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BACKGROUND: Chronic subdural hematomas (CSDHs) are common in the elderly, with a relatively high rate of recurrence after initial surgical intervention. Our research team previously created a predictive grading system, the Puerto Rico Recurrence Scale (PRRS), to identify patients at high risk of CSDH recurrence. In this study, we introduce a modification of the (mPRRS) that includes pneumocephalus volume, which has been independently associated with recurrence. METHODS: A single-center Puerto Rican population-based retrospective study was performed to analyze data for patients treated for CSDH at 1 institution between July 1, 2017, and December 31, 2019. Univariate and multivariate analyses were used to create a grading scale predictive of recurrence. Retrospective validation was conducted for the cohort. RESULTS: Of 108 patients included in the study, 42 had recurrence, and 66 had nonrecurrence. Postoperative subdural space, postoperative midline shift, and pneumocephalus volume were all higher with recurrence (P = 0.002, P = 0.009, and P < 0.001, respectively). Multivariate analysis was used to create a 6-point grading scale comprising 3 variables (pneumocephalus volume [< 10, 10-20, 21-30, and > 30 cm3], postoperative midline shift [< 0.4, 0.41-1.0, and > 1.0 cm], and laterality [unilateral and bilateral]). Recurrence rates progressively increased in low-risk to high-risk groups (2/18 [11%] vs 21/34 [62%]; P < 0.003). CONCLUSION: The mPRRS incorporating pneumocephalus measurement improves CSDH recurrence prediction. The mPRRS indicated that patients with higher scores have a greater risk of recurrence and emphasized the importance of measuring postoperative variables for prediction. The mPRRS grading scale for CSDHs may be applicable not only to the Puerto Rican population but also to the general population.

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Background: Chronic subdural hematoma (CSDH) commonly affects older individuals and is associated with a relatively high rate of recurrence after surgery. Many studies have created grading systems to identify patients at high risk of CSDH recurrence after the initial surgery. However, no system has been adopted widely. The authors present the first CSDH grading system created from a population-based single-center data set. Methods: A single-center Puerto Rican population-based retrospective analysis was performed on consecutive patients treated for a CSDH at a designated institution from July 1, 2017 to December 31, 2019. Univariate and multivariate analyses were used to create a CSDH recurrence grading scale. Retrospective validation was conducted on this sample population. Results: The study included 428 patients. Preoperative midline shift, postoperative midline shift, and size of postoperative subdural space differed between the recurrence and nonrecurrence groups (P = 0.03, 0.002, and 0.002, respectively). A multivariate analysis was used to create a 10-point grading scale comprising four independent variables. Recurrence rates progressively increased from the low-risk (0-3 points) to high-risk (8-10 points) groups (2.9% vs. 20.3%; P < 0.001). Conclusion: A 10-point grading scale for CSDH recurrence was developed with four components: preoperative midline shift (≤1 and >1 cm), laterality (bilateral, unilateral-right, and unilateral-left), size of postoperative subdural space (≤1.6 and >1.6 cm), and pneumocephalus (present or absent). Patients who scored higher on the scale had a higher risk of recurrence. This CSDH grading scale has implications for Puerto Rico and the general population as the elderly population increases worldwide.

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OBJECTIVE: Multiple intracranial aneurysms (MIA) account for 30% of all intracranial aneurysms, while mirror aneurysms, a subgroup of MIA, are present in 5% of all patients with cerebral aneurysms. We investigated the risk factors associated with the presence of multiple and mirror intracranial aneurysms. METHODS: 1404 patients, 314 males (22.4%) and 1090 female (77.6%) were enrolled for this study. Diagnosis was performed with a digital subtraction angiography (DSA). Multiplicity was defined as the presence of two or more aneurysms and mirror aneurysms as one pair of aneurysms involving bilateral corresponding arteries. Patients were followed-up from September 2009 till August 2018. Individuals' characteristics such as sex, age, smoking, hypertension and use of contraceptives were evaluated. RESULTS: Five hundred and twelve patients (36.4%) were diagnosed with MIA, approximately 4%/year. We observed 203 pairs of mirror aneurysms, accounting for 406 aneurysms (13% of the population). There was an increased frequency of females with multiple (p < 0.001, OR = 1.883, 95% CI = 1.386-2.560) and mirror aneurysms (p < 0.001, OR = 2.828, 95% CI = 1.725-4.636). Smoking was associated with multiplicity (p< 0.001, OR = 1.458, 95% CI = 1.160-1.833), as well as advanced age (p < 0.001, OR = 1.938, 95% CI = 1.438-2.611), but there was no significant relation with presence of mirror aneurysms. We observed higher frequency of baby aneurysms (<3mm) in the group of patients with MIA, while giant aneurysms (>25 mm) were most found in patients with only one aneurysm (p < 0.001). No differences between patients who used contraceptives against patients who did not use were found (p = 0.600). CONCLUSIONS: Gender and smoking, known risk factors to the development of a single intracranial aneurysm, are proportionally increased in patients with MIA. Hypertension and oral contraceptives were not associated with multiplicity.

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OBJECTIVE: We performed a bibliometric analysis of studies reporting cases of brain and spinal arteriovenous malformations (AVMs). METHODS: We retrieved the 100 most cited reports in brain and spinal AVM research from Scopus and assessed the citation count, journal of publication and its impact factor, year of publication, first author and corresponding authors and their h-index, country, institution, department, and study category. RESULTS: The median number of citations per article was 215. The Journal of Neurosurgery was the most prolific journal (39 reports and 12,069 citations), including 9 of the 10 most cited reports. Seventy reports (19,251 citations), including 8 of the 10 most cited, were from the United States. The Barrow Neurological Institute was the most cited institution (7 reports; 2792 citations), and the Mayo Clinic had the greatest number of reports (8 reports; 1994 citations). Most studies had been reported before 2000 (71 reports; 19,262 citations). The most discussed topics were treatment (40 studies; 9560 citations) and natural history and/or clinical features (37 studies; 9595 citations). Neurosurgery was the most prolific department (58 studies; 15,860 citations). Spetzler was the author with the highest number of articles (n = 7) and citations (n = 2792). CONCLUSIONS: Brain and spinal AVM research was centralized in the United States, has been mainly reported in specific neurosurgical journals, and has been more often related to treatment and natural history and/or clinical features. It is possible that high impact AVM research has been decreasing recently. Because the best approach to these pathological entities remains controversial, research stimulation within this field should be encouraged.

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OBJECTIVE: The brainstem is a compact, delicate structure. The surgeon must have good anatomical knowledge of the safe entry points to safely resect intrinsic lesions. Lesions located at the lateral midbrain surface are better approached through the lateral mesencephalic sulcus (LMS). The goal of this study was to compare the surgical exposure to the LMS provided by the subtemporal (ST) approach and the paramedian and extreme-lateral variants of the supracerebellar infratentorial (SCIT) approach. METHODS: These 3 approaches were used in 10 cadaveric heads. The authors performed measurements of predetermined points by using a neuronavigation system. Areas of microsurgical exposure and angles of the approaches were determined. Statistical analysis was performed to identify significant differences in the respective exposures. RESULTS: The surgical exposure was similar for the different approaches-369.8 ± 70.1 mm2 for the ST; 341.2 ± 71.2 mm2 for the SCIT paramedian variant; and 312.0 ± 79.3 mm2 for the SCIT extreme-lateral variant (p = 0.13). However, the vertical angular exposure was 16.3° ± 3.6° for the ST, 19.4° ± 3.4° for the SCIT paramedian variant, and 25.1° ± 3.3° for the SCIT extreme-lateral variant craniotomy (p < 0.001). The horizontal angular exposure was 45.2° ± 6.3° for the ST, 35.6° ± 2.9° for the SCIT paramedian variant, and 45.5° ± 6.6° for the SCIT extreme-lateral variant opening, presenting no difference between the ST and extreme-lateral variant (p = 0.92), but both were superior to the paramedian variant (p < 0.001). Data are expressed as the mean ± SD. CONCLUSIONS: The extreme-lateral SCIT approach had the smaller area of surgical exposure; however, these differences were not statistically significant. The extreme-lateral SCIT approach presented a wider vertical and horizontal angle to the LMS compared to the other craniotomies. Also, it provides a 90° trajectory to the sulcus that facilitates the intraoperative microsurgical technique.

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Fedor Krause, the father of German neurosurgery, traveled to Latin America twice in the final years of his career (in 1920 and 1922). The associations and motivations for his travels to South America and his work there have not been well chronicled. In this paper, based on a review of historical official documents and publications, the authors describe Krause's activities in South America (focusing on Brazil) within the context of the Germanism doctrine and, most importantly, the professional enjoyment Krause reaped from his trips as well as his lasting influence on neurosurgery in South America. Fedor Krause's visits to Brazil occurred soon after World War I, when Germany sought to reestablish economic, political, cultural, and scientific power and influence. Science, particularly medicine, had been chosen as a field capable of meeting these needs. The advanced German system of academic organization and instruction, which included connections and collaborations with industry, was an optimal means to reestablish the economic viability of not only Germany but also Brazil. Krause, as a de facto ambassador, helped rebuild the German image and reconstruct diplomatic relations between Germany and Brazil. Krause's interactions during his visits helped put Brazilian neurosurgery on a firm foundation, and he left an indelible legacy of advancing professionalism and specialization in neurosurgery in Brazil.

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OBJECTIVE: To describe and compare surgical exposure through microsurgical cadaveric dissection of the intercollicular region afforded by the median, paramedian, and extreme-lateral supracerebellar infratentorial (SCIT) approaches. METHODS: Ten cadaveric heads were dissected using SCIT variant approaches. A neuronavigation system was used to determine tridimensional coordinates for the intercollicular zone in each route. The areas of surgical and angular exposure were evaluated and determined by software analysis for each specimen. RESULTS: The median surgical exposure was similar for the different craniotomies: 282.9 ± 72.4 mm2 for the median, 341.2 ± 71.2 mm2 for the paramedian, and 312.0 ± 79.3 mm2 for the extreme-lateral (P = 0.33). The vertical angular exposure to the center of the intercollicular safe entry zone was also similar between the approaches (P = 0.92). On the other hand, the horizontal angular exposure was significantly wider for the median approach (P < 0.001). CONCLUSIONS: All the SCIT approaches warrant a safe route to the quadrigeminal plate. Among the different variants, the median approach had the smallest median surgical area exposure but presented superior results to access the intercollicular safe entry zone.

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OBJECTIVE: Although pterional craniotomy and its variants are the most used approaches in neurosurgery, few studies have evaluated their precise indications. We evaluate the pterional (PT), pretemporal (PreT), and orbitozygomatic (OZ) approaches through quantitative measurements of area, linear, and angular exposures of the major intracranial vascular structures. METHODS: Eight fresh, adult cadavers were operated with the PT, followed by the PreT, and ending with the OZ approach. The working area, angular exposure of vascular structures and linear exposure of the basilar artery were measured. RESULTS: The OZ approach presented a wider area (1301.3 ± 215.9 mm2) with an increase of 456.7 mm2 compared with the PT and of 167.4 mm2 to the PreT (P = 0.011). The extension from PT to PreT and OZ increases linear exposure of the basilar artery. When comparing the PreT and OZ, we found an increase in the horizontal and vertical angle to the bifurcation of the ipsilateral middle cerebral artery (P = 0.005 and P = 0.032, respectively), horizontal angle to the basilar artery tip (P = 0.02), and horizontal angle to the contralateral ICA bifurcation (P = 0.048). CONCLUSIONS: The OZ approach offered notable surgical advantages compared with the traditional PT and PreT regarding to the area of exposure and linear exposure to basilar artery. Regarding angle of attack, the orbital rim and zygomatic arch removal provided quantitatively wider exposure and increased surgical freedom. A detailed anatomic study for each patient and surgeon experience must be considered for individualized surgical approach indication.

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ABSTRACT Introduction: Apoptosis is a contributing factor to degenerating intervertebral disc (IVD). Disc regeneration has been attempted by transplanting cells into the disc, with some gains in disc height achieved in animal models. Here, we study whether the apoptotic microenvironment affects the transplanted disc cells. Methods: Human annulus fibrosus (AF) and nucleus pulposus (NP) cells were grown in media then starved for 5 days in vitro by not changing the media. Three aspects of apoptotic cell influence on the transplanted cells were tested in a total of 32 samples: 1) the effect of apoptotic cytokines in the media, 2) reduced glucose in the media, and 3) apoptotic cell bodies in the flask. The Trypan Blue, AlamarBlue®, and 1,9-Dimethyl-Methylene Blue assays for sulfated glycosaminoglycan (sGAG) content were performed (n=4). Results: There were significant decreases in cell viability between the control, 25% conditioned media (CM) and starved control group. There were no significant differences in cell number, metabolic activity or sGAG production in cells grown in different conditioned media compared to cells grown in complete media. The cells of the control decreased in viability and number over the 5 days without feeding, then improved dramatically when feeding was resumed. Flasks that received transplanted cells in addition to renewed feeding did not recover as much as the cells in the re-fed group. Conclusions: Cytokines from starved cells negatively impact on the viability of healthy cells. Starving cells that receive new sources of nutrition have even higher viability than transplanted cells. This indicates that altering and improving the nutrient supply problem in the IVD could be a valuable option. Level of Evidence III; Case control studyg.

RESUMO Introdução: A apoptose é um fator que contribui para a degeneração do disco intervertebral (DIV). A tentativa de regenerar o disco foi por meio de transplante de células no disco, com alguns ganhos de altura do disco alcançados em modelos animais. Aqui estudamos se o microambiente apoptótico afeta as células do disco transplantadas. Métodos: Células humanas do ânulo fibroso (AF) e do núcleo pulposo (NP) foram cultivadas in vitro em meio de cultura e privadas de nutrição por cinco dias, sem alteração dos meios. Três aspectos da influência de células apoptóticas em células transplantadas foram testados em um total de 32 amostras: 1) o efeito de citocinas apoptóticas no meio de cultura, 2) redução de glicose no meio e 3) corpos celulares apoptóticos no frasco. Realizaram-se ensaios com azul de tripano, AlamarBlue® e 1,9-dimetil azul de metileno para o teor de glicosaminoglicano sulfatado (sGAG) (n = 4). Resultados: Constataram-se decréscimos significativos na viabilidade celular entre o grupo controle, meio condicionado (MC) a 25% e grupo controle privado de nutrição. Não houve diferenças significativas no número de células, atividade metabólica ou produção de sGAG em células cultivadas em diferentes meios condicionados em comparação com o meio completo. As células de controle tiveram redução de viabilidade e de número ao longo dos 5 dias sem alimentação; a seguir, houve melhorara substancial ao se retomar a alimentação. Os frascos que receberam células transplantadas, além da alimentação renovada, não se recuperaram tanto quanto as células do grupo realimentado. Conclusões: As citocinas de células famintas tiveram impacto negativo sobre a viabilidade das células saudáveis. As células famintas que recebem novas fontes de nutrição têm viabilidade ainda maior do que as células transplantadas. Isso indica que alterar e melhorar o fornecimento de nutrientes no DIV pode ser uma opção valiosa. Nível de Evidência III; Estudo de caso controleg.

RESUMEN Introducción: La apoptosis es un factor que contribuye a la degeneración del disco intervertebral (DIV). El intento de regenerar el disco fue por medio de trasplante de células en el disco, con el que se ganó el aumento de altura del disco logrado en modelos animales. Aquí estudiamos si el microambiente apoptótico afecta a las células del disco trasplantadas. Métodos: Células humanas del anillo fibroso (AF) humano y del núcleo pulposo (NP) fueron cultivadas in vitro en medio de cultivo y privadas de nutrición por 5 días, sin alteración de los medios. Tres aspectos de la influencia de las células apoptóticas trasplantadas se probaron en un total de 32 muestras: 1) el efecto de las citoquinas apoptóticas en el medio de cultivo, 2) reducción de la glucosa en el medio y 3) los cuerpos celulares apoptóticos en el matraz. Se realizaron ensayos con azul de tripano, AlamarBlue® y 1,9-dimetil-azul de metileno para el contenido de glicosaminoglicano sulfatado (sGAG) (n = 4). Resultados: Se constataron disminuciones significativas de la viabilidad celular entre el grupo control, medio condicionado (MC) al 25% y el grupo control privado de nutrición. No hubo diferencias significativas en el número de células, la actividad metabólica o producción de sGAG en células cultivadas en diferentes medios condicionados en comparación con el medio completo. Las células de control tuvieron reducción de viabilidad y de número a lo largo de los 5 días sin alimentación; luego, hubo una mejora sustancial al reanudar la alimentación. Los matraces que recibieron células trasplantadas, además de la alimentación renovada, no se recuperaron tanto como las células del grupo alimentado nuevamente. Conclusiones: Las citoquinas de las células privadas de alimento tuvieron un impacto negativo en la viabilidad de las células sanas. Las células hambrientas que reciben nuevas fuentes de nutrición tienen mayor viabilidad que las células trasplantadas. Esto indica que cambiar y mejorar suministro de nutrientes en el DIV puede ser una opción valiosa. Nivel de Evidencia III; Estudio de caso controlg.

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BACKGROUND: Despite the latest developments in microsurgery, electrophysiological monitoring, and neuroimaging, the surgical management of intrinsic brainstem lesions remains challenging. Several safe entry points have been described to access the different surfaces of the brainstem. Knowledge of this entry zone anatomy is critical to performing a safe and less morbid approach. To access the anterior midbrain surface, a well-known entry point is the anterior mesencephalic (AM) zone. Our aim was to quantify surgical AM zone exposure through the orbitozygomatic (OZ) and subtemporal (ST) approaches. We also analyzed the angular exposure along the horizontal and vertical axis angles for the AM zone. METHODS: Ten cadaveric heads were dissected using the OZ and ST approaches for anterior midbrain surface exposure. A neuronavigation system was used to determine the 3-dimensional coordinates. The area of surgical exposure, angular exposure, and anatomical limits of each craniotomy were evaluated and determined using software analysis and compared for intersection areas and AM safe zone exposure. RESULTS: The median surgical exposure was 164.7 ± 43.6 mm2 for OZ and 369.8 ± 70.1 mm2 for ST (P = 0.001). The vertical angular exposure was 37.7° ± 9.92° for the OZ and 18.4° ± 2.8° for the ST opening (P < 0.001). The horizontal angular exposure to the AM zone was 37.9° ± 7.3° for the OZ and 47.0° ± 3.2° for the ST opening (P = 0.002). CONCLUSIONS: Although the OZ craniotomy offers reduced surgical exposure, it provides a better trajectory to the AM zone compared with the ST approach.

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