Delineating Neurosurgery Resident Development: Insights from a 10-Year National Accreditation Council for Graduate Medical Education Milestones and Learning Trajectories.

Background And Objectives: The Accreditation Council for Graduate Medical Education Milestones assessment system provides a structured framework for evaluating the developmental progression of neurosurgery residents. Understanding the variability in learning trajectories and identifying critical intervention points are essential for refining educational strategies and enhancing training outcomes. In this article, we aim to identify learning trajectories of neurosurgery residents and pinpoint pivotal junctures for potential interventions to aid residents struggling to meet expected competency levels.

Treatment of iatrogenic vertebral artery injury during C1-C2 arthrodesis with a covered stent.

Iatrogenic vertebral artery injury (VAI) has been described in the context of both anterior and posterior approaches to the cervical spine.1 2 Endovascular treatment of VAI primarily entails vessel sacrifice or vascular reconstruction. The latter option offers the advantage of achieving hemostasis while maintaining parent vessel patency.

Transradial versus transfemoral access for mechanical thrombectomy: A single institution experience.

Background: There has been debate in the literature regarding the adoption of a "radial-first" approach for mechanical thrombectomy (MT) in acute ischemic stroke (AIS). Conflicting reports suggest that transradial access (TRA) may allow for shorter times to reperfusion while others conclude that long-term functional outcomes may favor transfemoral access (TFA). Here, we report a single-institution experience with the adoption of TRA as the primary route for acute stroke intervention.

Does disease etiology matter in long-term patency in extracranial-intracranial bypass?

Objective: Extracranial-intracranial (EC-IC) bypass has been well described in chronic vaso-occlusive cerebrovascular diseases, including both moyamoya disease (MMD) and atherosclerotic disease (AD). This study aimed to compare factors associated with bypass occlusion between these two diseases.

Methods: An institutional database of 357 patients with intracranial bypass procedures performed between August 2001 and May 2022 was retrospectively reviewed.

Preoperative embolization of brain arteriovenous malformation and efficacy in intraoperative blood loss reduction: a quantitative study.

Background: Embolization of brain arteriovenous malformations (bAVMs) is often used as adjuvant therapy to microsurgical resection to reduce the high-risk features of bAVMs such as large size and high flow. However, the effect of preoperative embolization on surgical performance and patient outcome has shown mixed results. Heterogeneity in treatment goals, selection criteria, and unpredictable changes in bAVM hemodynamics after partial embolization may account for these uncertain findings.

Transradial flow diversion with an aberrant right subclavian artery.

Transradial access for diagnostic and therapeutic neurointerventional procedures has gained popularity due to a decreased incidence of access site complications and improved patient comfort compared with transfemoral access.1-4 An aberrant right subclavian artery is an aortic arch variant characterized by a right subclavian artery that arises directly from the arch as the most distal great vessel. Transradial access with an aberrant right subclavian artery is anatomically challenging due to the predilection of the catheter system to collapse into the descending aorta.

A persistent trigeminal artery demonstrates cerebrovascular embryologic development.

Background: Cerebrovascular embryologic development is characterized by the presence of four well-described carotid-vertebrobasilar (VB) anastomoses. As the fetal hindbrain matures and the VB system develops, these connections involute, yet some may persist into adulthood. The persistent primitive trigeminal artery (PPTA) is the most common of these anastomoses.

Chronic invasive fungal sinusitis with orbital and olfactory cleft involvement secondary to indolent mucormycosis.

Purpose: Chronic invasive fungal sinusitis secondary to indolent mucormycosis is a rare clinical entity, and the ideal management is controversial. A case of indolent mucormycosis successfully managed with conservative debridement and retrobulbar amphotericin B is herein reported.

Observations: A 42-year-old man with diabetes mellitus and kidney transplant presented with chronic invasive fungal sinusitis with left orbital involvement from indolent mucormycosis.

Microsurgical Clipping of a Ruptured Basilar-P1 Junction Aneurysm.

In current neurosurgical practice, treatment paradigms for posterior circulation aneurysms have shifted away from microsurgical clip ligation toward endovascular therapy. This is largely due to the results of the International Subarachnoid Aneurysm Trial and International Study of Unruptured Intracranial Aneurysms, which, in part, showed that outcomes in patients with ruptured aneurysms were better with coiling and that a location in the posterior circulation was an independent risk factor for poor outcome, respectively. Nevertheless, there exist certain anatomic features that highlight the importance of a microsurgical approach.

Delayed intracerebral hemorrhage from a traumatic carotid-cavernous fistula associated with an enucleated orbit.

Spontaneous intracerebral hemorrhage (ICH) from a traumatic carotid-cavernous fistula (CCF) is a rare occurrence with few cases reported in the literature. Patients classically present shortly after the inciting trauma with symptoms of ocular venous hypertension. We report a case of an ICH due to delayed rupture of a venous aneurysm from a CCF in a patient with decades-old history of enucleation of the left globe secondary to trauma with no sentinel symptoms.

Impact of cerebral aneurysm size on distal intracranial hemodynamics and changes following flow diversion.

Background: The impact of cerebral aneurysm size on distal intracranial hemodynamics such as arterial pressure and Pulsatility Index is not completely understood, either before or after flow diversion.

Objective: The aim of the study is to assess the impact of aneurysm size on distal Pulsatility Index and pressure before and after flow diversion.

Methods: From December 2015, prospective measurement of middle cerebral artery pressure and Pulsatility Index was performed in consecutive patients with unruptured cerebral aneurysms in the cavernous to communicating segments of the internal carotid artery, which were treated with single flow diversion.

Predictors of Poor Outcome Despite Successful Mechanical Thrombectomy of Anterior Circulation Large Vessel Occlusions Within 6 h of Symptom Onset.

Successful reperfusion is a significant predictor of a good clinical outcome after mechanical thrombectomy (MT). However, some patients have a poor clinical outcome even with successful reperfusion. We aimed to study factors that predict a poor clinical outcome (90-day modified Rankin Scale ≥ 3) in patients with anterior circulation large vessel occlusion (LVO) treated by successful MT within 6 h of symptom onset.

Intracranial Leiomyoma Associated with Epstein-Barr Virus: A Cerebellopontine Angle Mass Presenting with Trigeminal Neuralgia.

Background: Primary intracranial leiomyoma is a rare smooth muscle tumor often associated with Epstein-Barr virus (EBV), with <30 cases reported worldwide. These tumors commonly occur in patients with immunocompromised status, especially those with human immunodeficiency virus. In the present report, we have described the case of an EBV-associated leiomyoma at the cerebellopontine angle.

Risk Factors for Distal Clot Migration during Mechanical Thrombectomy of Anterior Circulation Large Vessel Occlusion.

Introduction: Distal clot migration (DCM) is a known complication of mechanical thrombectomy (MT), but neither risk factors for DCM nor ways of how it might affect clinical outcomes have been extensively studied to date.

Methods: To identify risk factors for and outcomes in the setting of DCM, the records of all patients with acute ischemic stroke due to anterior circulation large vessel occlusion (LVO) treated with MT at a single center between May 2016 and June 2018 were retrospectively reviewed. Uni- and multivariable analyses were performed to evaluate predictors of DCM and good functional outcome (90-day modified Rankin Scale; mRS 0-2).

2D parametric contrast time-density analysis for the prediction of complete aneurysm occlusion at six months' post-flow diversion stent.

Objective: Indications for the treatment of cerebral aneurysms with flow diversion stents are expanding. The current aneurysm occlusion rate at six months ranges between 60 and 80%. Predictability of complete vs.

Intracranial venous sinus stenosis: hemodynamic assessment with two-dimensional parametric parenchymal blood flow software on digital subtraction angiography.

Objective: Intracranial venous sinus stenosis (IVSS) is the most common finding associated with idiopathic intracranial hypertension. A pressure gradient >8-10 mm Hg across the stenosis is considered hemodynamically significant, and typically responds to endovascular stent treatment. Here we assess the venous hemodynamics with two-dimensional (2D) parametric parenchymal blood flow software (Siemens-Healthineers, Forchheim, Germany) and its ability to predict significant IVSS.

The cut flow index revisited: utility of intraoperative blood flow measurements in extracranial-intracranial bypass surgery for ischemic cerebrovascular disease.

Objective: In extracranial-intracranial (EC-IC) bypass surgery, the cut flow index (CFI) is the ratio of bypass flow (ml/min) to donor vessel cut flow (ml/min), and a CFI ≥ 0.5 has been shown to correlate with bypass patency. The authors sought to validate this observation in a large cohort of EC-IC bypasses for ischemic cerebrovascular disease with long-term angiographic follow-up.

Role of Resistivity Index Analysis in the Prediction of Hemodynamically Significant Venous Sinus Stenosis in Patient With Idiopathic Intracranial Hypertension.

Background: The resistivity index (RI) in cerebral venous sinus stenosis (VSS) has not been studied in patients with idiopathic intracranial hypertension (IIH).

Objective: To evaluate the role of RI measured by quantitative magnetic resonance venogram (QMRV) as a noninvasive tool in the diagnosis of venous hypertension associated with VSS in IIH.

Methods: Retrospective evaluation of 13 consecutive IIH patients who underwent venous sinus stenting at our institution between 2013 and 2018.

High-Definition Zoom Mode: A High Resolution X-ray Microscope for Neurointerventional Treatment Procedures.

Background And Purpose: Visualization of structural details of treatment devices during neurointerventional procedures can be challenging. A new true two-resolution imaging X-ray detector system features a 194 µm pixel conventional flat-panel detector (FPD) mode and a 76 µm pixel high-resolution high-definition (Hi-Def) zoom mode in one detector panel. The Hi-Def zoom mode was developed for use in interventional procedures requiring superior image quality over a small field of view (FOV).

Transtentorial herniation from tumefactive multiple sclerosis mimicking primary brain tumor.

Background: Multiple sclerosis (MS) is a chronic central nervous system inflammatory demyelinating disease characterized by multiple lesions disseminated in time and space. The lesions often have characteristic imaging findings on magnetic resonance (MR) imaging and cerebrospinal fluid findings that lead to their diagnosis. At times, these lesions may resemble tumors due to their large size (>2 cm), significant vasogenic edema, and ring-enhancing MR imaging findings.

Management of Acute Ischemic Thrombosis.

Acute ischemic thrombosis in patients who have undergone neurosurgical procedures is a leading cause of mortality and long-term disability. Endovascular therapy has become an important treatment modality for acute ischemic thrombosis in these patients. Noninvasive imaging has dramatically changed the understanding of cerebral blood flow and the concepts of cerebrovascular reserve and salvageable penumbra.