent rupture and resultant clinical sequelae. Current, non-biodegradable metallic coils (platinum or tungsten) are the first-line choice to secure cerebral aneurysms. However, clinical studies report that up to 17% of aneurysms recur within 1 year after coiling, leading to retreatment and additional surgery. It would be ideal for the aneurysm coiling material to induce acute thrombotic occlusion, contribute to a tissue development process to fortify the degenerated vessel wall, and ultimately resorb to avoid leaving a permanent foreign body. With these properties in mind, a new fatty amide -based polyurethane urea (PHEUU) elastomer was synthesized and coated on biodegradable metallic (Mg alloy) coils to prepare a bioabsorbable cerebral saccular aneurysm embolization device. The chemical structure of PHEUU was confirmed using two-dimensional nuclear magnetic resonance spectroscopy. PHEUU showed com-parable physical properties to elastomeric biodegradable polyurethanes lacking fatty amide immobilization, modest enzymatic degradation profiles in the first 8 wks, inherent antioxidant activity (>70% at 48 h), no cytotoxicity, and better protection for the underlying Mg alloy than poly(lactic-co-glycolic acid) (PLGA) against surface corrosion and cracking. Rat aortic smooth muscle cell attachment and platelet deposition were higher with the PHEUUs compared to bare or PLGA coated Mg alloy in vitro. PHEUU-coated Mg alloy coils showed the potential to design a fully bioabsorbable embolization coil amenable to clinical placement conditions based on computational mechanics modeling and blood-contacting test using an in vitro aneurysm model. In vivo studies using a mouse aneurysm model elicited comparable inflammatory cytokine expression to a commercially available platinum coil.

An arachnoid web is a pathological formation of the arachnoid membrane. It is a rare phenomenon but is known to lead to syrinx formation in the spinal cord along with pain and neurological deficits. On imaging, the 'scalpel sign' is pathognomonic for an arachnoid web. The etiology of syrinx formation from an arachnoid web is currently unknown. This report documents the only two cases of arachnoid webs with an extensive syrinx in which a likely pathophysiologic mechanism is identified. Both cases presented with motor deficits. The patients had no history of trauma or infection. After extensive workup in both patients and observation of the scalpel sign an arachnoid web was suspected. In both cases, the patients were treated surgically after an arachnoid web was suspected. Intra-operative ultrasound visualized in both cases demonstrates a fenestration in the web that allowed passage of cerebrospinal fluid in a rostral-caudal direction due to a ball-valve effect.

INTRODUCTION: Comparative evaluation of efficacy of using a long sheath-first approach in stroke thrombectomy patients where no initial arch information is available does not exist. Lower door-to-reperfusion times are associated with better outcomes in stroke thrombectomy. Multiple factors affect reperfusion times including approach, arch navigability, and the amount of support provided by equipment. METHODS: Study Design and Setting: An institutional review-board-approved, prospectively maintained endovascular arterial thrombectomy database from 2016 to 2018 was reviewed. Inclusion criteria: manual aspiration thrombectomy or stent-assisted, femoral approach, >80 yo, and LVO in anterior circulation. Study Variables: Demographic information such as age, sex, medical comorbidities, NIHSS score on presentation, tPA administration, and thrombus location were extracted. Arch navigability was defined by time from puncture to first base catheter run. Procedural times, and angiographic results (TICI score) were recorded and used as metrics for efficacy. Ninety-day outcome was also evaluated based on modified Rankin scale. The analysis was performed based on an intention-to-treat analysis. Statistical Analysis: Univariate statistical analysis was performed using an unpaired t test with Bonferonni correction for continuous variables and Fisher’s exact test for categorical variables. Statistically significant differences between groups were defined as p < 0.05. Procedural Technique: All procedures were performed emergently under local anesthesia. Consent was obtained from the patient or their next of kin under our institution’s guidelines. RESULTS: A total of n = 287 patients were included in the final analysis. There were no significant differences in baseline demographics. Upfront “long-sheath first” approach resulted in improved outcomes: time to first run (15.6 vs 32 min, p = 0.0005), time to first pass (21.4 vs 40 min, p < 0.0001), time to final reperfusion (35.8 vs 50 min, p < 0.0001), delta NIHSS (2.2 vs 6.6, p < 0.0001). CONCLUSION: Upfront “long-sheath first” approach results in improved outcomes during stroke thrombectomy in octogenerian population.

Introduction: Mirror aneurysms of the middle cerebral artery (MCA) constitute 14% of all MCA aneurysms, which commonly arise from the MCA bifurcation. Giant MCA aneurysms (>25 mm in diameter) have a reported 5-year rupture rate of 40%, though can be difficult to treat surgically given their complex nature. Giant aneurysms may present with symptoms of mass effect, including neurological deficit, headaches, and/or cranial neuropathies. To our knowledge, no case of mirror bilateral giant MCA aneurysms exists in the neurosurgical literature. Case description: Here we present a case of mirror bilateral giant MCA aneurysms in an 84-year-old man who presented with altered mental status and increased falls in the last year. Imaging revealed mirror MCA aneurysms, 3.5 and 4 cm in diameter respectively, arising from bilateral M1 segments. The patient opted to forego further evaluation or surgical intervention and was discharged home. Conclusion: We report the first known case of mirror bilateral giant MCA aneurysms were found in an 84-year-old man presenting with altered mental status and progressive decline across the last year.