The patient presented with left-sided chemosis, exophthalmos, and progressive visual loss. Cerebral angiography ed a left orbital arteriovenous malformation and an associated hematoma, with the point of fistulation between the left ophthalmic artery and the anterior section of the inferior ophthalmic vein, with retrograde flow through the superior ophthalmic vein. Transvenous embolization through the anterior facial and angular veins was unsuccessful, with residual shunting. Stereotactic-guided direct venous puncture and Onyx embolization was subsequently performed in the hybrid operating room (OR) to cure the fistula. A subciliary incision allowed for retraction of the orbital contents, creating an optimal trajectory. An endonasal endoscopic approach was performed after the embolization to decompress the orbit. This procedure is shown in video 1.1-11

We present the case of a 40-year-old man who presented with symptoms of left-sided proptosis, conjunctival injection, and intermittent left-sided headaches. Clinical examination revealed left-sided exophthalmos, chemosis, and elevated intraocular pressure. Computed tomography angiography confirmed an indirect carotid-cavernous fistula, with thrombosed facial, angular, and superior ophthalmic veins. Owing to a lack of arterial or venous access for endovascular treatment, a percutaneous direct fistula puncture was planned. The patient was positioned in a hybrid operating room, and the ROSA stereotactic robot was used for accurate trajectory planning. A left transtemporal approach successfully punctured the fistula, confirmed by intraoperative O-arm fluoroscopic computed tomography and angiogram. Under roadmap guidance, a balloon was positioned, and Onyx 18 was injected, achieving complete fistula embolization. The postprocedure angiogram confirmed the resolution of the fistula, and the patient woke up with no deficits, demonstrating the resolution of symptoms. While coil embolization remains the standard treatment of carotid-cavernous fistulas, our case suggests that transtemporal needle puncture with Onyx embolization is a viable alternative, particularly when facilitated with the ROSA stereotactic robot and intraoperative imaging. This operative video provides valuable insights into the treatment of complex carotid-cavernous fistulas, emphasizing the utility of a hybrid OR and stereotactic robotic guidance.1-7 The patient consented to the procedure, and the participants and any identifiable individuals consented to publication of his/her image.

A middle-aged patient presented with right-sided chemosis, exophthalmos, and progressive visual loss. Digital subtraction angiography revealed a type D carotid-cavernous fistula (CCF). Transarterial embolization through the internal maxillary artery was unsuccessful, and there was no venous access to the CCF. A robotic-guided direct transtemporal embolization of the CCF with Onyx was performed, resulting in successful fistula obliteration and symptom resolution. This is the first reported case of a robotic-guided direct transcranial CCF embolization. We include a technical video that demonstrates this procedure (Supplemental File 1)

We present the case of a 67-year-old patient with a left middle cerebral artery (MCA) aneurysm treated with a Woven EndoBridge (WEB) device, who experienced neck recurrence after initial complete obliteration. The initial angiogram showed a wide-necked left MCA aneurysm that measured 8 × 7 mm with a 5-mm neck, treated with a WEB device. Post implantation, the initial follow-up angiogram showed complete obliteration. However, subsequent angiogram showed neck recurrence measuring 6.6 × 1.7 mm. The WEB device has become a popular alternative to traditional clipping and coiling procedures, with studies reporting successful treatment of 85%. However, concerns have been raised regarding the device's efficacy in achieving complete aneurysm obliteration, with a lower rate of complete aneurysm occlusion and a higher rate of recurrence compared with surgical clipping. The decision was made to retreat with clipping, and the surgery was successful in completely obliterating the aneurysm. The patient had no residual MCA aneurysm, with both M2 branches patent on postoperative angiogram. Literature review of retreatment options for WEB device failures highlights that the retreatment rate after WEB embolization is approximately 10%. For surgically accessible aneurysms, surgical clipping is an effective retreatment strategy after WEB failure given the compressibility of the device. Video 1 and our literature review provide valuable insights into a rare case of aneurysm recurrence after complete obliteration at initial follow-up after WEB embolization that was successfully treated with surgical clipping.1-8.

We present the case of a 62-year-old patient who presented with symptoms of difficulty in wordfinding and vertigo.Computed tomography scan of the head was performed, which showed an oval-shaped area of hyperdensity at the leftsuperior temporal lobe, measuring around 3.7 x 2.3 cm. MRI, axial T2 imaging revealed a giant, partially thrombosed,fusiform left middle cerebral artery (MCA) aneurysm. Further evaluation with digital subtraction angiography again revealed the filling portion of the fusiform aneurysm, involving the left temporal MCA division with visible stenosis of theparent vessel both before and after the fusiform segment, consistent with a dissecting aneurysm. The outflow branch of the aneurysm supplied the Wernicke area.Treatment options were discussed. Given the eloquence of the outflow vessel, a flow preservation option was necessary. The patient consented to the procedure. Direct superficial temporal artery to middle cerebral artery bypass was performed, and perfusion was maintained in eloquent regions. Under road map guidance, the aneurysmwas occluded using platinum coils. Fusiform aneurysmsof the middle cerebral artery MCA are uncommon and cancause compression or distal thrombus migration. In complex cases, surgical clipping or endovascular coiling maynot work, requiring vessel sacrifice and direct arterial bypass for effective treatment. A literature review was performed including 17 studies on cranial aneurysms treated with endovascular embolization and arterial bypass;the overall success rate was 84%, with 16% of patients experiencing postoperative infarction.(1-17)This video article and literature review provide valuable insights into the treatment of complex giant fusiform aneurysms with superficial temporal artery to middle cerebral artery bypass and endovascular vessel sacrifice.

Pure endoscopic technique in resection of intraventricular tumors is an emerging technology. This case demonstrates resection of a multicentric choroid plexus papilloma in a 2-month-old child. This child had two district tumors: one located in the left atrium and another in the third ventricle. Initial microsurgery was performed to resect the left atrial tumor. With the tumor noted to be not very vascular at initial surgery, the third ventricle tumor was resected with a GAAB neuroendoscope and NICO Myriad. A gross-total resection was achieved. At 3 years' follow-up, the child remains tumor free and developing without any functional deficits. The video can be found here: https://stream.cadmore.media/r10.3171/2023.1.FOCVID22145.

The coronavirus 2019 (COVID-19) pandemic has had drastic effects on the volume of neurosurgical procedures. This decrease was seen worldwide with institutions reporting a drop in surgical volume of up to 54.7%. In the United States, Emory University reported an 80% decrease in case of volume during the lockdown period from March 16 to April 15, 2020. In France, 32 centers reported a 21% decrease in mechanical thrombectomy volume during the lockdown period compared to 2019. However, there have been few reports of endovascular volume beyond the initial lockdown period of the pandemic. The present study reports neuro-endovascular volume in the US during various phases of the COVID-19 pandemic with a focus on aneurysm treatment. We also discuss how normalization of volume may be achieved.

OBJECTIVE The authors compared survival and multiple comorbidities in children diagnosed with craniopharyngioma who underwent gross-total resection (GTR) versus subtotal resection (STR) with radiation therapy (RT), either intensity-modulated radiation therapy (IMRT) or proton beam therapy (PBT). The authors hypothesized that there are differences between multimodal treatment methods with respect to morbidity and progression-free survival (PFS). METHODS The medical records of children diagnosed with craniopharyngioma and treated surgically between February 1997 and December 2018 at Texas Children's Hospital were reviewed. Surgical treatment was stratified as GTR or STR + RT. RT was further stratified as PBT or IMRT; PBT was stratified as STR + PBT versus cyst decompression (CD) + PBT. The authors used Kaplan-Meier analysis to compare PFS and overall survival, and chi-square analysis to compare rates for hypopituitarism, vision loss, and hypothalamic obesity (HyOb). RESULTS Sixty-three children were included in the analysis; 49% were female. The mean age was 8.16 years (95% CI 7.08-9.27). Twelve of 14 children in the IMRT cohort underwent CD. The 5-year PFS rates were as follows: 73% for GTR (n = 31), 54% for IMRT (n = 14), 100% for STR + PBT (n = 7), and 77% for CD + PBT (n = 11; p = 0.202). The overall survival rates were similar in all groups. Rates of hypopituitarism (96% GTR vs 75% IMRT vs 100% STR + PBT, 50% CD + PBT; p = 0.023) and diabetes insipidus (DI) (90% GTR vs 61% IMRT vs 85% STR + PBT, 20% CD + PBT; p = 0.004) were significantly higher in the GTR group. There was no significant difference in the HyOb or vision loss at the end of study follow-up among the different groups. Within the PBT group, 2 patients presented a progressive vasculopathy with subsequent strokes. One patient experienced a PBT-induced tumor. CONCLUSIONS GTR and CD + PBT presented similar rates of 5-year PFS. Hypopituitarism and DI rates were higher with GTR, but the rate of HyOb was similar among different treatment modalities. PBT may reduce the burden of hypopituitarism and DI, although radiation carries a risk of potential serious complications, including progressive vasculopathy and secondary malignancy. Further prospective study comparing neurocognitive outcomes is necessary.

Metastatic lesions to the choroid plexus, although far less common than colloid cysts, can present very similarly both symptomatically and radiographically. Choroid plexus metastases are most common in the lateral ventricles, however, when they occur in the third and fourth ventricles they may cause obstructive hydrocephalus typical of a colloid cyst lesion. Renal cell carcinoma is the most common primary cancer, but many rare primaries have been reported. When patients are presenting with symptoms typical of colloid cysts it is important to consider past oncological history and if past medical history is significant for cancer using MR spectroscopy may be valuable in distinguishing between cystic and metastatic lesions.

OBJECTIVE:The advent of endoscopic synostectomy has enabled early surgery for infants with craniosynostosis. Even though diagnosis is often made at birth, endoscopic synostectomy has traditionally been delayed until the infant is 3 months of age. There have been very few published reports of this procedure being performed in the early neonatal period. The authors discuss their experience with ultra-early endoscopic synostectomy, defined as an operation for infants aged 8 weeks or younger.METHODS:A retrospective analysis of infants who underwent operations at or before 8 weeks of age between 2011 and 2020 was done.RESULTS:Twenty-five infants underwent operations: 11 were 2 weeks of age or younger, 8 were between 3 and 4 weeks of age, and 6 were between 5 and 8 weeks of age. The infants weighed between 2.25 and 4.8 kg. Eighteen had single-suture synostosis, and 7 had multiple sutures involved. Of these 7, 4 had syndromic craniosynostosis. The average operative time was 35 minutes, and it was less than 40 minutes in 19 cases. The estimated operative blood loss was 25 ml or less in 19 cases; 5 infants required an intraoperative blood transfusion. In 1 child with syndromic multisuture craniosynostosis, the surgery was staged due to blood loss. Two children experienced complications related to the procedure: one had an incidental durotomy with skin infection, and the other had postoperative kernicterus. All infants were fitted for cranial remodeling orthoses following surgery. Three of the 25 infants required reoperations, with 2 patients with syndromic craniosynostosis needing repeat surgery for cranial volume expansion and cosmetic appearance. Another child with syndromic craniosynostosis is awaiting cranial expansion surgery. Follow-up varied between 6 months and 8 years.CONCLUSIONS:The data show that ultra-early synostectomy is safe and not associated with increased complications compared with surgery performed between 3 and 6 months of age. Infants with multisuture synostosis had increased operative time, required blood transfusion, and were more likely to require a second operation.

The growing elderly population in Western societies has led to an increasing number of primary brain tumors occurring in patients beyond the age of 65. The purpose of this study was to assess and compare the safety, efficacy, and outcomes of oncological craniotomy procedures between patients above and below 65 years. We performed a retrospective analysis of the ACS-NSQIP database to identify patients undergoing supratentorial and infratentorial tumor excisions by neurosurgeons between 2008 and 2016. We stratified them based on a cutoff age of 65 years and analyzed for minor and major complications, reoperation, the total length of hospital stay, and mortality within a standardized 30-day follow-up. Among the 30,183 analyzed patients, 9,652 (32%) were elderly (age >= 65). The bivariate analysis demonstrated significantly increased risk of complications, including major and minor complications and mortality in patients with metabolic syndrome, preoperative steroid use, and ASA classification >= 3. (pvalue <= 0.001***). After controlling for confounding variables in our logistic regression models, older age, metabolic syndrome, extended operative time beyond 5 h, dependent functional health status, ASA class >= 3, steroid use pre-operatively, and black/African American race were found to be significant predictors of major and minor complication. Our study provides a comprehensive analysis of perioperative risk factors and predictors of adverse outcomes following craniotomy for supratentorial and infratentorial tumors in elderly patients. We identified increased age as an independent risk factor for minor and major adverse events as well as extended hospitalization. (C) 2020 Elsevier Ltd. All rights reserved.

BACKGROUND: When diagnosed simultaneously, obesity, diabetes, and hypertension form a medical constellation called metabolic syndrome (MetS). The prevalence of MetS in Western cultures has been on a steady increase and MetS has been associated with increased postoperative complications in multiple surgical settings. OBJECTIVE: In this study, we evaluate the relationship between MetS and the outcomes of craniotomy for supratentorial brain tumor. METHODS: Cases of craniotomy for supratentorial brain tumors were extracted from the American College of Surgeons National Surgical Quality Improvement Program for 2012-2016. The 15,136 patients identified were divided into 2 cohorts based on the presence (4.1%) or absence (95.9%) of MetS. We compared the 2 cohorts for preoperative comorbidities, intraoperative details, and postoperative morbidity and mortality. RESULTS: Patients in the MetSD cohort were significantly older (63.4 vs. 56.1 years) and were more likely to show comorbidities of various organ systems (all P <= 0.05). However, operative times were similar (P = 0.573). The number of medical complications was almost double in patients with MetS (15.8% vs. 8.5%; P <= 0.001). Unplanned readmissions (14.6% vs. 10.4%; P = 0.004), reoperations (6.9% vs. 4.6%; P = 0.007), and mortality (5.6% vs. 2.9%; P <= 0.001) were also more frequent in our MetSD group. Nevertheless, surgical complications localized to the operative site were not statistically increased (7.4% vs. 5.8%; P = 0.098). CONCLUSIONS: A diagnosis of MetS does not seem to be associated with increased rates of surgical site events. However, neurosurgeons should be aware that these patients have a significantly higher likelihood of general medical complications, readmissions, reoperations, and death.

INTRODUCTION: Idiopathic scoliosis is the lateral curvature of the spinal column greater than 10° with no established etiology. In skeletally immature pediatric patients, risk of progression is associated with the severity of curvature. It has been estimated that this risk is nearly 90% for patients with curvatures exceeding 50°, and this is typically the severity at which surgical management is indicated. Current surgical techniques rely heavily on posterior instrumentation with pedicle screw systems. Cortical bone trajectory (CBT) screws are increasingly used in the adult lumbar spine. CBT screws utilize a significantly different medial-to-lateral, inferior-to-superior trajectory compared with traditional pedicle screws. They require less tissue dissection and shorter length screws. Additionally, biomechanical studies have demonstrated greater pullout strength of CBT screws in comparison with traditional pedicle screws owing to greater purchase of cortical bone. These features make them attractive for use in pediatric lumbar spine; however, there are few clinical or radiographic studies regarding CBT screw fixation in children. The authors examined the lumbar spine in pediatric patients to define morphometric differences compared with adults, establish guidelines for CBT instrumentation in idiopathic scoliosis, and define potential limitations of this technique in the pediatric age group. METHODS: Measurements of the trajectory diameter, length, lateral angle to the vertebral sagittal plane, and cephalad angle to the vertebral horizontal plane were obtained from 3-dimensional reconstructions of abdominal and pelvic CT scans of 30 pediatric patients. RESULTS: For most levels and measurements, results in boys and girls did not differ significantly; the few values that were significantly different are not likely to be clinically significant. However, younger (<12 years of age) and older children (>12 years of age) differed significantly in screw acceptance size at multiple levels. A screw acceptance analysis found that all patients >4 years of age could accept at least a 4 × 20 mm CBT screw. CONCLUSION: Cortical bone trajectory screws appear to be a useful proposed fixation strategy in JIS and AIS. This may offer an alternative to pedicle screw instrumentation for the surgical management of idiopathic scoliosis.