Julian Brown

Objective: The optimal pre‐implantation evaluation and surgical targeting strategies for responsive neurostimulation (RNS) in patients with unresectable, drug‐resistant focal epilepsy continue to be debated. Although stereo‐electroencephalography (sEEG) is central to characterizing the seizure‐onset zone, its role in preoperative testing for neuromodulation remains undefined. We examined whether sEEG‐guided targeting for RNS implantation confers seizure‐reduction benefit compared with RNS implantation without sEEG. Methods: We retrospectively reviewed patients who underwent RNS implantation at our institution in 2015–2024. Patients were propensity score–matched based on demographics and epilepsy characteristics to create balanced groups of patients with and without prior sEEG. The primary outcome measure was seizure reduction as a percent change from baseline frequency, determined using linear regression. Results: Of 99 patients (median ± standard error [SE] follow‐up 45.3 ± 2.9 months), 78 (79%) underwent sEEG monitoring before RNS implantation and 21 (21%) did not. Most patients (62%) had no prior interventions for epilepsy and had non‐lesional epilepsy (75%). Mean seizure reduction at last follow‐up was 72.4% ± 29.3%. There were 21 patients in each propensity‐matched group. The use of preoperative sEEG was not associated with greater seizure reduction in the original ( p = .835) and propensity score–matched cohorts ( p = .914). In the unmatched cohort, female sex ( β = 16.7, p = .006,) older age ( β = .55, p = .027), thalamic RNS stimulation ( β = 18.0, p = .030), and follow‐up duration ( β = .2, p = .029) were associated with greater seizure reduction on linear regression. Subgroup analyses among epilepsy subtypes (bitemporal, temporal, or extratemporal) found no statistically significant differences in seizure reduction. Significance: In a climate of growing delays in epilepsy care, we did not observe differences in RNS efficacy with or without prior sEEG monitoring in patients with unilateral or bilateral temporal lobe epilepsy, temporal‐plus epilepsy, and extratemporal epilepsy. Although prospective data are needed to investigate the relative benefit of preoperative sEEG use, these findings may help guide patient selection and optimize definitive surgical planning.

BACKGROUND: The Mechanical Thrombectomy Global Access for Stroke study demonstrated that access to mechanical thrombectomy (MT) is P =0.36) or good clinical outcome at 90 days (odds ratio, 0.94 [95% CI, 0.18–4.88]; P =0.94). There were no significant differences in reperfusion rates and clinical outcomes in the unmatched comparison. In the unmatched cohort, higher numbers of patients with medium- or distal-vessel occlusions and posterior circulation strokes were treated in the biplane suite. CONCLUSIONS: This propensity score–matched analysis comparing MT for large-vessel occlusion in single-plane versus biplane angiography suites demonstrated no statistically significant differences in procedural and clinical outcomes or safety measures. These results indicate that MT using single-plane angiography suites can serve as a viable alternative for treating proximal large-vessel occlusions within the anterior circulation in areas where establishing a full biplane suite is not feasible.

BACKGROUND AND OBJECTIVES: Traumatic cerebral venous sinus injury (tCVSI) is a rare but serious complication of traumatic brain injury. Although similar radiographically to spontaneous cerebral venous sinus thrombosis (CVST), tCVSI treatment approaches have not been fully investigated. We characterized complications, clinical outcomes, and recanalization in tCVSI and evaluated treatment approaches. METHODS: In this retrospective review of patients with radiographically confirmed tCVSI across 3 Level 1 trauma centers from 2018 to 2024, we collected patient characteristics, injury patterns, treatment modalities, complications, clinical outcomes, and recanalization data. Primary outcomes were favorable recovery (extended Glasgow Outcome Scale score ≥5) and 30-day mortality. Multivariate regression identified independent predictors of outcomes and recanalization. RESULTS: Among 11 300 patients screened, 254 (2.2%) had tCVSI. Antiplatelet (AP) and anticoagulation (AC) therapy were used in 32% and 19% of patients, respectively. Hemorrhagic complications occurred in 31% of patients treated with AC and 10% receiving AP. Favorable outcomes were achieved in 73.9% of patients, and 30-day mortality was 12.6%. On multivariate analysis, AP (odds ratio [OR] 6.5, 95% CI 2.1-20.0) and AC (OR 4.7, 95% CI 1.3-17.7) therapies were both associated with better outcomes. AP therapy was independently associated with lower 30-day mortality (OR 0.2, 95% CI 0.06-0.66). At the follow-up, 39.9% of patients had complete recanalization of the involved sinus, 17.5% had partial recanalization, and 42.7% were unchanged. Recanalization status on repeat imaging did not correlate with clinical outcomes. CONCLUSION: This multicenter series demonstrates treatment response in patients after tCVSI and describes differences in natural history compared with spontaneous CVST. Both antithrombotic regimens were associated with favorable outcomes, and AP therapy was independently associated with lower mortality, suggesting a potential role in tCVSI management. Recanalization status at follow-up appeared unrelated to clinical outcomes, supporting the need for unique therapeutic approaches for tCVSI compared with spontaneous CVST, particularly in the acute management period.

BACKGROUND AND OBJECTIVES: Because of the proximity of optic pathway-hypothalamic gliomas (OPHGs) to critical neuroanatomical structures and their unpredictable natural history, the role of resection in their treatment is often debated. We present our institutional surgical experience and a systematic review of outcomes in patients with surgically treated OPHG. METHODS: The health records of patients with OPHGs who underwent surgery at our institution were retrospectively reviewed. A systematic review of the literature was also performed to extract surgically treated OPHG cases. Clinical presentation, surgical approach, extent of resection, complications, and outcomes were analyzed. RESULTS: A total of 9 adult patients from our institution were included (mean age 32.3 ± 17.3 years; 5 women [56%]), and we identified 15 studies that met inclusion criteria with a total of 50 patients (mean age 14.4 ± 11.2 years; 24 women [48%]). Visual disturbance was the most common presenting symptom (56% of our patients and 76% of patients from the literature). The most common pathology was pilocytic astrocytoma (67% in our cohort, 62% of patients in the literature). In our cohort, tumors involved the hypothalamus (67%), optic chiasm (67%), and optic nerve (56%), and 33% of patients had gross total resection. In the historical cases, tumors involved the hypothalamus (94%), optic chiasm (42%), and optic nerve (16%), and 12% of patients had gross total resection. Complications in our series included diabetes insipidus (11%), anterior choroidal infarct (11%), and ptosis (11%), and in the literature, new endocrine dysfunction (28%) and visual disturbance (16%) were reported. Three patients (33%) had tumor recurrence at a mean of 27.3 ± 7.6 months, whereas 11 patients (22%) reported in the literature had tumor recurrence at a mean of 55.7 ± 44.3 months. CONCLUSION: Surgery can be performed with reasonable risk and can play a key role in the multidisciplinary management of select patients with OPHG.