BACKGROUND:Complex cranial wounds can be a problematic occurrence for surgeons. Vacuum-assisted closure devices have a wide variety of applications and have recently been used in neurosurgical cases involving complex cranial wounds. There is only one report regarding the use of a vacuum-assisted closure device with loss of dura mater. We report a complicated case of a necrotic cranial wound with loss of dura mater. CASE DESCRIPTION:A 68-year-old female underwent an evacuation of a subdural hematoma. Postoperatively, the patient developed a wound infection that required removal of the bone flap. The wound developed a wedge-shaped necrosis of the scalp with exposure of brain tissue due to loss of dura mater from previous surgeries. She underwent debridement and excision of the necrotic tissue with placement of a synthetic dural graft (Durepair®, Medtronic, Inc.) and placement of a wound vac. The patient underwent a latissismus dorsi muscle flap reconstruction that subsequently failed. After the wound vac was replaced, the synthetic dural graft was replaced with a fascia lata graft and an anterolateral thigh free flap reconstruction. We describe the technical nuances of this complicated case, how the obstacles were handled, and the literature that discusses the utility. CONCLUSION:We describe a case of a complex cranial wound and technical nuances on how to utilize a wound-vac with loss of dura mater.

Background: Traumatic injuries to the thoracolumbar spine result in a high incidence of unstable fractures. The goal of the surgical management is to achieve an adequate decompression and stabilization. We have analyzed operative and postoperative features of anterior surgical approaches.Methods: We retrospectively analyzed the medical records of 45 patients that presented with traumatic unstable thoracolumbar fractures who underwent anterior corpectomy with stabilization from January 1999 to January 2009. The neurological status of the patient was defined using the American Spinal Injury Association (ASIA) impairment scale.Results: The average age of the patients was 37.6 years (range: 13-70), with a male-to-female ratio of 1.5:1. Retroperitoneal approach was used in 64.4%, transthoracic in 13.3%, and transthoracic transdiaghragmatic in 22.2%. The average operation time, estimated blood loss (EBL), and length of stay after surgery was 4123 min, 1098 ml and 9.1 days, respectively. A BMI > 25 was associated with longer operative times (p < 0.02) and higher EBL (p < 0.006). Perioperative complications occurred in 37.7%, (7 major, 10 minor). The mean sagittal angulation improved from 15.5 degree preoperatively to 8.7 degree postoperatively (p < 0.001). Postoperative neurological status remained intact in all patients having preoperative ASIA-E status (n = 18), improved in 7 of 14 patients with ASIA-D, and improved in 1 of 5 patients with ASIA-B preoperative neurological deficit. There were no cases of neurological deterioration postoperatively, and majority of the patient (84.4%) of the patients were discharged home. At latest follow-up (mean 27.2 months) there were no new cases of neurological deficits, and 9 patients had a further improvement of neurological status.Conclusions: Based on our findings, anterior surgical approach appears to be a safe and effective technique for managing traumatic thoracic and lumbar unstable burst fractures. This is also evident that anterior decompression and stabilization achieves a significant correction of kyphotic deformity with a lower risk of neurological deterioration and pseudoarthrosis. (C) 2015 Published by Elsevier B.V.

The aim of our study was to evaluate the long term efficacy of microvascular decompression (MVD) and gamma knife radiosurgery (GKRS) with respect to pain relief and patient satisfaction. Both these modalities are accepted modalities of treatment for intractable trigeminal neuralgia. We excluded deceased patients, those who had a prior intervention and those requiring an additional intervention following initial treatment. A total of 69 patients were included in the study. Of these, 49 patients underwent treatment by GKRS and 20 by MVD. Pain status was assessed using the Barrow Neurological Institute (BNI) pain scale. The median follow up was 5.3years. There was no significant difference between the two groups with respect to initial pain relief (100% MVD, 84% GKRS; p=0.055). There was no significant difference in pain recurrence between the two groups (39% GKRS, 20% MVD; p=0.133). At last follow up, 85% of patients who underwent MVD had total pain relief (BNI scale I) compared to only 45% of GKRS patients (p=0.002). There was no significant difference in the patient satisfaction with respect to undergoing the same procedure again (90% MVD, 69% GKRS; p=0.1) and recommending it to family members (95% MVD, 84% GKRS; p=0.2). MVD offered total pain relief in a significantly higher number of patients than GKRS. There was no significant difference in the patient satisfaction rate between the two groups.

BACKGROUND AND PURPOSE:The use of computed tomography angiography (CTA) as the sole vascular imaging study for preoperative planning for clipping of aneurysms is well described in the literature. CTA is widely available, provides quick acquisition, has low morbidity, and low cost. In this study, we describe the accuracy of CTA in determining the blood supply dominance in comparison to standard digital subtraction angiography.MATERIALS AND METHODS:Sixty-six patients, with both CTAs and angiograms, were reviewed by two independent neuroradiologists. The posterior cerebral artery was determined to have dominant supply from the posterior communicating artery if it was of similar size to the P2 segment and the P1 segment was smaller by approximately 50%. If the posterior communicating artery and P1 segment were the same size, it was considered to have a dual supply. If P1 and P2 segments were the same caliber and the posterior communicating artery was smaller by 50%, it was deemed to have posterior circulation dominance.RESULTS:Based on the findings of our reviewers, CTA had a sensitivity and specificity of 69% and 96%, respectively, in predicting the presence of a fetal PCA. The positive predictive value was found to be 82% while a negative predictive value was estimated as 93%. A small-caliber P1 segment and large-caliber posterior communicating artery led to inaccurate interpretations of the CTAs.CONCLUSION:This study shows that one cannot accurately predict blood supply dominance of the posterior cerebral artery. Knowledge of the blood flow dominance is essential when clipping a posterior communicating artery aneurysm to avoid compromise in posterior circulation.

Introduction: Hemangiopericytomas usually occur in the soft tissue and skeletal system. They rarely present in the spinal canal as a primary tumor. There are several case reports describing primary spinal hemangiopericytomas of the cervical and thoracic spine; however, there are only 3 reports of sacral hemangioperictyomas (Liu, 2013; McMaster, 1975; Zhao, 2007). We report an extremely rare presentation of a primary spinal hemangiopericytoma arising from the S2 nerve root with local bony destruction of the sacrum. Case Report: A 52 year-old male presented with low back pain and left lower extremity numbness and tingling. MRI showed a 5.2 cm x 5.7 cm sacral mass, and CT showed local bony destruction of the sacrum. He complained of left S2 pain. The patient was taken for resection of the tumor. A gross total resection was achieved from a posterior midline approach. A corridor lateral to the sacral nerves allows resection of the ventral portion of the tumor. A gross total resection was achieved with a small residual adherent to the left S2 nerve root. Pathology confirmed the tumor to be a grade II hemangiopericytoma. Adjuvant radiotherapy was recommended due to the residual.

Background: Tissue plasminogen activator (tPA) is the only FDA-approved therapy for acute ischemic stroke, but it has narrow therapeutic window (within 4.5h) and increased risks of intracerebral hemorrhage. Taurine, an endogenous 2-aminoethansulfolic amino acid, exhibits a plethora of physiological functions. It has been found to protect against ischemic brain injury in animal models of stroke by diverse mechanisms. Strikingly, published data show that the therapeutic window of taurine was at least 8h after the onset of ischemic stroke, thus potentially allowing for delayed or more effective thrombolysis. In this study we investigated whether combination therapy with taurine plus tPA can block hemorrhagic transformation and thus extend the time window of tPA after delayed tPA treatment for ischemic stroke. Methods and Results: Male adult rats (330-380g) were subjected to embolic middle cerebral artery occlusion and then randomized into different treatment groups: saline injected at 4h; taurine (50 mg/kg) at 4h, tPA (10 mg/kg) at 6h, and combination therapy with taurine at 4h plus tPA at 6h after the onset of ischemia. Delayed 6-hour tPA did not decrease infarction but instead worsened brain hemorrhage. Combining taurine with delayed 6-hour tPA reduced tissue infarction, attenuated blood-brain barrier disruption by reduced degradation of tight junction proteins (claudin-5 and collagen IV), and ameliorated brain hemorrhage. These protective effects are correlated with decreased brain matrix metallopeptidase-9 activity possibly through inactivation of NF-kB and CD147 (a potent inducer of MMPs) in the postischemic brain, particularly in the cerebral microvessels (using structurally intact microvessels isolated from the brain). Conclusion: The present study demonstrates for the first time that combination therapy with taurine may attenuate delayed tPA-associated hemorrhagic transformation and extend tPA treatment time windows in a clinically relevant thromboembolic stroke model. Inhibition of MMP-9 in brain microvessels via inactivation of NF-κB and CD147 signaling may underlie the protective mechanisms of taurine.

Background: Preoperative assessment of anterior communicating artery (AcoA) aneurysms with cerebral angiography is common, but not without risk. Computed tomography angiography (CTA) is a widely available imaging modality that provides quick acquisition, low morbidity, and low cost. One disadvantage is that it does not provide dynamic information. In this study, the authors sought to determine whether CTA alone can reliably predict the inflow dominance to an AcoA aneurysm.Methods: Eighty-three patients with ruptured AcoA aneurysms were reviewed retrospectively. Only those patients with both preoperative CTA and cerebral angiogram were included, thus excluding six patients. Four independent observers reviewed the CTAs and attempted to identify the dominant A1. Additionally, three mathematical models were created to identify the dominant A1. These responses were compared to cerebral angiograms.Results: Four observers were correct in judging the dominant A1 an average of 93% of the time. Seventeen cases were read incorrectly by only one of four observers, and three cases were read incorrectly by two observers. For cases with incorrect readings, the average percentage difference in A1 sizes was 19.6%. For cases read unanimously correct, the average percentage difference in A1 sizes was 42.7%. Mathematical model #3 correctly evaluated the dominant A1 in 97% of the cases.Conclusions: This study found CT angiograms can be reliable in predicting the inflow dominance to the majority of AcoA aneurysms.

OBJECT:Treatment of complex intracranial aneurysms with Pipeline embolization device (PED) (ev3/Covidien Vascular Therapies) has gained recent popularity. One application of PEDs that is not well described in the literature is the utility and long-term safety in treatment of vertebrobasilar fusiform (VBF) aneurysms. Despite the advancements in endovascular therapy, VBF aneurysms continue to challenging pathology. The authors provide long-term follow-up of VBF aneurysms treated with PEDs.METHODS:We retrospectively reviewed four patients that were treated at Louisiana State University Health Sciences Center in Shreveport with PEDs for VBFs from 2012 to 2014. Each patient was discussed in a multidisciplinary setting between neurosurgeons and neurointerventionalists. Each patient underwent platelet function tests to ensure responsiveness to anti-platelet agents and was treated by one neurointerventionalist (HC). All patients were placed on aspirin and Plavix and were confirmed for therapeutic response prior to discharge.RESULTS:Follow-up ranged from 12 to 25 months, with a mean of 14.25 months. Two cases presented with a recurrence after the initial treatment, both of which required subsequent treatment. Of the four patients treated, one patient developed hemiparesis and three died.CONCLUSION:Despite reports describing successful treatment of VBF aneurysms with PEDs, delayed complications after obliteration and remodeling can occur. We describe our institutional experience of VBFs treated with PEDs. Treatment of holobasilar fusiform aneurysms may carry a worse prognosis after treatment. Further long-term follow-up will provide a better understanding of this pathology.

Objective: The use of CT angiography (CTA) as the sole, vascular imaging study for preoperative planning for clipping of aneurysms is well described in the literature. Many surgeons will do their preoperative planning and assessment of angioarchitecture based off a CTA. CT angiography is widely available, provides quick acquisition, has low morbidity, and low cost. One disadvantage to conventional angiography is that CT angiography does not provide dynamic information. In this study, we describe the accuracy of CT angiography in determining the presence of a fetal posterior cerebral artery (PCA) in comparison to standard digital subtraction angiography (DSA).

Introduction Spinal intradural lipoma is a rare condition, accounting for < 1% of all spinal cord tumors. Spinal cord lipomas are frequently associated with dysraphism and occur in the thoracic spine. Another common finding is that spinal cord lipomas tend to present in the pediatric population. Isolated nondysraphic cervical lipomas are a rare entity. We discuss a case of nondysraphic cervical lipoma with an exophytic component. Case A 31 year-old woman presented with bilateral numbness in her hands and a burning and aching sensation in her arms for similar to 6 months. The patient did not have any weakness or myelopathic signs. Magnetic resonance imaging T1 showed a T1 hyperintense, T2 hypointense, non-contrast-enhancing mass on the dorsal aspect of the spinal cord with significant compression. The patient underwent a dorsal cervical laminectomy with subtotal resection of an isolated cervical lipoma with an exophytic component. The pathology confirmed the diagnosis of a lipoma.Conclusions Surgicalmanagement of this rare pathology has awide variety of options. Depending on the neurologic deficits, observation to gross total resection may be reasonable options. In our case, a subtotal resection was achieved with no further worsening of neurologic symptoms.

BACKGROUND: Lumbar pedicle screws are placed for internal fixation and help to enhance bony fusion. Optimal screws are medially directed, should be parallel or pointing to the superior endplate, and penetrate 50%-80% of the vertebral body. "Nonparallel" pedicle screws can be inadvertently placed within the confines of the pedicle and vertebral body but are sometimes replaced to obtain a more acceptable postoperative image. A nonparallel (suboptimal) screw is one that is located within the pedicle and body and does not violate bone; however, it is not parallel to the superior endplate. These "cored-out" grooves left in the bone from the initial tap and screw placement may compromise the integrity of the bone and the construct.METHODS: Dual-energy x-ray absorptiometry scans and L4-5 laminectomies were performed on 6 fresh-frozen cadaveric lumbar spines. We placed 2 optimal pedicle screws in L4, 1 optimal screwin L5, and 1 suboptimal screwin L5 (construct A). Axial rotation, flexion/extension, and lateral bending were tested. The suboptimal screw was repositioned in an optimal trajectory and retested (construct B). Pullout strength was performed on optimal and revised L5 pedicle screws.RESULTS: The mean axial rotation stiffness was 1.31 N-m/degrees +/- 0.22 in construct A and 1.19 N-m/degrees +/- 0.17 in construct B (P =0.023; 95% CI [CI], 0.20-0.02). The mean lateral bending stiffness was 0.015 N/mm +/- 0.002 in construct A and 0.016 N/mm +/- 0.002 in construct B (P=0.3; 95% CI, 0.0008e0.001). The mean flexion/extension stiffness was 0.0139 N/mm +/- 0.002 in construct A and 0.0126 N/mm +/- 0.002 in construct B (P =0.01; 95% CI, 0.002-0.0004). Axial rotation and flexion/extension stiffness were significantly different between the 2 groups. The mean pullout strength was significantly higher in the nonrevised parallel screw group compared with the reimplanted parallel screw group (906.93 N +/- 271.17 vs. 608.32 N +/- 207.23, P =0.031). Dual-energy x-ray absorptiometry imaging demonstrated 4 osteopenic and 2 osteoporotic specimens, although differences in bone mineral density did not play a significant role in assessing either the biomechanical parameters or the pullout strength.CONCLUSIONS: Great care is warranted in the initial placement of lumbar pedicle screws. Revising a nonparallel screw placement decreases pullout strength and alters biomechanical movements (axial rotation and flexion/extension) in patients with decreased bone mineral density. If a screw is inadvertently placed nonparallel to the endplate but is within the confines of the pedicle and vertebral body with adequate bone purchase, it should not be revised and rather be left in its place.

Traumatic injury to the posterior fossa is a complex pathologic condition because of the great heterogeneity of lesions present. Treatment of primary brain injuries and prevention of secondary brain injuries is the mainstay of management. It is imperative to recognize traumatic lesions of the posterior fossa early because of the occurrence of rapid neurologic decline. The decision regarding whether or not to proceed with surgical intervention depends on the patient's clinical condition, neurologic status, and imaging findings. Nonoperative management should be considered only if the patient is fully conscious and the associated posterior fossa lesions are small with little or no mass effect.

Spinal arteriovenous lesions represent a heterogeneous set of pathologic entities. As our general understanding of these lesions has evolved, so have the classification systems clini‐ cians use to describe them. Historically, the most common classification of arteriovenous fistulas (AVF) has been the Type I-IV classification. More recently these lesions have been described from an anatomical and physiologic perspective.

Introduction: Skull base and cerebrovascular surgery is laden with technical challenges. These complex surgeries may sometimes lead to morbidities, often with grave consequences. Stroke, cranial neuropathies, CSF fistulas, and hemorrhage are among the complications noted in skull base surgery. Expertise in skull base surgery takes many years of training and practice to obtain. Fellowships, cadaver dissections, and courses are frequent modalities by which the road to expertise is begun in skull base surgery. However, the early years of practice in skull base surgery are a "crash course" in avoidance and management of complications. Our objective is to describe some of these lessons that we have learned in the early years of our skull base practice. We emphasize surgical decision making, technical errors, and learning from those with more experience.

Spine trauma is a devastating clinical condition that affects many people annually on a worldwide basis. Management of spinal trauma has become much more surgically oriented with advances in stabilization techniques over the past two decades. The degree of injury to the spinal cord dictates the prognosis of the patient in cervical and thoracolumbar trauma. Traumatic spinal cord injury is a major area of socioeconomic burden and, as such, is a burgeoning area of ongoing research interest.

Inflammation plays an important role in the pathogenesis of ischemic stroke and other forms of ischemic brain injury. Increasing evidence suggests that inflammatory response is a double-edged sword, as it not only exacerbates secondary brain injury in the acute stage of stroke but also beneficially contributes to brain recovery after stroke. In this article, we provide an overview on the role of inflammation and its mediators in acute ischemic stroke. We discuss various pro-inflammatory and anti-inflammatory responses in different phases after ischemic stroke and the possible reasons for their failures in clinical trials. Undoubtedly, there is still much to be done in order to translate promising pre-clinical findings into clinical practice. A better understanding of the dynamic balance between pro- and anti-inflammatory responses and identifying the discrepancies between pre-clinical studies and clinical trials may serve as a basis for designing effective therapies.

Spinal arteriovenous lesions represent a heterogeneous set of pathologic entities. As our general understanding of these lesions has evolved, so have the classification systems clini‐ cians use to describe them. Historically, the most common classification of arteriovenous fistulas (AVF) has been the Type I-IV classification. More recently these lesions have been described from an anatomical and physiologic perspective.

Spine trauma is a devastating clinical condition that affects many people annually on a worldwide basis. Management of spinal trauma has become much more surgically oriented with advances in stabilization techniques over the past two decades. The degree of injury to the spinal cord dictates the prognosis of the patient in cervical and thoracolumbar trauma. Traumatic spinal cord injury is a major area of socioeconomic burden and, as such, is a burgeoning area of ongoing research interest.

Introduction: The data on correlation of posterior fossa morphometric analysis (PFMA) in adult Chiari I Malformation (CIM) with the extent of tonsillar herniation (EOTH), syrinx formation, and clinical outcomes are lacking. The objective of this study is to elucidate the same and, additionally, assess the role of EOTH and syrinx formation on clinical outcomes.

Introduction: The management nuances of skull base meningiomas in the current era include optimal tumor control and maximal preservation of neurological status. Consequently, gamma knife (GK) radiosurgery has emerged as a popular alternative. Literature on maximum duration after which follow-up can be safely weaned is lacking. This study evaluates the temporal patterns of recurrence of skull base meningioma after secondary GK, either used as an adjuvant to microsurgery for residual lesions (Group A) or for treating recurrent lesions following surgical resection (Group B).