The Importance of Exercise in the Well-Rounded Physician: Dialogue for the Inclusion of a Physical Fitness Program in Neurosurgery Resident Training.

Exercise, diet, and personal fitness programs are essentially lacking in modern graduate medical education. In the context of long hours and alternating shift and sleep cycles, the lack of exercise and poor dietary choices may have negative consequences on physician physical and mental health. This opinion piece aims to generate important dialogue regarding the scope of the problem, the literature supporting the health benefits of exercise, potential solutions to enhancing diet and exercise among resident trainees, and possible pitfalls to the adoption of exercise programs within graduate medical education.

Factors That Affect Physiologic Tremor and Dexterity During Surgery: A Primer for Neurosurgeons.

Introduction: All individuals have a physiologic tremor that may become more pronounced in periods of stress, stimulant use, or caffeine. There are few publications measuring the effects of these factors on surgeons or trainees and no comprehensive reviews. We sought to review the representative literature.

Blood Pressure Guideline Adherence in Patients with Ischemic and Hemorrhagic Stroke in the Neurointensive Care Unit Setting.

Background And Purpose: Patients with acute brain injuries require strict physiologic control to minimize morbidity and mortality. This study aimed to assess in-hospital compliance to strict physiologic parameters (BP, HR, ICP, SpO2) in these populations.

Methods: Patients with severe cerebrovascular events were admitted to the neurointensive care unit (NSICU) and were continuously monitored using the BedMasterEX (Excel Medical Electronics Inc, FL) system, which recorded hemodynamic data via an arterial catheter continuously in 5-s intervals.

Initial multicenter technical experience with the Apollo device for minimally invasive intracerebral hematoma evacuation.

Background: No conventional surgical intervention has been shown to improve outcomes for patients with spontaneous intracerebral hemorrhage (ICH) compared with medical management.

Objective: We report the initial multicenter experience with a novel technique for the minimally invasive evacuation of ICH using the Penumbra Apollo system (Penumbra Inc, Alameda, California).

Methods: Institutional databases were queried to perform a retrospective analysis of all patients who underwent ICH evacuation with the Apollo system from May 2014 to September 2014 at 4 centers (Medical University of South Carolina, Stony Brook University, University of California at San Diego, and Semmes-Murphy Clinic).

The case for a milestone-based simulation curriculum in modern neuroendovascular training.

The role of simulation in formal neuroendovascular training has not been defined. This report details the general principles underlying the use of simulation in training, the critical aspects of the simulation environment which would aid it as a teaching tool specific to the field of neuroendovascular care, summarizes the available evidence to support a milestone-based curriculum, and outlines an example of what such a curriculum would entail. Building on these foundations, we articulate the rationale for the development and widespread adoption of a simulation curriculum for formal neuroendovascular training.

Acute stroke after carotid endarterectomy: time for a paradigm shift? Multicenter experience with emergent carotid artery stenting with or without intracranial tandem occlusion thrombectomy.

Background: Stroke in the immediate postoperative period after carotid endarterectomy is a rare complication. Many centers have begun incorporating angiography before surgical re-exploration, which has the advantage of confirming carotid occlusion and treating tandem intracranial lesions if present.

Objective: To determine the safety and efficacy of this strategy.

Novel device and technique for minimally invasive intracerebral hematoma evacuation in the same setting of a ruptured intracranial aneurysm: combined treatment in the neurointerventional angiography suite.

Background: The presence of intracerebral hematoma from aneurysm rupture is an indication for craniotomy for clot evacuation and aneurysm clipping. Some centers have begun securing aneurysms with coil embolization followed by clot evacuation in the operating room. This approach requires transporting a patient from the angiography suite to the operating room, which can take valuable time and resources.

Initial experience with the PulseRider for the treatment of bifurcation aneurysms: report of first three cases in the USA.

Introduction: The PulseRider is a novel device intended for use in the treatment of aneurysms arising at bifurcations. We present the initial results of the first three cases in the USA employing the PulseRider device.

Methods: Aneurysms intended to be treated with the PulseRider device at a single institution were identified prospectively.

Carotid sacrifice with a single Penumbra occlusion device: a feasibility study in a swine model.

Introduction: Carotid sacrifice is a valuable tool in the treatment of select vascular lesions. Traditional coil embolization as the primary means of carotid sacrifice can be expensive, with high radiation exposure. We investigated the feasibility of a novel hybrid coil, the Penumbra occlusion device (POD), for carotid sacrifice in a swine model.

Diagnostic angiography skill acquisition with a secondary curve catheter: phase 2 of a curriculum-based endovascular simulation program.

Background: We have previously reported the efficacy of a simulator-based training paradigm for residents in neurosurgery with little or no prior experience in diagnostic cerebral angiography with straightfoward arch anatomy. This study investigates the utility of a simulation-based training curriculum for the acquisition of skills employing a secondary curve catheter to navigate more complex arch anatomy.

Methods: Residents at the Medical University of South Carolina (MUSC) with moderate exposure to diagnostic angiography enrolled into a standardized Institutional Review Board-approved training protocol using SimSuite Compass and Simbionix simulators.

Y-Stenting for Bifurcation Aneurysm Coil Embolization: What is the Risk?

The use of two stents in a "Y" configuration (Y-stenting) to assist with coil embolization of complex bifurcation aneurysms has been accepted as an alternative to clip reconstruction of a select subset of challenging aneurysms. We review the risks associated with Y-stenting, including its procedural complication rates, angiographic occlusion rates, rerupture, and retreatment rates.

Balloon-augmented Onyx embolization of cerebral arteriovenous malformations using a dual-lumen balloon: a multicenter experience.

Introduction: Conventional Onyx embolization of cerebral arteriovenous malformations (AVMs) requires lengthy procedure and fluoroscopy times to form an adequate 'proximal plug' which allows forward nidal penetration while preventing reflux and non-targeted embolization. We review our experience with balloon-augmented Onyx embolization of cerebral AVMs using a dual-lumen balloon catheter technique designed to minimize these challenges.

Methods: Retrospectively acquired data for all balloon-augmented cerebral AVM embolizations performed between 2011 and 2014 were obtained from four tertiary care centers.

Impact of the ASPECT scores and distribution on outcome among patients undergoing thrombectomy for acute ischemic stroke.

Introduction: This study investigates whether the Alberta Stroke Program Early CT Score (ASPECTS) quantification is associated with outcome following mechanical thrombectomy.

Objective: To determine whether preintervention non-perfect ASPECT scores involving cortical or subcortical regions and the side of the non-perfect ASPECT score affects outcomes.

Methods: A retrospective review of a prospectively maintained database of patients with acute ischemic stroke involving the anterior circulation who underwent thrombectomy between May 2008 and August 2012 at a single tertiary care center.

Mycotic aneurysm detection rates with cerebral angiography in patients with infective endocarditis.

Background: Cerebral angiography remains the gold standard for the detection of mycotic aneurysms, and it has been estimated that ruptured mycotic aneurysms result in 5% of the neurological complications of patients with infective endocarditis (IE).

Objective: To determine the diagnostic yield of cerebral angiography in the above patient population and to assess patient factors that might suggest greater or lesser utility.

Methods: We retrospectively reviewed 168 patients who underwent cerebral angiography with a diagnosis of IE or infected left ventricular assist device at the Cleveland Clinic between January 2003 and March 2010 in accordance with institutional review board guidelines.

Proximal to distal approach in the treatment of tandem occlusions causing an acute stroke.

Introduction: A tandem occlusion is a rare presentation of acute stroke that involves an occlusion of the internal carotid artery at the bifurcation with an intracranial middle cerebral artery occlusion. This study describes the experience at our institution in treating tandem occlusions with a proximal to distal approach in the acute stroke setting.

Methods: A retrospective review of acute strokes caused by tandem occlusions requiring thrombectomy were performed.

Evolution of thrombectomy approaches and devices for acute stroke: a technical review.

While intravenous administration of tissue plasminogen activator (tPA) remains the only FDA-approved treatment modality for acute ischemic stroke, many patients do not meet the criteria for intravenous tPA and are offered intra-arterial therapy. Rapid advances in devices and approaches have marked the evolution of thrombectomy over the past decade from rudimentary mechanical disruption, followed by intra-arterial thrombolytic infusions to increasingly effective thrombectomy devices. We review the critical advancements in thrombectomy technique that have evolved and the key anatomic and technical challenges they address, from first-generation Merci retrieval systems to second-generation Penumbra aspiration systems and third-generation stent retrievers, as well as nuances of their uses to maximize their effectiveness.

Balloon augmented Onyx embolization utilizing a dual lumen balloon catheter: utility in the treatment of a variety of head and neck lesions.

Introduction: Endovascular embolization for tumors and vascular malformations has emerged as an important preoperative adjunct prior to resection. We describe the advantages of utilizing a recently released dual lumen balloon catheter for ethylene vinyl alcohol copolymer, also known as Onyx (ev3, Irvine, California, USA), embolization for a variety of head and neck pathologies.

Methods: A retrospective review of all cases utilizing the Scepter C balloon catheter (MicroVention Inc, Tustin, California, USA) for use in balloon augmented embolization was performed over a 4 month period from October 2012 to February 2013 at the Medical University of South Carolina, Charleston, South Carolina, USA.

Flexible tip guides and intermediate catheters: two center experience and a proposed taxonomy.

Background: Stable access to target lesions is foundational to endovascular therapy, be it in hemorrhagic or ischemic disease. Continued evolution in access technology has resulted in next generation catheters that afford improved trackability and proximal support.

Objective: Assess safety and patterns of use at two high volume centers, and conceptualize usage patterns.

The golden hour of stroke intervention: effect of thrombectomy procedural time in acute ischemic stroke on outcome.

Introduction: Outcome studies in acute ischemic stroke (AIS) have focused on time from symptom onset to treatment. The purpose of this study was to investigate whether time to achieve vessel recanalization from groin puncture affects outcomes.

Methods: We studied all AIS cases that underwent intra-arterial therapy between May 2008 and October 2012 at a high volume center for anterior circulation occlusions.

Hounsfield unit value and clot length in the acutely occluded vessel and time required to achieve thrombectomy, complications and outcome.

Introduction: Intra-arterial therapy for acute ischemic stroke (AIS) now has an established role. We investigated if Hounsfield Units (HU) quantification on non-contrast CT is associated with ease and efficacy of mechanical thrombectomy and outcomes.

Methods: We retrospectively studied a prospectively maintained database of cases of AIS given intra-arterial therapy between May 2008 and August 2012.

Multiple overlapping stents as monotherapy in the treatment of 'blister' pseudoaneurysms arising from the supraclinoid internal carotid artery: a single institution series and review of the literature.

Background: The 'blister-type' aneurysm is one of the most devastating cerebrovascular lesions. Flow diversion with stent reconstruction is an emerging treatment and has shown promising initial results.

Objective: To evaluate the experience of one institution using stent reconstruction for pseudoaneurysms of the supraclinoid internal carotid artery and to compare with a review of the literature.

Transfemoral venous approach for Onyx embolization of anterior fossa dural arteriovenous fistulae.

Background: Dural arteriovenous fistulae (dAVF) of the anterior fossa have a malignant course since they exclusively drain into cortical frontal veins and warrant aggressive treatment. Classically, these lesions have been treated with microsurgical clipping of the fistulous connection. We describe a transvenous approach for Onyx embolization of these lesions that relies on distal venous access using a flexible new-generation guide catheter.

Absence of immunostaining for growth hormone in a subset of patients with acromegaly.

The presence of growth hormone (GH) immunostaining in patients who lack the biochemical and clinical features of acromegaly has been described. In contrast, there is little information on the absence of GH immunostaining in patients with acromegaly. We describe five patients with acromegaly with no intratumoral immunostaining for GH.

Initial experience with the coaxial dual-lumen Scepter C balloon catheter for endovascular management of cerebral vasospasm from subarachnoid hemorrhage.

Background: Post-hemorrhagic cerebral vasospasm accounts for significant morbidity and mortality in patients with subarachnoid hemorrhage (SAH). Intra-arterial therapies including vasodilator administration and/or balloon angioplasty are used when medical management fails. The Scepter C is a newer dual coaxial lumen temporary occlusion balloon catheter used for the treatment of post-hemorrhagic cerebral vasospasm.