Neurosurgery
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Review
Mechanism of Action and Biology of Flow Diverters in the Treatment of Intracranial Aneurysms.
Flow diverters have drastically changed the landscape of intracranial aneurysm treatment and are now considered first-line therapy for select lesions. Their mechanism of action relies on intrinsic alteration in hemodynamic parameters, both at the parent artery and within the aneurysm sac. ⋯ In silico computational analyses and investigations in preclinical animal models have provided valuable insights into the underlying biological basis for flow diverter therapy. Here, we review the present understanding pertaining to flow diverter biology and mechanisms of action, focusing on stent design, induction of intra-aneurysmal thrombosis, endothelialization, and alterations in hemodynamics.
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Skull base osteosarcomas are aggressive neoplasms characterized by bony invasion and extracompartmental/extra-osseous soft tissue extension that pose obstacles to achieving complete resection. Management is further complicated by the paucity of data regarding the efficacy of surgery within the treatment paradigm. ⋯ Skull base osteosarcomas present management challenges in which both local and systemic disease progression is the cause of mortality. Achieving R0 resections significantly improves PFS and DSS in treatment-naïve patients within multimodality treatment paradigms. Salvage surgery may benefit in patients after failing previous radiation and chemotherapy treatments. Further work is needed to determine optimal treatment strategies. These data represent the largest series reported to date.
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Neurosciences intensive care units (NICUs) provide institutional centers for specialized care. Despite a demonstrable reduction in morbidity and mortality, NICUs may experience significant capacity strain with resulting supraoptimal utilization and diseconomies of scale. We present an implementation study in the recognition and management of capacity strain within a large NICU in the United States. Excessive resource demand in an NICU creates significant operational issues. ⋯ Capacity strain is a significant issue for hospital units. Reducing capacity strain can increase unit efficiency, improve resource utilization, and augment service-line throughput. RBPP implementation resulted in a significant improvement in service-line operations, regional access to care, and resource efficiency, with minimal externalities at the institutional level.
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Limited dorsal myeloschisis (LDM) is postulated to be a result of incomplete dysjunction in primary neurulation. However, clinical experience of LDM located below the first-second sacral (S1-S2) vertebral level, which is formed from secondary neurulation (S2-coccyx), suggested that LDM may not be entirely explained as an error of primary neurulation. ⋯ By elucidating the location of LDM lesions (in particular, the interspinous level), we propose that LDM may be caused by errors of secondary neurulation. The hypothesis seems more plausible due to the supportive fact that the process of separation between the cutaneous and neural ectoderm is present during secondary neurulation. Hence, incomplete disjunction of the two ectoderms during secondary neurulation may result in LDM, similar to the pathomechanism proposed during primary neurulation.