Acute spinal cord injury (SCI) often results in severe neurologic deficits, with hemodynamic instability contributing to secondary ischemic damage. Beyond surgical decompression, maintaining adequate mean arterial pressure (MAP) is key to enhancing spinal cord perfusion and oxygenation. Vasopressor therapy is frequently used to achieve hemodynamic stability, but optimal MAP targets and vasopressor selection remain controversial. This review explores updated guidelines and current evidence regarding MAP management and the use of vasopressors in SCI, focusing on their impact on spinal cord perfusion and neurologic outcomes. Recent studies highlight the role of durotomy in directly improving spinal cord perfusion pressure (SCPP) by reducing intraspinal pressure (ISP), offering a complementary mechanical intervention as part of pharmacologic therapies. Recent guidelines suggest an MAP range of 75–80 mmHg as a lower limit and 90–95 mmHg as an upper limit for 3–7 days post-injury, highlighting the need for personalized hemodynamic management. Norepinephrine is commonly preferred due to its balanced effects on peripheral vascular resistance and spinal cord perfusion pressure (SCPP), though dopamine, phenylephrine, and dobutamine each offer unique hemodynamic profiles suited to specific clinical scenarios. Despite their benefits, vasopressors carry significant risks, including arrhythmias and potential myocardial strain, necessitating careful selection based on individual patient factors. Further research is needed to refine vasopressor use and establish evidence-based protocols that optimize neurologic recovery, alongside continued exploration of SCPP as a potential therapeutic target.

BACKGROUND AND OBJECTIVES: Glucagon-like peptide-1 receptor agonists (GLP-1 RAs) have gained increasing popularity since the approval of semaglutide by the United States Food and Drug Administration for chronic weight management. Significant benefits have been noted in glycemic control and cardiovascular health. However, as increasing numbers of patients are started on these medications, it is important for neurosurgeons to have knowledge of any perioperative considerations and side effects related to this class of drugs. METHODS: We performed a qualitative literature review using the PubMed and Embase databases, using the following key words: GLP-1 RAs adverse events; GLP-1 RAs and anesthesia; substance use disorders; and addiction, functional neurosurgery, nervous system rehabilitation, and spinal cord injury. Articles of relevance to perioperative management of these medications and specific benefits in the neurosurgical field were discussed. RESULTS: Recent guidance from the American Society of Anesthesiologists demonstrates the importance of tailored management of GLP-RA drugs for surgical patients. In addition, certain positive effects have been noted with relation to substance use disorders, neural protection and rehabilitation, and neurodegenerative disorders such as Alzheimer's disease. CONCLUSION: In this article, we review what the neurosurgeon needs to know about the perioperative management of GLP-1 RAs and discuss existing literature in clinical and preclinical studies for potential indications and benefits of these medications, which can influence the management of conditions treated by neurosurgeons.

Background: Cesium-131 collagen tile has gained traction as an intraoperative brachytherapy platform for recurrent intracranial tumors, but outcome data in newly diagnosed brain metastases (nBM) remain sparse, with fewer than ten cases reported. This study evaluates the safety and efficacy of cesium-131 collagen tiles in nBM patients. Methods: Clinical information was collected for consecutive nBM patients treated at three neurosurgical centers. Local control and overall survival (OS) were calculated. Results: The cohort comprised 36 patients (14 men, 22 women; mean age, 62.1 ± 8.9 years) with 39 nBM. Histologies included lung (n = 19), melanoma (n = 8), breast (n = 4), gastrointestinal (n = 3), and genitourinary (n = 5) metastases. The mean pre-operative tumor diameter was 3.29 ± 1.35 cm. Gross total resection was achieved in all but one case. Mean Karnofsky Performance Score (KPS) before resection/tile implant was 81 ± 11.1. The average hospital stay was 2.2 ± 1.6 days. Thirty-day and 90-day readmission rates were 25.0% and 19.4%, respectively; there were no unplanned returns to the operating room. With a median follow-up of 328 days, one-year actuarial local control was 100%, with one recurrence at two years. Median overall survival (OS) was 182 days. Radiation necrosis was observed in one patient (2.6%). KPS improved or remained stable in 28 patients (77.8%) and declined in 8 (22.2%). A decline in KPS at one month post-procedure was associated with shorter OS (65 vs. 211 days; P = .02). Conclusion: This multi-institutional study provides the first dedicated evaluation of cesium-131 collagen tiles for the treatment of nBM, demonstrating excellent safety and local control.

Introduction: The Rhode Island Stroke Prevention and Treatment Act aimed to establish a standardized system of care for stroke patients through designated stroke centers, revise emergency medical services (EMS) protocols, and establish a centralized stroke database. While Stroke Systems of Care (SSOC) laws have proven effective in reducing overall stroke mortality, their benefits among racial minorities and economically disadvantaged groups remain unclear. This study investigates the impact of the Act on stroke mortality rates across different racial groups. Methods: Data from the Rhode Island Department of Labor and Training, CDC Atlas of Heart Disease and Stroke, and U.S. Census Bureau for 2005–2019 were analyzed. A difference-in-difference analysis compared mortality rates among White, Black, and Hispanic residents before and after the Act’s implementation. Trends were further validated using a mixed-effects model. Results: Following SSOC implementation, the White group had significant reductions in ischemic stroke mortality (-5.38 per 100,000, 95% CI [-6.63, -4.12]; P<0.001). Analysis did not identify a difference in ischemic stroke mortality in the Hispanic (-2.67, 95% CI [-1.49, 6.83]; P=0.174) or Black group (4.69, 95% CI [-25.40, 16.01]; P=0.638). After Act-driven field triage implementation, there was a decline in all-stroke mortality among Black (-15.9 per 100,000, 95% CI [-30.52, -1.19]; P=0.035) and Hispanic (-7.07 per 100,000, 95% CI [-11.81, -2.32]; P=0.005) groups. However, the Black group maintained higher all-stroke mortality compared to the White population (RR 1.34, 95% CI [1.27, 1.41]; P<0.001). Conclusion: While SSOC significantly reduced overall stroke mortality in Rhode Island, the benefits were not equitably distributed across racial groups. These findings underscore the need for future stroke legislation to incorporate culturally competent, evidence-based strategies addressing social determinants of health to reduce disparities and ensure equitable care.

Background/Objectives: To evaluate the safety, efficacy, and predictors of rhBMP-2 use in atlantoaxial (C1–2) fusion through institutional outcomes and a pooled analysis from the literature. Methods: We retrospectively analyzed adult patients who underwent C1–2 fusion at a tertiary care center between 2015 and 2020. Primary outcomes included radiographic fusion and postoperative complications. Univariate logistic regression was used to identify predictors of intraoperative rhBMP-2 use. A subset of eight patients who underwent isolated C1–2 fusion using rhBMP-2 were analyzed and evaluated against 260 cases from a PRISMA-compliant systematic review of the literature. Results: Among our 49 patients (mean age, 61.8 ± 22.8 years; 57% female), 24 (49%) received rhBMP-2. Radiographic fusion or early signs were observed in 89.8% of patients, with no significant difference between rhBMP-2 and non-rhBMP-2 groups (p = 0.678). Complications were similar (12.5% vs. 25.0%, p = 0.702). All postoperative instabilities occurred in non-rhBMP-2 patients (p = 0.043). Degenerative pathology was associated with increased use of rhBMP-2 (OR of 7.96, p = 0.051), while trauma was associated with decreased use (OR of 0.21, p = 0.019). Among the eight local isolated cases, seven achieved fusion and none required revision. Our literature review yielded a group of 260 patients, 241 of which achieved successful fusion with a complication rate of 10.8% and a revision surgery rate of 3.8%. Conclusions: rhBMP-2 appears to be a safe and effective adjunct in C1–2 fusion, with outcomes comparable to alternative techniques. Although off-label, its selective use may benefit patients at risk of nonunion. Interpretation should be tempered by the retrospective design and heterogeneity across cohorts; pooled rates are descriptive. Further prospective studies are needed to establish standardized protocols, optimal dosing, and long-term efficacy.

BACKGROUND: Atlantoaxial pseudoarticulation is a rare condition characterized by atypical joint formation at C1–2, potentially causing severe neck pain and progressive cervical myelopathy due to spinal cord compression. Traditional treatments often involve decompression with or without fusion and can lead to significant tissue disruption and extended recovery time. Here, the authors describe a novel, minimally invasive full endoscopic technique for resecting atlantoaxial pseudoarticulation, achieving successful spinal decompression. OBSERVATIONS: A 44-year-old female patient presented with 6 months of progressive cervical myelopathy, including gait instability, right-sided weakness, and numbness. Imaging confirmed a C1–2 pseudoarticulation causing severe spinal cord compression. A paraspinal endoscopic approach was used, avoiding the need for instrumented fusion. Postoperatively, the patient’s condition rapidly improved, with complete symptom resolution at 6 months and only mild intermittent hand numbness at 18 months. Imaging confirmed stable, effective decompression without complications. LESSONS: This case represents the first documented application of a full endoscopic approach for atlantoaxial pseudoarticulation, achieving effective decompression while preserving spinal integrity and reducing recovery time. This technique offers a promising, minimally invasive alternative for complex cervical pathologies, supporting a shift toward less invasive, tissue-sparing spinal surgery. https://thejns.org/doi/10.3171/CASE24766