BACKGROUND:Stereo-electroencephalography (sEEG) is increasingly used in the presurgical evaluation of drug-resistant epilepsy (DRE). While most studies emphasize predictors of long-term seizure freedom, less is known about which patients actually proceed to a therapeutic intervention following invasive monitoring. METHODS:We performed a retrospective review of consecutive patients with DRE who underwent sEEG at Albany Medical Center between 2019 and 2024. Clinical, radiographic, and electrophysiologic variables were compared between patients who proceeded to intervention-defined as resection, laser ablation, or neuromodulation-and those who did not. Multivariable logistic regression identified independent predictors of intervention. RESULTS:Twenty-seven patients underwent sEEG during the study period; 18 (66.7%) proceeded to a therapeutic intervention. Event capture occurred in all patients who underwent intervention versus 55.6% of those who did not (p = 0.007), while habitual seizure capture was more common among treated patients (83.3% vs. 33.3%, p = 0.026). Longer epilepsy duration (>10 years) was associated with intervention (88.9% vs. 44.4%, p = 0.023). In multivariable analysis, habitual seizure capture was the strongest predictor of treatment candidacy (OR 15.3, 95% CI 0.99-233.96, p = 0.050). Subgroup analysis suggested that resection/ablation was associated with more focal implantation strategies (fewer electrodes, less bilateral coverage), whereas neuromodulation was more often chosen after broader or bilateral implantation. CONCLUSION:In this contemporary sEEG cohort, habitual seizure capture and longer epilepsy duration were associated with proceeding to intervention, while implantation scope influenced treatment type. These findings highlight that predictors of surgical candidacy differ from those of long-term seizure outcomes, with important implications for patient selection, counseling, and efficient use of invasive monitoring.

BACKGROUND:Craniosynostosis, characterized by premature fusion of cranial sutures, can impede childhood development. This study compares outcomes between open cranial vault remodeling and endoscopic strip craniectomy with helmet therapy in children with isolated craniosynostosis of the sagittal, metopic, coronal, and lambdoid sutures. METHODS:Retrospectively, 89 patients treated over 13 years were analyzed; 44 underwent endoscopic repair, and 45 underwent open surgery. Key operative variables including intraoperative blood loss, operative time, transfusion rates, and hospital stay were analyzed. Neurodevelopment was assessed at multiple postoperative intervals. RESULTS:The endoscopic group experienced significant perioperative advantages with lower mean intraoperative blood loss (58.84 mL vs. 107.61 mL, P  < 0.001), reduced operative time (96 minutes vs. 244 minutes, P  < 0.001), shorter hospital stays (2.67 days vs. 4.07 days, P  < 0.001), and reduced opioid prescription rates (40.9% vs. 71.1%; P  = 0.004) compared to the open group. Overall developmental delay rates were similar (29.3% vs. 20.9%, P  = 0.378). However, those with isolated coronal synostosis (OR, 4.81, P  = 0.057) and isolated metopic synostosis (OR, 16.73; P  = 0.005) had increased odds of developmental delay compared to those with sagittal synostosis. Endoscopic intervention (OR, 11.32; P  = 0.044), each additional month of age at surgery (OR, 1.25; P  = 0.026), and drain placement (OR, 12.59; P  = 0.018) were each independently and significantly associated with greater odds of delay. CONCLUSIONS:Endoscopic repair may offer perioperative benefits yet may be an independent predictor of postoperative developmental delay alongside age and drain placement.

OBJECTIVE:In patients with mild traumatic brain injury (TBI; Glasgow Coma Scale scores 13-15), the presence of anticoagulant or antiplatelet therapy, collectively referred to as blood thinners (BTs), has been presumed to elevate the risk of intracranial hemorrhage (ICH) progression. Current Brain Injury Guidelines (BIG) automatically classify all patients receiving BTs as high-risk (modified BIG [mBIG] 3), requiring hospital admission and repeat imaging. The aim of this study was to evaluate whether BTs independently increase the risk of hemorrhage progression, surgical intervention, or mortality in mild TBI with ICH, and whether risk varies by specific BT agent. METHODS:The authors conducted a retrospective cohort study of 2312 adult patients presenting with mild TBI and traumatic ICH at a level 1 trauma center (2016-2021). Patients were categorized by mBIG criteria and then reclassified using hemorrhage characteristics (reclassified mBIG [RmBIG]), excluding BT status. Outcomes included radiographic progression, surgical intervention, and in-hospital mortality. A subgroup analysis was performed to assess outcomes by specific BT type. RESULTS:Radiographic progression occurred in 14.1% of mBIG 3 patients versus 1.7% and 6.8% of mBIG 1 and 2 patients, respectively. Among reclassified patients, those receiving BTs had similar progression rates to non-BT patients within the same RmBIG category. Patients classified as mBIG 3 based only on BT use had significantly lower progression rates (11.9%) compared with those classified based on hemorrhage severity (18.1%, p < 0.001). Mortality and surgical intervention rates did not differ overall by BT status. In the BT subgroup analysis, warfarin was the only agent significantly associated with increased radiographic progression (OR 1.93, p = 0.01). CONCLUSIONS:Anticoagulant and antiplatelet therapy might not warrant automatic classification of all patients with mild TBI as high risk. While warfarin represents the upper end of the risk spectrum, most agents did not increase adverse outcomes. Refining BIG to incorporate hemorrhage features and agent-specific risk might improve patient care and resource utilization.

Objective The 2024 Residency Match was the first in recent history where most applicants did not report a numerical United States Medical Licensing Examination Step 1 score. This study will quantify the effects the scoring change had on the research productivity of successfully matched neurosurgery applicants. Methods Data on sex, MD/PhD status, medical school attended, and residency program were collected. Articles were categorized based on authorship, relation to neurosurgery, type of article, and the h5-index of the journal. Differences were evaluated based on sex, top 40 National Institutes of Health-funded medical school status, and acceptance at a top 30 residency program. Results This study evaluated the publications of 181 out of 241 matched students. They produced 2,002 articles, 85% of which were related to neurosurgery. Clinical studies were the most frequently published. The mean and median total publications were 11.1±12.8 and 8.0, respectively. On average, first-author publications accounted for 2.9±4.0 (median=2.0) of publications. Significant differences in publication metrics were found when comparing based on sex and matching into a top 30 residency program. Conclusions The transition of the Step 1 scoring system to Pass/Fail amplified the emphasis successful applicants placed on research. The need for an extensive research portfolio has only become greater. Results of this study may also suggest that the change to Step 1 scoring may not have lessened the burden on medical students but rather shifted it elsewhere.

OBJECTIVES:Surgical intervention for thoracolumbar spinal injury (TLSI) is rare in pediatric trauma. Current guidelines recommend CT scanning of the entire spine if one spinal injury is found, and localized CT if spinal injury is suspected, likely resulting in significant radiation exposure for these injuries. This study identifies the frequency of various imaging techniques utilized across trauma centers of varied designations for confirmed pediatric TLSI. METHODS:The American College of Surgeons Trauma Quality Improvement Program Participant Use File (TQIP PUF) was queried from 2017 to 2022. Patients aged younger than or equal to 14 years with thoracic or lumbar injuries were included. ICD-10 codes for injuries, imaging, procedures, and bracing were analyzed by patient age and trauma center level. RESULTS:Thirteen thousand three hundred ten children were identified with blunt TLSI. The most common injury was thoracic spine fracture (58.23%) followed by lumbar spine fracture (45.11%). Spinal cord injuries were less common (5.8% lumbar, 7.18% thoracic), as were joint injuries (5.8% lumbar, 0.86% thoracic). The need for surgical intervention was rare (6.49%) and varied significantly with age and trauma center type. Older children were more likely to be evaluated with CT and younger children were more likely to be evaluated with MRI. Adult centers were much more likely to image with CT, and pediatric centers were much more likely to use plain film or MRI. CONCLUSIONS:Although TLSI is common in blunt pediatric trauma, intervention is rarely needed. CT imaging is liberally used, particularly in adult trauma centers. Improved guidelines for cross-sectional imaging in neurologically normal patients are needed.

The modified brain injury guidelines (mBIG) were developed to improve care of traumatic brain injury (TBI) patients and resource utilization. This represents a retrospective cohort study at one level one trauma center. Utilization of the mBIG began in November 2021. Patient related outcome and safety measures for patients 18 years and older meeting mBIG 1 criteria treated 18 months prior to (pre-mBIG) and after implementation (post-mBIG) were compared. Patients meeting criteria for mBIG 2 or mBIG 3 classification were excluded. In contrast to the mBIG, neurosurgery was involved in the care of all TBI patients. 170 patients meeting mBIG 1 criteria were included (77 pre-mBIG, 93 post-mBIG). 53 patients (57%) post-mBIG were discharged from the emergency department after a period of observation, compared to 3 (4%) pre-mBIG (p=<0.01). Patients not discharged post-mBIG were most often admitted for care of unrelated traumatic injuries (85%). Repeat neuroimaging was less frequent post-mBIG (15% vs. 62%, p=<0.01). 0 patients in either cohort needed operative neurosurgical interventions, medical therapy for intracranial hypertension, or suffered neurologic deterioration. 8 (10%) pre-mBIG patients and 4 (4%) post-mBIG patients re-presented to the emergency department within 30 days (p=0.14), of which 2 pre-mBIG and 1 post-mBIG were for a TBI related complaint (p=0.59). At re-presentation, 0 patients had radiographic injury progression, needed operative neurosurgical interventions, medical therapy for intracranial hypertension, or suffered neurologic deterioration. Identification of TBI patients that may be safe for a short period of observation and discharge utilizing the mBIG 1 criteria with neurosurgery oversight appears to be safe and effective. Neurosurgery involvement may help to ensure safety and promote adoption by the neurosurgical community.

Surgical intervention for thoracolumbar spinal injury (TLSI) is rare in pediatric trauma. Current guidelines recommend CT scanning of the entire spine if one spinal injury is found, and localized CT if spinal injury is suspected, likely resulting in significant radiation exposure for these injuries. This study identifies the frequency of various imaging techniques utilized across trauma centers of varied designations for confirmed pediatric TLSI. The American College of Surgeons Trauma Quality Improvement Program Participant Use File (TQIP PUF) was queried from 2017 to 2022. Patients aged younger than or equal to 14 years with thoracic or lumbar injuries were included. ICD-10 codes for injuries, imaging, procedures, and bracing were analyzed by patient age and trauma center level. Thirteen thousand three hundred ten children were identified with blunt TLSI. The most common injury was thoracic spine fracture (58.23%) followed by lumbar spine fracture (45.11%). Spinal cord injuries were less common (5.8% lumbar, 7.18% thoracic), as were joint injuries (5.8% lumbar, 0.86% thoracic). The need for surgical intervention was rare (6.49%) and varied significantly with age and trauma center type. Older children were more likely to be evaluated with CT and younger children were more likely to be evaluated with MRI. Adult centers were much more likely to image with CT, and pediatric centers were much more likely to use plain film or MRI. Although TLSI is common in blunt pediatric trauma, intervention is rarely needed. CT imaging is liberally used, particularly in adult trauma centers. Improved guidelines for cross-sectional imaging in neurologically normal patients are needed.

Neuroborreliosis is a well-described complication of Lyme disease in the pediatric population. Intracranial hypertension can occur with this condition in children presenting with transient or permanent vision loss in severe cases. A systematic review of the literature was undertaken to answer the following questions: what forms of neurosurgical management have been used in the treatment of intracranial hypertension in pediatric Lyme disease, what are the indications for such neurosurgical management, and what outcomes are associated with these interventions? 43 publications were identified including 131 cases of intracranial hypertension secondary to neuroborreliosis. Of these, 4 cases were identified where neurosurgical intervention was required for the management of intracranial hypertension in neuroborreliosis. All cases involved cerebrospinal fluid diversion procedures including lumbar drains, ventriculoperitoneal shunts, and external ventricular drains. Neurosurgical intervention was utilized for intracranial hypertension refractory to medical therapy in all cases, with all patients experiencing vision loss. Resolution of papilledema was observed in all cases. 2 of 4 cases experienced complete resolution of vision loss, while 2 had long lasting visual deficits despite intervention. This review highlights the role for cerebrospinal fluid diversion in refractory intracranial hypertension secondary to neuroborreliosis. Timely recognition, awareness of this potential complication, and early neurosurgical involvement, if necessary, may help improve outcomes for this patient population. Further study is warranted.

OBJECTIVE: The modified Brain Injury Guidelines (mBIG) were developed to improve care of patients with traumatic brain injury (TBI). This study aimed to assess if utilization of mBIG by neurosurgeons would improve TBI patient throughput at a Level I trauma center, particularly for patients meeting mBIG 1 criteria. METHODS: This was a retrospective observational study at a Level I trauma center. The mBIG were adopted in November 2021. Outcome and safety data for patients >= 18 years old meeting mBIG 1 criteria treated 18 months before (pre-mBIG cohort) or after (post-mBIG cohort) implementation were compared. Patients meeting criteria for mBIG 2 or mBIG 3 classification were excluded. In contrast to mBIG, neurosurgery was involved in the care of all patients. RESULTS: The study included 170 patients with traumatic brain injury (77 pre-mBIG, 93 post-mBIG). In the post-mBIG cohort, 53 patients (57%) were discharged from the emergency department after a period of observation versus 3 patients (4%) in the pre-mBIG cohort (P <= 0.01). Post-mBIG patients who were not discharged were most often admitted for care of other injuries (85%). Repeat neuroimaging was less frequent in post-mBIG patients (15% vs. 62%, P <= 0.01). No patients in either cohort needed operative neurosurgical interventions or medical therapy for intracranial hypertension or experienced neurological deterioration. No post-mBIG patients had radiographic injury progression. The rate of repeat emergency department presentation within 30 days was not different between cohorts (P = 0.14). CONCLUSIONS: The mBIG 1 criteria were safe and improved low-risk TBI patient throughput at a Level I trauma center. Neurosurgical involvement may be beneficial to the mBIG while still facilitating significant resource savings.

BACKGROUND Approximately 15% of Lyme disease cases involve the nervous system and are termed “neuroborreliosis.” A rare complication of neuroborreliosis is idiopathic intracranial hypertension with resulting neurological deterioration. There are very few reports of this in the literature, most of which consist of case reports and small case series. Neurosurgical intervention is exceedingly rare but may be needed in select cases. OBSERVATIONS The authors present the case of a 13-year-old male with Lyme disease and concurrent babesiosis with progressive headache, meningismus, emesis, and visual loss over several weeks. Serum and cerebrospinal fluid (CSF) testing confirmed a diagnosis of neuroborreliosis. Despite antimicrobial therapy and acetazolamide, visual loss worsened. An external ventricular drain (EVD) was urgently placed for CSF diversion. The use of CSF diversion, antimicrobial therapy, and acetazolamide led to significant improvement in the patient’s symptoms with nearly complete resolution. The EVD could be weaned, and permanent CSF diversion was not needed. LESSONS This case highlights a rare but significant complication of neuroborreliosis. Intracranial hypertension with resulting neurological deterioration, while uncommon, can occur in patients with Lyme disease. Management is most often medical, consisting of intravenous antibiotics and acetazolamide to reduce CSF production. In rare cases, temporary CSF diversion is necessary and can provide significant benefits to select patients. https://thejns.org/doi/10.3171/CASE2451

Objective: The purpose of this study is to analyze cranial width and length growth curves in the early postoperative period of patients by undergoing endoscopic sagittal strip craniectomy (ESC) to determine the timing of the maximal growth curve change. By analyzing the complex interplay of cephalic length and width measurements, we hope to better understand the cephalic index (CI) growth curve during this early period. This is the first of a multistep process to elucidate the ideal cranial remolding orthosis (CRO) treatment duration. Design: Retrospective review. Setting: Tertiary academic institution. Patients: Children with isolated sagittal craniosynostosis. Interventions: ESC and postoperative CRO treatment (2015-2019). Main Outcome Measures: One cranial orthotist obtained preoperative and postoperative measurements. The maximal rate of change of width, length, and CI were compared against the postoperative week these occurred. Results: Thirteen children (mean age: 3.3 months, average preoperative CI: 73.4) underwent this intervention. CI reached its highest growth rate by 4.9 average weeks postoperatively, which correlated with the maximal width growth rate (5.2 weeks). Length curves reached their maximal growth rate by 15.5 weeks. CI peaked (81.3) by 22.7 weeks postoperatively, a significant increase from baseline. Conclusions: Following ESC, in the early postoperative period, the CI growth curve has 4 phases: initial rapid expansion, early and late slowed expansion, and plateau, followed by possible regression phases. This highlights the importance of early postoperative CRO initiation, CRO compliance, and properly fitting CROs, especially in the first 2 phases. This data sets the stage for investigating the ideal treatment length.

Objective The study objective was to characterize shared online experiences surrounding craniosynostosis. Methods Isolated and syndromic craniosynostosis-related consecutive posts (N = 700) made by patients and caregivers were extracted from TikTok and Instagram between 2017-2024. A cross-sectional qualitative analysis following guidelines for practical thematic analysis was performed. Results The majority of posts were by caregivers (96%) and by females (97%). Forty categorical subthemes from social media posts were synthesized into 4 predominant themes. Overarching thematic trends included Emotional and Psychological Support (47%), Medical Information and Treatment (27%), Family and Social Dynamics (15%), and Awareness, Education, and Advocacy (12%). Conclusion Social media is used by caregivers, primarily mothers, for emotional support, processing health information, sharing experiences, raising awareness, and celebrating “cranioversaries.” Male and patient perspectives were underrepresented. Physicians may use social media to gain insights, disseminate quality health information, and connect with patients.

Decision-makers objectively commit to a definitive choice, yet at the subjective level, human decisions appear to be associated with a degree of uncertainty. Whether decisions are definitive (i.e., concluding in all-or-none choices), or whether the underlying representations are graded, remains unclear. To answer this question, we recorded intracranial neural signals directly from the brain while human subjects made perceptual decisions. The recordings revealed that broadband gamma activity reflecting each individual's decision-making process, ramped up gradually while being graded by the accumulated decision evidence. Crucially, this grading effect persisted throughout the decision process without ever reaching a definite bound at the time of choice. This effect was most prominent in the parietal cortex, a brain region traditionally implicated in decision-making. These results provide neural evidence for a graded decision process in humans and an analog framework for flexible choice behavior. Whether decisions are made in a graded or all-or-none fashion remains unclear. Here, the authors provide evidence to suggest that decisions conclude in a graded, rather than a binary, manner, thus providing an analog framework for flexible choice behavior.

BACKGROUND:Craniosynostosis, a condition involving the premature fusion of cranial sutures, can impair brain development and potentially lead to developmental delays. This study compares open cranial vault remodeling versus endoscopic strip craniectomy treatment for isolated sagittal craniosynostosis, primarily focusing on development outcomes. METHODS:A retrospective cohort study was conducted at a tertiary pediatric surgery center, involving all 45 patients treated surgically for isolated sagittal craniosynostosis from 2013 to 2024. Patients were categorized into 2 groups based on surgical intervention: open cranial vault remodeling (n=17) and endoscopic strip craniectomy (n=28). Data collected included patient demographics, intraoperative specifics, and postoperative outcomes. Developmental outcomes were assessed using postoperative progress notes. RESULTS:Of the 45 patients, those undergoing open surgery were older (10.7 mo and 9.4 kg versus 3.3 mo and 6.4 kg, P <0.001) and experienced higher use of intraoperative drains (65% versus 0%, P <0.001), more prolonged procedures (189 versus 58 min, P <0.001), more significant blood loss (102 versus 62 mL, P =0.009), longer stays (3.3 versus 2.6 d, P =0.011), and higher opioid prescription rates (82% versus 43%, P =0.013) compared to the endoscopic group. Within 12 months postoperatively, social delays were more common in the open group (19 versus 0%, P =0.049), and, postoperatively in general, cognitive delays were more common in the open group (31% versus 4%, P =0.023) when compared to the endoscopic group. CONCLUSIONS:Endoscopic cranial vault remodeling produces preferentially better hemodynamic, postoperative, and hospital stay outcomes. Although inferences into long-term developmental delay outcomes were limited due to sample size, a preferential benefit toward endoscopic intervention may exist.

Abstract PURPOSE To assess the surgical utility of intraoperative neuromonitoring (IONM) as a safety measure to ensure safe operative conditions in Chiari I malformation patients undergoing FMD. METHODS This represents a retrospective cohort study examining symptomatic Chiari I malformation patients at one tertiary care center that underwent FMD using IONM between January 2017 and 2022. Brainstem auditory evoked response (BAER), somatosensory evoked potentials (SSEP), motor evoked potentials (MEP), and electromyography (EMG) were utilized in all cases. Patients with and without IONM changes were directly compared. Linear regression analysis was completed to identify variables predictive of IONM changes. RESULTS Forty-eight patients met inclusion criteria, with ages ranging from 1 to 52 years (mean 15 years). The incidence of co-existing syringomyelia was 40% (n = 19), scoliosis 15% (n = 7), and tethered cord 0%. Four patients (8%) experienced IONM changes intraoperatively, all manifesting as decreases in MEPs. These were corrected by increasing mean arterial pressure (n = 1) or patient and head and neck repositioning (n = 3). Scoliosis predicted IONM changes (Beta 0.30, p = 0.04). Absence of syringomyelia trended towards predicting against IONM changes, however this did not reach significance (Beta − 0.24, p = 0.09). CONCLUSION IONM may be a useful tool to help facilitate safe FMD in Chiari I malformation patients. While this represents a single center experience with a small patient sample size, our data suggests that the utilization of IONM as a safety measure to prevent iatrogenic temporary or permanent neurologic deficit may be beneficial and warrants further study.

-BACKGROUND: Spontaneous primary intracerebral hemorrhage (ICH) accounts for 10%-15% of strokes and is accompanied by ventricular involvement in 10%-30% of cases. Intraventricular hemorrhage (IVH) is a poor prog-nostic factor and the current treatment paradigm of external ventricular drainage requires frequent flushing and replacement. Given the documented high rate of failure standard EVD catheters, we sought to determine if the use of the IRRAflow system with the addition of alteplase would be beneficial in this patient population for the treatment of IVH associated with primary hypertensive ganglionic hemorrhages.-METHODS: Three patients with ganglionic hemorrhages and IVH underwent treatment with the IRRAflow system at our institution from December 2022 to January 2023. A retrospective review was then performed of patients with primary hypertensive ganglionic hemorrhages and EVD placement at our institution from January 2021 to present day.-RESULTS: Three patients underwent treatment with the IRRAflow system and continuous lavage of Tissue Plas-minogen Activator (tPA). The IVH was efficiently cleared in all cases and the drains were removed within 8 days in all cases. No patients required replacement of the drain and there were no hemorrhagic complications noted. In our retrospective review, 28 patients were identified who un-derwent placement of a standard EVD for the treatment of primary hypertensive ganglionic hemorrhages. When pa-tients who had early withdrawal of care were excluded, the average length of EVD treatment was 11.3 days and the EVD replacement rate was 24%.-CONCLUSIONS: We demonstrate here that the use of the IRRAflow system for the treatment of primary hypertensive hemorrhages with IVH results in rapid clearance of the IVH without safety concerns. Compared to historical controls there was a decrease in EVD duration, EVD replacement and, ICU LOS.

BACKGROUND Diffuse leptomeningeal glioneuronal tumor (DLGNT) is a rare brain tumor only recently classified by the World Health Organization in 2016 and has few reports on its incidence in adults. OBSERVATIONS The authors describe a case of DLGNT presenting in a 47-year-old female with seizures, cranial neuropathies, and communicating hydrocephalus with rapid clinical progression. Workup demonstrated progressive leptomeningeal enhancement of the skull base, cranial nerves, and spine, and communicating hydrocephalus. Elevated serum rheumatological markers and early response to systemic corticosteroids and immunosuppressant therapy complicated the diagnosis. Multiple biopsy attempts were required to obtain diagnostic tissue. Pathology demonstrated hypercellularity surrounding leptomeningeal vessels with nuclear atypia, staining positive for GFAP, Olig2, S100, and synaptophysin. Molecular pathology demonstrated loss of chromosome 1p, BRAF overexpression but no rearrangement, and H3K27 mutation. Repeat cerebrospinal fluid (CSF) diversion procedures were required for hydrocephalus management due to high CSF protein content. LESSONS This report describes a rare, aggressive, adult presentation of DLGNT. Leptomeningeal enhancement and communicating hydrocephalus should raise suspicion for this disease process. Biopsy at early stages of disease progression is essential for early diagnosis and prompt treatment. Further study into the variable clinical presentation, histological and molecular pathology, and optimal means of diagnosis and management is needed.

Ventriculoperitoneal (VP) shunts are a common neurosurgical procedure used to treat hydrocephalus. Despite their efficacy, many shunts fail and require revisions. The most common causes of shunt failure include obstruction, infection, migration, and perforation. Extraperitoneal migrations require urgent attention. We present a case of migration to the scrotum, a unique complication that may be present in young patients due to the presence of a patent processus vaginalis. Here, we discuss a case of a 16-month-old male patient with a VP shunt presenting with cerebrospinal fluid (CSF) drainage from his scrotum after an indirect hernia repair. This case represents an important reminder for physicians about the sequelae associated with VP shunt complications, particularly extraperitoneal migration, and brings awareness to the underlying factors that may increase this risk.

Aim: The objective of this study was to assess which clinical and radiographic findings may be associated with neurological decline in patients with temporal lobe mass lesions. Patients and Methods: This represents a retrospective cohort study. Neurological decline was defined as a decline in Glasgow Coma Scale of 2 or more or new anisocoria. Adult patients aged 18 to 89 years with isolated temporal lobe, intra-axial, contrast-enhancing masses diagnosed between 1/1/2010 and 12/31/2020 were included. Clinical and radiographic findings were collected for each patient. Linear regression analysis was used to identify findings predictive of neurological decline. Patients with neurological decline were compared to stable patients to identify factors that may increase risk for neurological decline. Results: A total of 71 patients met the inclusion criteria. Four out of the 71 patients experienced neurological decline, representing an incidence of 6%. Linear regression analysis identified only radiographic transtentorial herniation as a predictor of neurological decline (β=0.26, p=0.03). A midline shift greater than 5 mm (100% vs. 40%; odds ratio=1.12, 95% confidence interval=1.00-1.32; p=0.05) and radiographic transtentorial herniation (75% vs. 18%; odds ratio=32.12, 95% confidence interval=3.91-264.18; p=0.03) were significantly more prevalent in patients with neurological decline and were associated with an increased risk of neurological decline. Conclusion: Radiographic transtentorial herniation and a midline shift greater than 5 mm may be useful findings to suggest an increased risk of neurological decline in patients with masses of the temporal lobe. This knowledge may be useful to neurosurgeons and physicians in other specialties to best care for this patient population.