BACKGROUND AND IMPORTANCE: Geniculate neuralgia (GN) is a rare disorder characterized by brief paroxysms of pain felt deeply in the auditory canal, like shock. The diagnosis of GN is essentially clinical and requiring the exclusion of other causes. The aim of this study was to report a case of surgical treatment of the disease and perform a systematic review of surgical treatment options. CLINICAL PRESENTATION: A 62-year-old female patient has had severe, sharp pain in her left ear—like an ice pick—for the past 8 months, without any history of trauma or infection. She had triggers for pain, such as talking or swallowing. Imaging investigation showed a vessel touching VIIth and VIIIth nerves, possibly the anterior inferior cerebellar artery. After finding a clinical presentation compatible with GN, treatment with anticonvulsants, gabapentinoids, and opioids was attempted, but without success with such conservative treatments. Therefore, we opted for microvascular decompression and section of the nervus intermedius, which were performed without complications. Neurophysiological assessment was essential to monitor the long tracts and stimulate VIIth and VIIIth nerves to help identify the intermediate nerve. After the procedure, the patient was without pain, and after 12 months of follow-up, she remains without any pain. CONCLUSION: Surgical treatment of GN might be beneficial when medical treatment has not worked. Cranial nerves neurophysiological monitoring is not routinely performed, and the identification is based on anatomy. A more comprehensive knowledge of this condition will help in the surgical treatment choice and in achieving better results.

BACKGROUND: Prediction of long-term outcome based on initial neurological condition after aneurysmal subarachnoid hemorrhage varies with time. To date, studies have been limited to early time points and have reported that prognostication is best after resuscitation. OBJECTIVE: To describe how prediction of outcome varies from ictus through the first week of admission. METHODS: A retrospective analysis of patients with a diagnosis of aneurysmal subarachnoid hemorrhage recruited to a prospective database. Neurological condition was recorded on each day of the inpatient stay, up to day 7, using World Federation of Neurological Societies score (WFNS). Poor outcome was defined by modified Rankin scale of 3-6 at 3 months. Outcome prediction was assessed using area under the curve (AUC) after binary logistic regression. RESULTS: Of 645 patients, 55(14%) patients with WFNS 1&2 and 77(45%) patients with WFNS 4&5 on day 0 had a poor outcome. 30(8%) patients with WFNS 1&2 and 54(81%) patients with WFNS 4&5 on day 7 had a poor outcome. Prognostication using WFNS improved from day 0 to day 7 (AUC = 70.1%, CI 65.0%–75.1% vs AUC = 81.9%, CI 77.4%–86.0%) with an incremental improvement with each day in between, and the largest increases early around the time of resuscitation. CONCLUSION: Prediction of outcome improves beyond the initial resuscitation, up to day 7 of admission, with no evidence of any deterioration around the time of treatment or delayed complications like delayed cerebral ischemia. This is important when prognosticating for clinical purposes and emphasizes the importance of standardization of timing of WFNS in research.

BACKGROUND: Patients increasingly rely on readily available physician reviews to inform their provider choices. Sentiment analysis and machine learning techniques quantitatively analyze written prose to understand patient desires from physician encounters. Patient perspectives on their medical care have been understudied in neurosurgery. OBJECTIVE: To analyze patient reviews of neurosurgeons to uncover trends between patient ratings of their encounters and content in their reviews. METHODS: Identification of neurosurgeons and demographic data were collected from 115 Accreditation Council for Graduate Medical Education–accredited programs using public data. Healthgrades.com was used to obtain online written and star rating reviews which were analyzed using a machine learning sentiment analysis package to generate a sentiment score. Student t tests compared differences between demographics and outcomes from the sentiment analysis. Multivariate regression was performed to examine associations between sentiment rating and word/word pair frequency. RESULTS: One thousand two hundred eighty-four neurosurgeons were found to have review profiles which consisted of 6815 reviews. Analysis revealed a direct correlation between sentiment score and star rating (r2 = 0.554, P < .0001). There were no differences in the sentiment score based on neurosurgeons' sex; however, younger surgeons had more positive reviews (P = .022). Word frequency analysis showed that reviews were less likely to be positive if they included “pain” (odds ratio [OR]: 0.28, CI: 0.24-0.32, P < .0001) or “rude” (OR: 0.03, CI: 0.01-0.06, P < .0001). Reviews were more likely to be positive when they included “kind” (OR: 3.7, CI: 2.6-5.3, P < .0001) or “pain-free” (OR: 3.1, CI: 2.1-4.7, P < .0001). CONCLUSION: Top-rated reviews demonstrate the importance of compassion in patient satisfaction. The word “pain” arose for both negative and positive reviews. Pain management seems to be a salient component of patients' evaluation of their neurosurgical care, thereby underscoring the importance of guiding patient pain expectations.

BACKGROUND AND IMPORTANCE: Nearly 25% of all epilepsy is drug-resistant epilepsy. Responsive neurostimulation (RNS) and deep brain stimulation (DBS) offer viable options when resection or ablation is not feasible. Neuromodulation leads to improved seizure control. However, in patients with highly complex epileptogenic networks, a multimodality approach using simultaneous RNS and DBS may provide a summative benefit. CLINICAL PRESENTATION: We present 2 cases of drug-resistant epilepsy who received simultaneous anterior nucleus of the thalamus DBS and RNS neuromodulation. To our knowledge, this is the first report of simultaneous DBS and RNS neurostimulation for the treatment of epilepsy. Given the complexity of their seizure networks, a combined neuromodulatory approach was deemed best to achieve seizure control. Both experienced multiple seizure semiology patterns consistent with multifocal onsets which were confirmed on phase I monitoring, nuclear medicine, and magnetoencephalography studies. Case 1 had a seizure reduction of 75% to 89% at 12 months which has remained stable at last follow-up (26 months) and case 2 achieved near seizure freedom and remained seizure-free at last follow-up (16 months). CONCLUSION: Neuromodulation has proven efficacious and safe in randomized controlled trials for the treatment of epilepsy. This is particularly important in multifocal epilepsy or if resective surgery is not an option. The optimal stimulation pathways and multimodal neuromodulation technique remains under investigation. We are the first to report that RNS and DBS implantation in the same patient is feasible, without major adverse effects and potentially effective.

BACKGROUND AND IMPORTANCE: In adults and elderly patients, most arachnoid cysts are asymptomatic. Interhemispheric arachnoid cyst (IHAC) is clinically rare. In this report, we describe a rare case of a symptomatic IHAC without the agenesis of the corpus callosum in an elderly patient who underwent stereotactic endoscopic neurosurgery with excellent results. CLINICAL PRESENTATION: An 85-year-old woman with multiple systemic complications presented with progressive left hemiparesis. MR images, including diffusion tensor images, at the initial examination showed a large IHAC in the right parietal region without the agenesis of the corpus callosum. The patient underwent 3 MR image scans over the next year, and the lesions were markedly enlarged. Endoscopic cyst fenestration using a stereotactic neuronavigation system was performed between the IHAC and the bilateral ventricles. Postoperatively, the IHAC was reduced to a size sufficient to improve her hemiparesis. CONCLUSION: This is the first report of successful stereotactic endoscopic neurosurgery for a symptomatic IHAC without the agenesis of the corpus callosum. Further experience is required to confirm the usefulness of this minimally invasive procedure.

BACKGROUND: The genetic determinants and mechanisms underlying intracranial aneurysm rupture (rIA) are largely unknown. Given the ∼50% mortality rate of rIA, approaches to identify patients at high risk will inform screening, diagnostic, and preventative measures. OBJECTIVE: To identify and characterize the genetic basis of rIA. METHODS: We perform a genome-wide association study (GWAS) using functional genomics approaches to identify and characterize rIA-associated loci and genes. We perform a meta-analysis across 24 published GWAS of rIA. Single nucleotide polymorphisms, gene-burden analysis, and functional genomics identify and characterize genetic risk factors for rIA. RESULTS: Our cohort contains 84 353 individuals (7843 rIA cases and 76 510 controls). We identify 5 independent genetic loci reaching genome-wide significance (P < 5.0 × 10−8) for rIA including rs12310399 (FGD6, odds ratio = 1.16), which has been implicated in prior GWAS of IA. We then quantified gene-level mutation burden across ∼20 000 genes, and only FGD6 (containing 21 rIA-associated single nucleotide polymorphisms) reached transcriptome-wide significance. Expression quantitative trait loci mapping indicates that rs12310399 causes decreased FGD6 gene expression in arterial tissue. Next, we used publicly available single-cell RNA sequencing of normal human cerebrovascular cells obtained during resection surgery and identify high expression of FGD6 in 1 of 3 arterial lineages but absent in perivascular cells. These data suggest how alterations in FGD6 may confer risk to rIA. CONCLUSION: We identify and characterize a known risk loci for IA, but not for rIA, containing FGD6. Elucidation of high-risk genetic loci may instruct population-genetic screening and clinical-genetic testing strategies to identify patients predisposed to rIA.

BACKGROUND: In parasagittal dural arteriovenous fistulas (DAVFs), the shunt point is on the falx cerebri and drains directly into the cortical vein. The venous structure anatomy of the falx cerebri is not well understood. OBJECTIVE: To describe a parasagittal DAVF as a non–sinus-type DAVF using clinical expertise and cadaver analysis. We focused on the clinical characteristics of parasagittal DAVFs, anatomy of the cortical vein directly flowing into the falx cerebri, and venous route in the falx cerebri. METHODS: Six patients with parasagittal DAVFs were examined between April 2009 and March 2019. In 7 cadaver heads, we examined the entire falx cerebri length and the cortical veins flowing into it were noted. The falx cerebri was divided down from the midline into the dura propria to examine the venous pattern. RESULTS: Clinically, all 6 cases were classified as parasagittal DAVFs. Intracerebral hemorrhage occurred in 2 patients (33.3%). In all 6 cases, only the cortical vein was the draining vein ipsilateral to the shunt point. One patient (16.7%) underwent transarterial embolization, 2 (33.3%) underwent direct surgery, and 2 (33.3%) underwent combined transarterial embolization with direct surgery. In the anatomic study, 7 (50.0%) venous structures directly flowed into the falx cerebri and 5 (35.7%) were located in the parasinus portion. The veins directly flowing into the falx ran through the dura propria on each side. CONCLUSION: Based on the clinical characteristics and anatomic features, clinicians must pay attention to cerebral hemorrhage in patients with parasagittal DAVFs to manage aggressive symptoms.

BACKGROUND AND IMPORTANCE: Traumatic intracranial aneurysms are uncommon and are mostly located in the anterior circulation. Aneurysms involving the posterior circulation are extremely rare and account for less than 10% of traumatic aneurysms. In this study, we describe an extremely rare case of a traumatic pseudoaneurysm of the posterior inferior cerebellar artery due to a fracture of the clivus that ruptured in the acute stage after blunt brain injury and that was successfully cured endovascularly. CLINICAL PRESENTATION: A 68-year-old man presented with loss of consciousness because of a severe subarachnoid hemorrhage and multiple contusions after blunt brain injury. Angiography the day after trauma revealed a traumatic pseudoaneurysm near the clivus fracture that had not been identified on the first day of trauma. The aneurysm's location was consistent with the location of the increased thick subarachnoid hemorrhage. The aneurysm was successfully occluded endovascularly through posterior inferior cerebellar artery parent artery occlusion. The patient survived the acute stage because of management that included endovascular treatment followed by decompressive craniectomy. CONCLUSION: A traumatic pseudoaneurysm that is likely to rupture due to the fragility of the aneurysm wall can be identified within 1 day after trauma. Neurosurgeons should pay careful attention to the aneurysm formation and perform early treatment to prevent its rupture, which could lead to a fatal hemorrhage.

BACKGROUND: The tenets of minimally invasive neurosurgery require small craniotomies that nevertheless afford sufficient surgical freedom to safely accomplish the operative goal. OBJECTIVE: To present a novel technique which couples surgical rehearsal in virtual reality (VR) with navigation-integrated, microscope-synchronized augmented reality (AR) to optimize minimally invasive openings. METHODS: A retrospective review of the senior author's early experience with this mixed reality (VR + AR) platform was conducted. Patient-specific VR models were rendered from standard computed tomography/MRI. Surgical rehearsal with these models created templates with the optimal opening, which were integrated with the AR system. In surgery, the templates were projected through a navigation-tracked microscope and appeared as AR objects onto the patient. The templates guided the planning of the incision and steps of the approach. RESULTS: Sixteen patients were included in this study, 11 women and 5 men (33-79 years; median: 59.5). Twelve operations were performed for mass lesions and 4 for microvascular decompression for trigeminal neuralgia. There were no intraoperative adverse events related to AR. For 15 patients (94%), the templates provided major advantage in optimizing the bony opening and guided the operation to the specific anatomic location chosen preoperatively. For 1 patient, the AR template guided the drilling away from the critical structures inside the temporal bone. In addition, 3-dimensional AR markers relieve the surgeon from ergonomically cumbersome monitor-based navigation (Video 1). CONCLUSION: This novel mixed reality platform combines surgical rehearsal in VR and navigation-integrated, microscope-synchronized overlay of AR templates to ensure that optimal exposure is efficiently obtained.

BACKGROUND: Quality systematic reviews with meta-analyses (SRMA's) are the standard for recommendations in clinical practice. One problem with the current literature is susceptibility to publication bias, which has been shown to inflate effect estimates of SRMA's. OBJECTIVE: To combat publication bias, Cochrane Collaboration requires searching at least 1 clinical trial registry (CTR) for unpublished data. Therefore, we investigated SRMA's published in the top 5 neurosurgery journals and whether they incorporated CTR searches. METHODS: All meta-analyses published the top 5 journals in Neurosurgery over the past 5 years were queried using the h-5 index of Google Scholar: Journal of Neurosurgery, Neurosurgery, World Neurosurgery, Journal of Neurosurgery: Spine, and Neurosurgical Focus. Search strings were generated to incorporate SRMA's over the past 5 years in these journals. We selected a random sample of 100 studies from the list of SRMA's that did not incorporate CTR searches and searched ClinicalTrials.gov for unpublished, completed CTR's with relevant outcomes. RESULTS: Of 761 papers, 22/761 searched CTR's, meaning only 2.8% of SRMA's in these journals included CTR data. Among 100 randomized papers in secondary analysis, 39% had relevant CTR data, and 16 of those 39 papers had multiple sets of data relevant to the study (41%). Meanwhile, papers published by Cochrane had 69 of 72 reviews (95.8%) that included CTR searches. CONCLUSION: This shows that the top neurosurgery journals seldom published SRMA's containing searches for unpublished CTR's while Cochrane almost always had searches. In addition, 41% of the randomized sample in our secondary analysis could have included CTR studies.