Category Archives: Operative Neurosurgery

Venous sinus stenting for idiopathic intracranial hypertension


Trials suggest that venous sinus stenting offers both comparable rates of efficacy – with improved papilledema in 97% of patients, resolved headache in 83%, and improved visual acuity in 78% .

Patients whose sight is threatened by medically refractory IIH must often consider invasive procedures to control their disease. Venous sinus stenting may offer equal efficacy and lower failure and complication rates than traditional surgical approaches such as optic nerve sheath fenestration and cerebrospinal fluid diversion 3).

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Reviews

2017

A systematic review of the surgical treatment of IIH was carried out. Cochrane Library, MEDLINE and EMBASE databases were systematically searched from 1985 to 2014 to identify all relevant manuscripts written in English. Additional studies were identified by searching the references of retrieved papers and relative narrative reviews.

Forty-one (41) studies were included (36 case series and 5 case reports), totalling 728 patients. Three hundred forty-one patients were treated with optic nerve sheath fenestration (ONSF), 128 patients with lumboperitoneal shunting (LPS), 72 patients with ventriculoperitoneal shunting (VPS), 155 patients with venous sinus stenting and 32 patients with bariatric surgery. ONSF showed considerable efficacy in vision improvement, while CSF shunting had a superior headache response. Venous sinus stenting demonstrated satisfactory results in both vision and headache improvement along with the best complication profile and low relapse rate, but longer follow-up periods are needed. The complication rate of bariatric surgery was high when compared to other interventions and visual outcomes have not been reported adequately. ONSF had the lowest cost.

No surgical modality proved to be clearly superior to any other in IIH management. However, in certain contexts, a given approach appears more justified. Therefore, a treatment algorithm has been formulated, based on the extracted evidence of this review. The traditional treatment paradigm may need to be re-examined with sinus stenting as a first-line treatment modality 4).

2015

Kanagalingam et al., review the role of cerebral venous sinus stenting in the management of patients with medically refractory pseudotumor cerebri. Although long- term studies are needed in this field, the current reports indicate a favorable outcome for preventing vision loss and symptom control 5).

2013

In 2013, a review of the literature was performed which identified patients with IIH treated with venous sinus stenting. The procedural data and outcomes are presented. A total of 143 patients with IIH (87% women, mean age 41.4 years, mean body mass index 31.6 kg/m(2)) treated with venous sinus stenting were included in the analysis. Symptoms at initial presentation included headache (90%), papilledema (89%), visual changes (62%) and pulsatile tinnitus (48%). There was a technical success rate of 99% for the stent placement procedure with a total of nine complications (6%). At follow-up (mean 22.3 months), 88% of patients experienced improvement in headache, 97% demonstrated improvement or resolution of papilledema, 87% experienced improvement or resolution of visual symptoms and 93% had resolution of pulsatile tinnitus. In patients with IIH with focal venous sinus stenosis, endovascular stent placement across the stenotic sinus region represents an effective treatment strategy with a high technical success rate and decreased rate of complications compared with treatment modalities currently used 6).


Teleb et al., aimed to review all published cases and case series of dural sinus stenting for IIH, with analysis of patient presenting symptoms, objective findings (CSF pressures, papilledema, pressure gradients across dural sinuses), follow-up of objective findings, and complications.

A Medline search was performed to identify studies meeting pre-specified criteria of a case report or case series of patients treated with dural sinus stent placement for IIH. The manuscripts were reviewed and data was extracted.

A total of 22 studies were identified, of which 19 studies representing 207 patients met criteria and were included in the analysis. Only 3 major complications related to procedure were identified. Headaches resolved or improved in 81% of patients. Papilledema improved the (172/189) 90%. Sinus pressure decreased from an average of 30.3 to 15 mm Hg. Sinus pressure gradient decreased from 18.5 (n=185) to 3.2 mm Hg (n=172). Stenting had an overall symptom improvement rate of 87%.

Although all published case reports and case series are nonrandomized, the low complication and high symptom improvement rate make dural sinus stenting for IIH a potential alternative surgical treatment. Standardized patient selection and randomization trials or registry are warranted 7).

Case series

2017

Seventeen patients underwent dural venous sinus stenting (DVSS). Average pre- and post-intervention pressure gradients were 23.06 and 1.18 mmHg, respectively (p < 0.0001). Sixteen (94%) noted improvement in headache, fourteen (82%) had visual improvement and all (100%) patients had improved main symptom. Of 11 patients with optical coherence tomography, 8 showed decreased RNFL thickness and 3 remained stable; furthermore, these 11 patients had improved vision with improved papilledema in 8, lack of pre-existing papilledema in 2 and stable, mild edema in 1 patient.

This series of patients with dural sinus stenosis demonstrated improvement in vision and reduction in RNFL thickness. DVSS appears to be a useful treatment for IIH patients with dural sinus stenosis 8).

2016

Ten patients for whom medical therapy had failed were prospectively followed. Ophthalmological examinations were assessed, and patients with venous sinus stenosis on MR angiography proceeded to catheter angiography, venography with assessment of pressure gradient, and ICP monitoring. Patients with elevated ICP measurements and an elevated pressure gradient across the stenosis were treated with stent placement. RESULTS All patients had elevated venous pressure (mean 39.5 ± 14.9 mm Hg), an elevated gradient across the venous sinus stenosis (30.0 ± 13.2 mm Hg), and elevated ICP (42.2 ± 15.9 mm Hg). Following stent placement, all patients had resolution of the stenosis and gradient (1 ± 1 mm Hg). The ICP values showed an immediate decrease (to a mean of 17.0 ± 8.3 mm Hg), and further decreased overnight (to a mean of 8 ± 4.2 mm Hg). All patients had subjective and objective improvement, and all but one improved during follow-up (median 23.4 months; range 15.7-31.6 months). Two patients developed stent-adjacent stenosis; retreatment abolished the stenosis and gradient in both cases. Patients presenting with papilledema had resolution on follow-up funduscopic imaging and optical coherence tomography (OCT) and improvement on visual field testing. Patients presenting with optic atrophy had optic nerve thinning on follow-up OCT, but improved visual fields. CONCLUSIONS For selected patients with IIH and venous sinus stenosis with an elevated pressure gradient and elevated ICP, venous sinus stenting results in resolution of the venous pressure gradient, reduction in ICP, and functional, neurological, and ophthalmological improvement. As patients are at risk for stent-adjacent stenosis, further follow-up is necessary to determine long-term outcomes and gain an understanding of venous sinus stenosis as a primary or secondary pathological process behind elevated ICP 9).


El Mekabaty et al., retrospectively reviewed a prospectively maintained database spanning December 2011 to May 2015 of all patients with idiopathic intracranial hypertension who were screened for possible venous sinus stenting, including only patients who received a stent, noting symptomatic improvements, changes in opening lumbar puncture pressure, demographic characteristics, and any subsequent intervention after stent placement. Fisher’s exact test and logistic regression were used to test each of seven potential predictors for retreatment. RESULTS: There were eight revisions in 31 patients (25.8%). Among Caucasians, 8.0% required a revision compared with 100% of African-Americans (p<0.001). The c-index for race was 0.857. Body mass index (BMI) was also a significant predictor of revision (p=0.031): among class III obese patients the revision rate was 46.2% compared with 16.7% among class I and II obese patients and 0% among overweight to normal weight patients.

BMI was a significant predictor of revision, suggesting that higher BMI may have a higher risk of revision. The small number of African-Americans in the study makes interpretation of the practical significance of the revision rate in these patients uncertain. None of the other studied factors was statistically significant. 10).


A written informed consent approved by the Weill Cornell institutional review board was signed and obtained from the study participants. Thirty-seven consecutive patients with IIH and venous sinus stenosis who were treated with venous sinus stenting between Jan.2012-Jan.2016 were prospectively evaluated. Patients without pulsatile tinnitus were excluded. Tinnitus severity was categorized based on “Tinnitus Handicap Inventory” (THI) at pre-stent, day-0, 1-month, 3-month, 6-month, 12-month, 18-month and 2-year follow-up. Demographics, body-mass index (BMI), pre and post VSS trans-stenotic pressure gradient were documented. Statistical analysis performed using Pearson’s correlation, Chi-square analysis and Fischer’s exact test.

29 patients with a mean age of 29.5±8.5 years M:F = 1:28. Median (mean) THI pre and post stenting were: 4 (3.7) and 1 (1) respectively. Median time of tinnitus resolution post VSS was 0-days. There was significant improvement of THI (Δ Mean: 2.7 THI [95% CI: 2.3-3.1 THI], p<0.001) and transverse-distal sigmoid sinus gradient (Δ Mean: -15.3 mm Hg [95% CI: 12.7-18 mm Hg], p<0.001) post-stenting. Mean follow-up duration of 26.4±9.8 months (3-44 months). VSS was feasible in 100% patients with no procedural complications. Three-patients (10%) had recurrent sinus stenosis and tinnitus at mean follow-up of 12 months (6-30 months).

Venous sinus stenting is an effective treatment for pulsatile tinnitus in patients with IIH and venous sinus stenosis 11).

2013

Fields et al reviewed all cases of dural stents for IIH. Eligibility criteria included medically refractory IIH with documented papilledema and dural venous sinus stenosis of the dominant venous outflow system (gradient ≥10 mm Hg).

Fifteen cases (all women) of mean age 34 years were identified. All had failed medical therapy and six had failed surgical intervention. Technical success was achieved in all patients without major periprocedural complications. The mean preprocedural gradient across the venous stenosis was reduced from 24 mm Hg before the procedure to 4 mm Hg after the procedure. Headache resolved or improved in 10 patients. Papilledema resolved in all patients and visual acuity stabilized or improved in 14 patients. There were no instances of restenosis among the 14 patients with follow-up imaging.

In this small case series, dural sinus stenting for IIH was performed safely with a high degree of technical success and with excellent clinical outcomes. These results suggest that angioplasty and stenting for the treatment of medically refractory IIH in patients with dural sinus stenosis warrants further investigation as an alternative to LPS, VPS and ONSF 12).


1) , 4) Kalyvas AV, Hughes M, Koutsarnakis C, Moris D, Liakos F, Sakas DE, Stranjalis G, Fouyas I. Efficacy, complications and cost of surgical interventions for idiopathic intracranial hypertension: a systematic review of the literature. Acta Neurochir (Wien). 2017 Jan;159(1):33-49. doi: 10.1007/s00701-016-3010-2. Review. PubMed PMID: 27830325.
2) Dinkin MJ, Patsalides A. Venous Sinus Stenting for Idiopathic Intracranial Hypertension: Where Are We Now? Neurol Clin. 2017 Feb;35(1):59-81. doi: 10.1016/j.ncl.2016.08.006. Review. PubMed PMID: 27886896.
3) Chaudhry S, Bryant TK, Peeler CE. Venous sinus stenting in idiopathic intracranial hypertension: a safer surgical approach? Curr Opin Ophthalmol. 2016 Nov;27(6):481-485. Review. PubMed PMID: 27585210.
5) Kanagalingam S, Subramanian PS. Cerebral venous sinus stenting for pseudotumor cerebri: A review. Saudi J Ophthalmol. 2015 Jan-Mar;29(1):3-8. doi: 10.1016/j.sjopt.2014.09.007. Review. PubMed PMID: 25859134; PubMed Central PMCID: PMC4314570.
6) Puffer RC, Mustafa W, Lanzino G. Venous sinus stenting for idiopathic intracranial hypertension: a review of the literature. J Neurointerv Surg. 2013 Sep 1;5(5):483-6. doi: 10.1136/neurintsurg-2012-010468. Review. PubMed PMID: 22863980.
7) Teleb MS, Cziep ME, Lazzaro MA, Gheith A, Asif K, Remler B, Zaidat OO. Idiopathic Intracranial Hypertension. A Systematic Analysis of Transverse Sinus Stenting. Interv Neurol. 2013;2(3):132-143. PubMed PMID: 24999351; PubMed Central PMCID: PMC4080637.
8) Smith KA, Peterson JC, Arnold PM, Camarata PJ, Whittaker TJ, Abraham MG. A case series of dural venous sinus stenting in idiopathic intracranial hypertension: association of outcomes with optical coherence tomography. Int J Neurosci. 2017 Feb;127(2):145-153. PubMed PMID: 26863329.
9) Liu KC, Starke RM, Durst CR, Wang TR, Ding D, Crowley RW, Newman SA. Venous sinus stenting for reduction of intracranial pressure in IIH: a prospective pilot study. J Neurosurg. 2016 Dec 23:1-8. doi: 10.3171/2016.8.JNS16879. [Epub ahead of print] PubMed PMID: 28009240.
10) El Mekabaty A, Obuchowski NA, Luciano MG, John S, Chung CY, Moghekar A, Jones S, Hui FK. Predictors for venous sinus stent retreatment in patients with idiopathic intracranial hypertension. J Neurointerv Surg. 2016 Dec 13. pii: neurintsurg-2016-012803. doi: 10.1136/neurintsurg-2016-012803. [Epub ahead of print] PubMed PMID: 27965382.
11) Boddu S, Dinkin M, Suurna M, Hannsgen K, Bui X, Patsalides A. Resolution of Pulsatile Tinnitus after Venous Sinus Stenting in Patients with Idiopathic Intracranial Hypertension. PLoS One. 2016 Oct 21;11(10):e0164466. doi: 10.1371/journal.pone.0164466. PubMed PMID: 27768690; PubMed Central PMCID: PMC5074492.
12) Fields JD, Javedani PP, Falardeau J, Nesbit GM, Dogan A, Helseth EK, Liu KC, Barnwell SL, Petersen BD. Dural venous sinus angioplasty and stenting for the treatment of idiopathic intracranial hypertension. J Neurointerv Surg. 2013 Jan 1;5(1):62-8. doi: 10.1136/neurintsurg-2011-010156. PubMed PMID: 22146571.

A New Way into the Brain

The traditional way to reach a deep-seated lesion within the brain is through an open craniotomy. While this route is effective at accomplishing the primary goal of accessing the tumor, it’s littered with collateral damage, says Johns Hopkins Hospital neurosurgeon Kaisorn Chaichana.

Assistant Professor of Neurosurgery, Oncology, and Otolaryngology

“It usually requires a big incision, a big opening in the skull, a big opening in the dura,” he says. “As we dissect downward, we’re compromising the white matter the whole time.” The end result, he adds, is substantial blood loss, long hospital stays, long recovery times and an increased risk of damage to brain structures, which can cause neurological deficits.

Enter the minimally invasive tubular retractor, a device that Chaichana has recently incorporated into many of the procedures he’s performed to help mitigate these issues. With a tubular diameter slightly less than a nickel, this retractor allows for less invasive brain surgery by using an obturator with an atraumatic tip to push white matter away instead of cutting it.

During procedures that use this device, Chaichana and his colleagues typically rely on MRI with diffusion tensor imaging data gathered before surgery to guide an interoperative navigation system. Using these data to pinpoint the location of a lesion, the surgeons make a small opening about the size of a silver dollar through the scalp, skull and dura. They then insert the tubular retractor between white matter tracts directly over the tumor.

Once the obdurator is in place, the surgeons can remove an inner metal insert, leaving behind an inner clear sheath. The surgery is performed with an exoscope—a small camera that hovers over the surgical field—and tools to go within the device. Using this protocol, Chaichana and his colleagues can resect entire tumors with minimal disruption to the surrounding brain structures.

This approach is particularly valuable for tumors in eloquent locations, Chaichana says. Treating these tumors using traditional surgical methods would increase the result in motor, language or visual field deficits because of the large dissection of the critical brain matter. However, in the 30 cases he’s already treated using this device over the past year, these functions have been largely preserved. These patients have also had shorter surgeries, significantly less blood loss, shorter hospital stays and quicker recoveries, he adds.

Because of its host of benefits, Chaichana says, he expects that use of this device will grow throughout this field over time.

“With this approach, we can offer patients the same great results as an open resection,” he says, “while also giving them a much greater chance of preserving their neurological function and quality of life.”

Association of Perioperative Statin Use With Mortality and Morbidity After Major Noncardiac Surgery

Metaanalysis indicated that the use of statins decreases the occurrence of cerebral vasospasm, whereas did not support a beneficial effect of statins on the occurrence of delayed ischemic neurological deficit (DIND), death or poor neurological outcomes in patients with aneurysmal SAH 1).


Statins have been shown to decrease aneurysm progression and rupture in two experimental settings: animals with cerebral aneurysm and humans with abdominal aortic aneurysms. AIMS: To investigate statin use and outcomes in humans with unruptured cerebral aneurysms through Medicare administrative data.

Bekelis et al. used a 40% random sample Medicare denominator file and corresponding inpatient, outpatient (2003-2011), and prescription (2006-2011) claims to conduct a retrospective cohort study of patients diagnosed with unruptured cerebral aneurysms, between 2003 and 2011. We used propensity score-adjusted models to investigate the association between statin use and risk of subarachnoid hemorrhage. Secondary analyses repeated the main models stratified on tobacco use status and separately assessed other composite outcomes.

They identified 28 931 patients with unruptured cerebral aneurysms (average age 72·0 years, 72·6% female); mean follow-up was 30·0 months; 41·3% used statins. Overall, 593 patients developed subarachnoid hemorrhage, and 703 underwent treatment before subarachnoid hemorrhage. Current or recent statin use was not associated with a difference in subarachnoid hemorrhage risk (odds ratio, 1·03; 95% conflict of interest 0·86-1·23); models stratified on tobacco use status were nearly identical. No association was observed between statin use and the composite outcome of subarachnoid hemorrhage or aneurysm treatment (odds ratio, 0·94; 95% conflict of interest, 0·84-1·06). The risk of subarachnoid hemorrhage or out-of-hospital death was lower among statin users (odds ratio, 0·69; 95% conflict of interest, 0·64-0·74).

Statin use by patients with unruptured cerebral aneurysms was not associated with subarachnoid hemorrhage risk. Given the prior animal experimental studies demonstrating a protective effect, further prospective studies are needed to investigate the potential relationship 2).


A retrospective, observational cohort analysis included 180 478 veterans undergoing elective or emergent noncardiac surgery (including vascular, general, neurosurgery, orthopedic, thoracic, urologic, and otolaryngologic) who were admitted within 7 days of surgery and sampled by the Veterans Affairs Surgical Quality Improvement Program (VASQIP). Patients were admitted to Department of Veterans Affairs hospitals and underwent 30-day postoperative follow-up. Data were collected from October 1, 2005, to September 30, 2010, and analyzed from November 28, 2013, to October 31, 2016.

Statin use on the day of or the day after surgery.

All-cause 30-day mortality (primary outcome) and standardized 30-day cardiovascular and noncardiovascular outcomes captured by VASQIP. Use of statins and other perioperative cardiovascular medications was ascertained from the Veterans Affairs Pharmacy Benefits Management research database.

A total of 180 478 eligible patients (95.6% men and 4.4% women; mean [SD] age, 63.8 [11.6] years) underwent analysis, and 96 486 were included in the propensity score-matched cohort (96.3% men; 3.7% women; mean [SD] age, 65.9 [10.6] years). At the time of hospital admission, 37.8% of patients had an active outpatient prescription for a statin, of whom 80.8% were prescribed simvastatin and 59.5% used moderate-intensity dosing. Exposure to a statin on the day of or the day after surgery based on an inpatient prescription was noted in 31.5% of the cohort. Among 48 243 propensity score-matched pairs of early perioperative statin-exposed and nonexposed patients, 30-day all-cause mortality was significantly reduced in exposed patients (relative risk, 0.82; 95% CI, 0.75-0.89; P < .001; number needed to treat, 244; 95% CI, 170-432). Of the secondary outcomes, a significant association with reduced risk of any complication was noted (relative risk, 0.82; 95% CI, 0.79-0.86; P < .001; number needed to treat, 67; 95% CI, 55-87); all were significant except for the central nervous system and thrombosis categories, with the greatest risk reduction (relative risk, 0.73; 95% CI, 0.64-0.83) for cardiac complications.

Early perioperative exposure to a statin was associated with a significant reduction in all-cause perioperative mortality and several cardiovascular and noncardiovascular complications. However, the potential for selection biases in these results must be considered 3).


1) Zhu RL, Chen ZJ, Li S, Lu XC, Tang LJ, Huang BS, Yu W, Wang X, Qian TD, Li LX. Statin-treated patients with aneurysmal subarachnoid haemorrhage: a meta-analysis. Eur Rev Med Pharmacol Sci. 2016 May;20(10):2090-8. PubMed PMID: 27249609.
2) Bekelis K, Smith J, Zhou W, MacKenzie TA, Roberts DW, Skinner J, Morden NE. Statins and subarachnoid hemorrhage in Medicare patients with unruptured cerebral aneurysms. Int J Stroke. 2015 Jun 29. doi: 10.1111/ijs.12559. [Epub ahead of print] PubMed PMID: 26120925.
3) London MJ, Schwartz GG, Hur K, Henderson WG. Association of Perioperative Statin Use With Mortality and Morbidity After Major Noncardiac Surgery. JAMA Intern Med. 2016 Dec 19. doi: 10.1001/jamainternmed.2016.8005. [Epub ahead of print] PubMed PMID: 27992624.

Neurosurgery and ACS National Surgical Quality Improvement Program (ACS-NSQIP)


VP shunts were placed in 3,984 patients either as an initial placement (n = 1,093) or as a revision (n = 2,891). Compared to the initial-placement group, the revision group was significantly more likely to experience shunt failure (14 vs. 8%, p < 0.0001). In the initial-placement group, congenital hydrocephalus was independently associated with shunt failure (OR 1.83; 95% CI 1.01-3.31, p = 0.047). In the revision group, cardiac risk factors (OR 1.38; 95% CI 1.00-1.90, p = 0.047), a chronic history of seizures (OR 1.33; 95% CI 1.04-1.71, p = 0.022), and a history of neuromuscular disease (OR 0.61; 95% CI 0.41-0.90, p = 0.014) were independently associated with shunt failure.

Identifying the factors associated with VP shunt failure may allow the development of interventions to decrease failures. Further refinement of the collected variables in the ACS National Surgical Quality Improvement Program (NSQIP) Pediatric specific to neurosurgical procedures is necessary to identify modifiable risk factors 1).


Cote et al., performed a search of the ACS National Surgical Quality Improvement Program (ACS-NSQIP) database for all patients undergoing operations with a neurosurgeon from 2006 to 2013. They analyzed demographics, past medical history, and post-operative respiratory failure, defined as unplanned intubation and/or ventilator dependence for more than 48 h post-operatively.

Of 94,621 NSQIP-reported neurosurgical patients from 2006 to 2013, 2325 (2.5 %) developed post-operative respiratory failure. Of these patients, 1270 (54.6 %) were male, with an overall mean age of 60.59 years; 571 (24.56 %) were current smokers and 756 (32.52 %) were ventilator-dependent. Past medical history included dyspnea in 204 patients (8.8 %), COPD in 198 (8.5 %), and congestive heart failure in 66 (2.8 %). The rate of post-operative respiratory failure decreased from 4.1 % in 2006 to 2.1 % in 2013 (p < 0.001). Of the 2325 patients with respiratory failure, 1061 (45.6 %) underwent unplanned intubation post-operatively and 1900 (81.7 %) were ventilator-dependent for more than 48 h. The rate of both unplanned intubation (p < 0.001) and ventilator dependence (p < 0.001) decreased significantly from 2006 to 2013. Multivariate analysis demonstrated that significant risk factors for respiratory failure included inpatient status (p < 0.001, OR = 0.165), age (p < 0.001, OR = 1.014), diabetes (p = 0.001, OR = 1.489), functional dependence prior to surgery (p < 0.001, OR = 2.081), ventilator dependence (p < 0.001, OR = 10.304), hypertension requiring medication (p = 0.005, OR = 1.287), impaired sensorium (p < 0.001, OR = 2.054), CVA/stroke with or without neurological deficit (p < 0.001, OR = 2.662; p = 0.002, OR = 1.816), systemic sepsis (p < 0.001, OR = 1.916), prior operation within 30 days (p = 0.026, OR = 1.439), and operation type (cranial relative to spine, p < 0.001, OR = 4.344).

Based on the NSQIP database, risk factors for respiratory failure after neurosurgery include pre-operative ventilator dependence, alcohol use, functional dependence prior to surgery, stroke, and recent operation. The overall rate of respiratory failure decreased from 4.1 % in 2006 to 2.1 % in 2013 according to these data 2).


Data from adult patients who underwent surgery for spinal tumors (2011-2014) were extracted from the prospective National Surgical Quality Improvement Program (NSQIP) registry. Multivariable logistic regression was used to evaluate predictors of reoperation, readmission, and major complications (death, neurological, cardiopulmonary, venous thromboembolism [VTE], surgical site infection [SSI], and sepsis). Variables screened included patient age, sex, tumor location, American Society of Anesthesiologists (ASA) physical classification, preoperative functional status, comorbidities, preoperative laboratory values, case urgency, and operative time. Additional variables that were evaluated when analyzing readmission included complications during the surgical hospitalization, hospital length of stay (LOS), and discharge disposition.

Among the 2207 patients evaluated, 51.4% had extradural tumors, 36.4% had intradural extramedullary tumors, and 12.3% had intramedullary tumors. By spinal level, 20.7% were cervical lesions, 47.4% were thoracic lesions, 29.1% were lumbar lesions, and 2.8% were sacral lesions. Readmission occurred in 10.2% of patients at a median of 18 days (interquartile range [IQR] 12-23 days); the most common reasons for readmission were SSIs (23.7%), systemic infections (17.8%), VTE (12.7%), and CNS complications (11.9%). Predictors of readmission were comorbidities (dyspnea, hypertension, and anemia), disseminated cancer, preoperative steroid use, and an extended hospitalization. Reoperation occurred in 5.3% of patients at a median of 13 days (IQR 8-20 days) postoperatively and was associated with preoperative steroid use and ASA Class 4-5 designation. Major complications occurred in 14.4% of patients: the most common complications and their median time to occurrence were VTE (4.5%) at 9 days (IQR 4-19 days) postoperatively, SSIs (3.6%) at 18 days (IQR 14-25 days), and sepsis (2.9%) at 13 days (IQR 7-21 days). Predictors of major complications included dependent functional status, emergency case status, male sex, comorbidities (dyspnea, bleeding disorders, preoperative systemic inflammatory response syndrome, preoperative leukocytosis), and ASA Class 3-5 designation (p < 0.05). The median hospital LOS was 5 days (IQR 3-9 days), the 30-day mortality rate was 3.3%, and the median time to death was 20 days (IQR 12.5-26 days).

In a ACS National Surgical Quality Improvement Program analysis, 10.2% of patients undergoing surgery for spinal tumors were readmitted within 30 days, 5.3% underwent a reoperation, and 14.4% experienced a major complication. The most common complications were SSIs, systemic infections, and VTE, which often occurred late (after discharge from the surgical hospitalization). Patients were primarily readmitted for new complications that developed following discharge rather than exacerbation of complications from the surgical hospital stay. The strongest predictors of adverse events were comorbidities, preoperative steroid use, and higher ASA score. These models can be used by surgeons to risk-stratify patients preoperatively and identify those who may benefit from increased surveillance following hospital discharge 3).


Using the American College of Surgeons’ National Surgical Quality Improvement Program (ACS-NSQIP) dataset, a retrospective analysis of the complications experienced by patients that underwent surgical management of a UIA between the years of 2007 and 2013. The primary outcomes of interest were mortality within the 30-day perioperative period and adverse discharge disposition to a location other than home. Predictors of morbidity and mortality were elucidated using multivariable logistic regression analyses controlling for available patient demographic, comorbidity, and operative characteristics.

662 patients were identified in the ACS-NSQIP dataset for operative management of an unruptured aneurysm. The observed rates of 30-day mortality and adverse discharge disposition were 2.27% and 19.47%, respectively. A hundred and eight (16.31%) patients developed at least one major complication. On multivariable analysis, death within 30days was significantly associated with increased operative time (OR 1.005 per minute, 95% CI 1.002-1.008) and chronic preoperative corticosteroid use (OR 28.4, 95% CI 1.68-480.42), whereas major complication development was associated with increased operative time (OR 1.004 per minute, 95% CI 1.002-1.006), age (OR 1.017 per year, 95% CI 1-1.034), preoperative dependency (OR 3.3, 95% CI 1.16-9.40) and diabetes mellitus (OR 2.89, 95% CI 1.45-5.75). Lastly, increasing age (OR 1.017 per year, 95% CI 1-1.034) as well as ASA Class 3 (OR 1.73, 95% CI 1.08-2.77) and 4 (OR 2.28, 95% CI 1.1-4.72) were independent predictors of discharge to a location other than home.

The study yields morbidity and mortality benchmarks for UIA surgery in a representative, national surgical registry. It will hopefully aid in recognizing those patients at greater risk for postoperative complications following surgical management, leading to appropriate changes in treatment strategies for this selected group of patients 4).


2351 patients underwent peripheral nerve surgery, 120 complications were identified in 100 patients (4.25%), and 103 patients (4.38%) received nerve grafting. Thirty-one (1.95%) of the 1593 patients underwent unplanned readmission. Nerve grafting procedures had no association with postoperative complications and unplanned readmission rates. Patients who experienced an inpatient procedure (OR= 2.54, P<0.001), a longer operative time (OR= 1.00, P<0.001) and worse wound classifications (OR= 1.83, P<0.001) all had increased odds of postoperative complications. An inpatient procedure (OR= 2.74, P=0.014) and any complications (OR= 24.43, P<0.001) were significantly associated with unplanned readmission.

The study confirms that peripheral nerve surgery and nerve graft procedures can be safely performed with low complication risks and low unplanned readmission rates. We also identified the risks associated with perioperative adverse outcomes, and these data may be used as an adjunct for risk stratification for patients under consideration for peripheral nerve surgery. This approach may enable the improved targeting of the most costly and harmful complications of preventive measures 5).


1) Gonzalez DO, Mahida JB, Asti L, Ambeba EJ, Kenney B, Governale L, Deans KJ, Minneci PC. Predictors of Ventriculoperitoneal Shunt Failure in Children Undergoing Initial Placement or Revision. Pediatr Neurosurg. 2017;52(1):6-12. PubMed PMID: 27490129.
2) Cote DJ, Karhade AV, Burke WT, Larsen AM, Smith TR. Risk factors for post-operative respiratory failure among 94,621 neurosurgical patients from 2006 to 2013: a NSQIP analysis. Acta Neurochir (Wien). 2016 Sep;158(9):1639-45. doi: 10.1007/s00701-016-2871-8. Epub 2016 Jun 23. PubMed PMID: 27339268.
3) Karhade AV, Vasudeva VS, Dasenbrock HH, Lu Y, Gormley WB, Groff MW, Chi JH, Smith TR. Thirty-day readmission and reoperation after surgery for spinal tumors: a National Surgical Quality Improvement Program analysis. Neurosurg Focus. 2016 Aug;41(2):E5. doi: 10.3171/2016.5.FOCUS16168. PubMed PMID: 27476847.
4) Kerezoudis P, McCutcheon BA, Murphy M, Rayan T, Gilder H, Rinaldo L, Shepherd D, Maloney PR, Hirshman BR, Carter BS, Bydon M, Meyer F, Lanzino G. Predictors of 30-day perioperative morbidity and mortality of unruptured intracranial aneurysm surgery. Clin Neurol Neurosurg. 2016 Oct;149:75-80. doi: 10.1016/j.clineuro.2016.07.027. Epub 2016 Jul 27. PubMed PMID: 27490305.
5) Hu K, Zhang T, Hutter MM, Xu W, Williams ZM. Thirty-Day Perioperative Adverse Outcomes Following Peripheral Nerve Surgery: An Analysis of 2351 Patients in the ACS NSQIP Database. World Neurosurg. 2016 Jul 16. pii: S1878-8750(16)30545-9. doi: 10.1016/j.wneu.2016.07.023. [Epub ahead of print] PubMed PMID: 27436210.

Video Atlas of Neurosurgery: Contemporary Tumor and Skull Base Surgery, 1e

Video Atlas of Neurosurgery: Contemporary Tumor and Skull Base Surgery, 1e

By Alfredo Quinones-Hinojosa MD FAANS FACS

Video Atlas of Neurosurgery: Contemporary Tumor and Skull Base Surgery, 1e

List Price: $299.99

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Video Atlas of Neurosurgery: Contemporary Tumor and Skull Base Surgery is a unique resource that consists of 40 procedural videos and a concise companion book to reinforce your understanding of the material. Dr. Alfredo Quiñones-Hinojosa brings together a group of outstanding faculty, residents, and fellows lead by Dr. Jordina Rincon-Torroella, who carefully designed, assembled, and edited each chapter. The videos are enhanced through the inclusion of intraoperative photos, anatomical dissections, outstanding anatomical drawings, and animations that detail key steps and provide the experience of viewing a real-time surgery. Whether consulted together or independently of each other, the video and print content deliver all of the expert knowledge you need for effectively planning and understanding tumor and skull base surgeries.

  • Step-by-step, state-of-the-art videos – 40 in total – are accessible through Expert Consult and narrated by Dr. Quiñones-Hinojosa.
  • Each video is around 10 minutes with a total running time of over 6 hours
  • Videos highlight key surgical anatomy, focusing special attention on the relationship between lesions and important landmarks.
  • Procedures are broken down step-by-step for easy overview and comprehension.
  • Covers advanced techniques such as: intraoperative brain mapping; intraoperative assessment of resection through iMRI; fluorescence imaging; brain stem mapping techniques; combined open-and-endoscopic approaches, cortical-subcortical stimulation in awake surgery; and more.
  • Dedicated neurosurgical artwork by Devon Stuart includes superb figures that depict the surgical neuroanatomy and approaches in a step-wise fashion.
  • Chapters are presented from the less complex, more common surgeries to the most complex and cutting-edge procedures that may require multidisciplinary approaches.
  • Expert Consult eBook version included with purchase. This enhanced eBook experience allows you to access all of the text, figures, videos, and references from the book on a variety of devices.

Product Details

  • Published on: 2016-12-02
  • Original language: English
  • Dimensions: 11.06″ h x 1.18″ w x 8.74″ l, .0 pounds
  • Binding: Hardcover
  • 316 pages

Editorial Reviews

Review

“One can only imagine the prodigious amount of work involved in producing this educational treasure chest. Credit is due to the authors and to the publishers for creating this appealing and useful Atlas.” Reviewed by: Edward R. Laws, Professor of Neurosurgery, Harvard Medical School, Oct 2015

“Useful, complete and visual are the words which best summarize the aim of this masterpiece. Really great job! Congratulations for this excellent Video-Book!!” Reviewed by: Dr. J. Gonzalez, Director of the Residency Program Hospital Clinic Barcelona, Oct 2015

About the Author
Alfredo Quinones-Hinojosa has edited several books including Schmidek and Sweet: Operative Neurosurgical Techniques, Controversies in Neuro-Oncology: Best Evidence Medicine for Brain Tumor Surgery, and Video Atlas of Neurosurgery: Contemporary Tumor and Skull Base Surgery, and Neural Stem Cells (An Issue of Neurosurgery Clinics). He has clinical expertise in Neuro-Oncology, tumor surgery, and is a world authority on these aspects of Neuro-Oncology.

Today: 5th Homburger Neuroendoscopy Week

5th Homburger Neuroendoscopy Week

September 19 — September 23

Homburg-Saar, Germany

More Information

International faculty with experts in all fields of neuroendoscopy:

A. Alias (Malaysia)

R. Bosnjak (Slovenia)

G. Cinalli (Italy)

S. Constantini (Israel)

A. Cordoba (Uruguay)

R. H. Dahlan (Indonesia)

H. Delye (The Netherlands)

C. Deopujari (India)

S. Gore (India)

S. Gorelyshev (Russia)

A. Grotenhuis (The Netherlands)

A. O. Gushcha (Russia)

H. Leu (Switzerland)

D. Locatelli (Italy)

T. Lübbers (Germany)

P. P. Menchetti (Italy)

I. Polythodorakis (Greece)

R. Ramina (Brazil)

S. Rohidas (India)

H. Schroeder (Germany)

S. Sgouros (Greece)

S. Sharif (Pakistan)

C. Tschan (Germany)

S. Vulcu (Switzerland)

How Surgical Theater Changes The Way Neurosurgeons Operate

Dr. Robert Louis, a neurosurgeon at Hoag Memorial Hospital Presbyterian in Orange County, CA, is pitched some type of new technology, gadget or medication every day. He’s shown things so often that he developed an internal filter that automatically sets expectations a lot lower than the enthusiasm of the rep. But that all changed in October 2015.

That’s when Surgical Theater reps dropped by to showcase the Surgical Navigation Advanced Platform, or SNAP. Designed by former Israeli fighter pilots, the technology uses virtual reality to allow neurosurgeons to “fly” through a patient’s brain to get a better look at tumors, nerves, blood vessels and tissue prior to surgery. Before surgery, the patient’s brain is captured and recreated as a 3D model for Dr. Louis or his colleague Dr. Christopher Duma, neurosurgeon and director of Hoag’s Brain Tumor Program, to navigate.

Hoag is currently using an Oculus DK2, but the FDA recently cleared the consumer Oculus Rift for use and that will be deployed moving forward in all medical facilities, according to Jim Breidenstein, president and COO at Surgical Theater’s SNAP division.

Louis said prior to the introduction of this technology, he’d have to reference black-and-white 2D “slices” of the brain and then use his imagination (and 20 years of surgical experience) to map out the surgical procedure in his head before entering the Operating Room.

Since SNAP is registered with both Stealth, a technology Hoag uses, and Brainlab, that 3D model of the patient’s brain is used to track the tips of the instruments as the neurosurgeon navigates the brain. It works like a GPS inside the head, allowing doctors to track their instrument in real-time.

“Instead of looking at a 2D model, I can now see the tips of the instruments on the 3D Surgical Theater System on screen and compare that to what I’m seeing through the lens of the microscope,” said Louis, who is also director of Hoag’s Skull Base and Pituitary Tumor Program.

Hoag, one of 10 hospitals using this technology, has already used SNAP on 100 patients.
“We’ve seen an increase in the rate of complete tumor removal and a decrease in the rate of neurological complications,” Louis said.

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Louis said this new technology helped him save Marcus Barnes, 41, who had a brain tumor. Louis focuses on non-evasive surgeries whenever possible, preferring to take tumors out through the nose, ear or eyebrow whenever possible. His original plan was to make a small incision by the eyebrow for Barnes, but when he put on the Oculus headset and explored the virtual reality model of his brain, he found that the patient’s optic nerve would block him from extricating the entire tumor that route.

“We changed the approach and we did a small incision behind the hairline instead,” Louis said. “We made this change before even touching the patient and we were able to get the entire tumor out successfully.”

SNAP also played another role in this particular operation. The technology has been designed so anyone, including patients, can get a look inside their head. Louis wheeled the headset into Barnes’ room while he was being prepped for surgery so he could show him why he was changing the operation the morning of, which Louis admits is something that would normally make a patient nervous. But this technology allowed the patient to see exactly what the doctor sees – and will see during surgery.

“Everybody loves seeing their brain in 3D and in color,” Louis said. “They feel much more engaged in their own process with VR. It goes from ‘I trust you’ to ‘I understand what’s going on with my body.’ Research shows patients who are more engaged and have a better understanding of their pathology will have a better outcome.”

In September, Louis will begin testing a brand new augmented reality technology from Surgical Theater. The new technology will be used inside the OR, and use the 3D model of the patient’s head to project a real-time 20-30% shadowed view of exactly where the tumor is via AR while the neurosurgeon is performing the operation through the lens of a microscope or viewing the screen of the endoscope.

“The tumor is visible partially in my field-of-view so I know exactly what direction I’m going,” Louis said. “I don’t think AR will replace the pre-op rehearsal in VR, but it adds to the tools we use during surgery and it’s another big advance to be more precise.”

Louis said the less disruption of normal tissue and critical anatomy in getting to the tumor, the fewer neurological complications and less blood loss there is for the patient.

There are 10 hospitals using this VR technology today, including University Hospitals Case Medical Center, University Hospitals Rainbow Babies and Children’s Hospital, The Ronald Reagan UCLA Medical Center, The Mount Sinai Hospital, Mayo Clinic and NYU Langone Medical Center. Some of these hospitals are using SNAP in an additional way.

VR can also be used to train residents, Breidenstein said.

“Students can see in 20 minutes what has taken neurosurgeons like Dr. Louis 20 years to perfect in his own mind,” Breidenstein said. “It can dramatically shorten the learning curve of tomorrow’s surgeons.”

At UCLA, Dr. Neil Martin uses Surgical Theater to travel pre-operatively through a patent’s head.

There are multi-user options, so the doctor and the student each can have an individual avatar and they can look at the anatomy of the brain from a teaching perspective. This option is also available online, so that the doctor and student don’t have to be in the same state or country.

Breidenstein said over 2,000 patients have been treated using Surgical Theater technology to date.

“By design, we’ve had a limited launch and strategic plan with 10 centers for the current physical year,” Breidenstein said. “In 2017, we’ll take our technology and expand and scale it based on the learning and volumes of clinical data we’re collecting. Our goal it to get SNAP into all key centers in the surgical world.”

Alon Geri, co-founder and executive vice president of engineering at Surgical Theater, said SNAP has been designed to evolve with technology. The Windows-based technology already works on both Oculus Rift and HTC Vive, as well as several enterprise AR devices. Geri said any headset that will be available in the market will be supported in the future, when it makes sense.

Geri, who used to fly Blackhawks in the Israeli Air Force, ended up designing this virtual reality technology on a challenge. He had spent several years developing a virtual reality flight simulator for pilots when a neurosurgeon asked him if he could do the same thing for doctors. He accepted the challenge.

“Once surgeons started to experience it, it blew their minds,” Geri said. “It allows them to prepare for complicated surgery cases and gets them into the zone to go under the microscope.”

Louis said using SNAP “is a no-brainer.”