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Minimally invasive surgeries for intracranial pathologies are gaining popularity, recognizing the intrinsic benefits, mostly related to recovery time, while minimizing injury to healthy parenchyma and adjacent functional areas, especially during the resection of deep and centrally located lesions. These procedures require technical familiarity and cultivated surgical experience, coupled with dedicated instruments, appropriate planning, and a stringent patient selection. To describe our novel experience with minimally invasive trans-sulcal parafascicular surgery (MIPS) in a single-center pediatric population, emphasizing the interdependencies between surgical experience, best practices, preparation, and positive surgical outcomes. This single center retrospective review included an electronic medical record (EMR) retrieval of all pediatric patients undergoing minimally invasive trans-sulcal parafascicular surgeries (MIPS) between 2018 and 2023. Clinical, demographic, and radiographic data were captured as were previous surgical procedures, operative approach and technique, operative duration, post-operative day discharge (POD) and length of follow up. Outcomes, including complications and the need for additional interventions, are reported. A total of 27 consecutive procedures, treating 22 patients aged 10-months to 19-years were evaluated. Treated pathologies included tumors, vascular lesions, infections, hemorrhage, and hydrocephalus, with the average follow-up > 19 months. Surgical outcomes were similar, if not superior to, the standard of care, considering the extent of resection of various types of lesions, evacuation of hematoma or abscess, as well as complex fenestrations. MIPS procedures were successfully used in a subgroup of patients previously undergoing operations with \"standard\" approaches. No patients experienced direct complications as a result of the procedure. Recovery times were shorter and the procedure itself was better tolerated in comparison to classical interventions. This largest reported pediatric series using MIPS for a variety of pathologies, demonstrates the feasibility, safety, and possibly superior outcomes in children. Technical familiarity and development of surgical experience with MIPS is critical to optimal outcomes.

Spinal arteriovenous malformations (sAVM) are abnormally developed spinal blood vessels with an increased risk of hemorrhage. Current literature regarding sAVMs is sparse and describes classic presentations in very young children or adults. We report a unique case of a sAVM in an adolescent patient. A 16-year-old female patient presented to the emergency department with a 3-day history of headaches. Initial CT showed no abnormalities. Worsening headaches led the patient to a neurology clinic and a fundoscopy revealed papilledema. The patient was transferred to a pediatric emergency department where repeat head CT showed a possible subarachnoid hemorrhage, and a cranial MRI/MRV showed what appeared to be a non-occlusive sinus venous thrombosis. CT angiography of the head and neck showed no evidence of thrombosis, but it did reveal possible upper thoracic vascular abnormalities. Thoracic MRI revealed an intradural sAVM at T3-T5. The sAVM was successfully resected with thoracic laminectomy with reconstructive laminoplasty. The patient experienced complications with development of right lower extremity motor and sensory deficits intra-op, but is showing continued improvement. This unique case encourages emergency medicine clinicians to expand the differential diagnoses for pediatric patients presenting with a headache and intracranial hypertension without a clear intracranial cause.

BackgroundIn acute ischaemic stroke, endovascular thrombectomy (ET) significantly reduces disability compared with thrombolytic therapy, but access to ET is currently limited. Leveraging telerobotic technology to disseminate neurosurgical expertise could increase access to ET. This proof-of-concept evaluation was performed to determine whether remote robotic ET (RRET), wherein an offsite neurosurgeon and an onsite interventional cardiologist collaboratively use telerobotics to perform ET, is technically feasible.MethodsAn ex vivo model of RRET was constructed by establishing a network connection between a robotic drive in a simulation laboratory and a robotic control unit 5 miles away. Using onsite assistance from an interventional cardiologist in the simulation laboratory, an offsite neurosurgeon used the robotic controls to attempt RRET on a fluid-filled silicone model of human vasculature containing simulated thrombus material in the left middle cerebral artery (MCA).ResultsFrom the offsite location 5 miles away, the neurosurgeon used the robotic system to successfully navigate a guidewire from the carotid artery to simulated thrombus in the MCA. Under the direction of the neurosurgeon, the onsite interventional cardiologist then successfully manually advanced an aspiration catheter over the guidewire to the thrombus, removed the guidewire and performed aspiration.ConclusionsIn this proof-of-concept evaluation, the technical feasibility of RRET was demonstrated in an ex vivo model and was collaboratively performed by an offsite neurosurgeon and an onsite interventional cardiologist. This report supports the design of future studies to determine if RRET could be used to increase access to ET for patients with acute ischaemic stroke.

BackgroundTransradial access (TRA) for neurointervention is becoming increasingly popular as experience with the technique grows. Despite reasonable efficacy using femoral catheters off-label, conversion to femoral access occurs in approximately 8.6–10.3% of TRA cases, due to an inability of the catheter to track into the vessel of interest, lack of support, or radial artery spasm.MethodsThis is a multicenter, retrospective case series of patients undergoing neurointerventions using the Rist Radial Access System. We also present our institutional protocol for using the system.Results152 patients were included in the cohort. The most common procedure was flow diversion (28.3%). The smallest radial diameter utilized was 1.9 mm, and 44.1% were performed without an intermediate catheter. A majority of cases (96.1%) were completed successfully; 3 (1.9%) required conversion to a different radial catheter, 2 (1.3%) required conversion to femoral access, and 1 (0.7%) was aborted. There was 1 (0.7%) minor access site complication and 4 (2.6%) neurological complications.ConclusionsThe Rist catheter is a safe and effective tool for a wide range of complex neurointerventions, with lower conversion rates than classically reported.

As the incidence of subdural hematoma is increasing, it is important to understand symptomatology and clinical variables associated with treatment outcomes and mortality in this population; patients with subdural hematoma were selected from the National Inpatient Sample (NIS) Database between 2016 and 2020 using International Classification of Disease 10th Edition (ICD10) codes. Moderate-to-severe subdural hematoma patients were identified using the Glasgow Coma Scale (GCS). Multivariate regression was first used to identify predictors of in-hospital mortality and then beta coefficients were used to create a weighted mortality score. Of 29,915 patients admitted with moderate-to-severe subdural hematomas, 12,135 (40.6%) died within the same hospital admission. In a multivariate model of relevant demographic and clinical covariates, age greater than 70, diabetes mellitus, mechanical ventilation, hydrocephalus, and herniation were independent predictors of mortality (p < 0.001 for all). Age greater than 70, diabetes mellitus, mechanical ventilation, hydrocephalus, and herniation were assigned a “1” in a weighted mortality score. The ROC curve for our model showed an area under the curve of 0.64. Age greater than 70, diabetes mellitus, mechanical ventilation, hydrocephalus, and herniation were predictive of mortality. We created the first clinically relevant weighted mortality score that can be used to stratify risk, guide prognosis, and inform family discussions.

Objective: Our study aims to evaluate the impact of a stay-at-home order on stroke metrics during the 2019-novel coronavirus (COVID-19) pandemic. Methods: Data on baseline characteristics, stroke subtype, initial National Institutes of Health Stroke Scale (NIHSS) score, the time between last known well (LKW) to emergency department (ED) arrival, tissue plasminogen activator (tPA) administration, the involvement of large vessel occlusion (LVO), and whether mechanical thrombectomy (MT) was pursued in patients with acute stroke were extracted from 24 March to 23 April 2020 (the time period of a stay-at-home order was placed due to the COVID-19 pandemic as the study group) at a tertiary care hospital in West Michigan, USA, compared with data from 24 March to 23 April 2019 (control group). Results: Our study demonstrated a reduction in cases of acute ischemic stroke (AIS), although this did not reach statistical significance. However, there was an increase in hemorrhagic stroke (7.5% controls vs. 19.2% study group). The age of stroke patients was significantly younger during the period of the stay-at-home order compared to the control group. We identified a significant overall delay of ED arrivals from LKW in the study group. Additionally, an increased number of AIS patients with LVO in the study group (34.8%) was found compared to the control group (17.5%). A significantly increased number of patients received MT in the study group. Additionally, 11 patients were COVID-19 PCR-positive in the study group, 10 with AIS and only 1 with hemorrhagic stroke. Patients with COVID-19 had a high incidence of atrial fibrillation and hyperlipidemia. One AIS patient with COVID-19 rapidly developed cytotoxic edema with corresponding elevated inflammatory biomarkers. No statistical significance was noted when stroke subtype, LVO, and MT groups were compared. Conclusions: There was a trend of decreasing AIS admissions during the COVID-19 pandemic. There was also a significantly increased number of AIS patients with LVO who received MT, especially those with COVID-19. We conclude that cytokine storm resulting from SARS-CoV-2 infection might play a role in AIS patients with COVID-19.

In patients with subdural hematoma and an indication for surgical evacuation, middle meningeal artery embolization plus surgery led to a lower risk of reoperation for recurrence or progression within 90 days than surgery alone.