Optimal surgical strategy for meningiomas involving the superior sagittal sinus: a systematic review.

Involvement of the superior sagittal sinus (SSS) by meningiomas poses specific challenges, without an agreement about the degree of surgical aggressiveness when dealing with these lesions. In this systematic review and meta-analysis, we compare outcomes and complication rates, after different surgical strategies. Studies focused on meningiomas involving the SSS were collected from numerous online databases. Surgical outcome and complication data were abstracted. Comparisons were made considering complication and recurrence rates between an "aggressive" and a "non-aggressive" surgical attitude. A total of 26 studies, encompassing 1614 patients, were identified. Most of the tumors (53%) arose from the middle third of SSS and 75% of patients had a patent sinus at the time of surgery. A favorable outcome was achieved in 73% of patients treated with an "aggressive" surgical attitude compared to 78% of patients treated with a "non-aggressive" surgical attitude. Complication rates were similar between "aggressive" and "non-aggressive" attitudes, except for a higher rate of venous infarct (4% versus 2%, respectively) and worsening of preexisting motor deficits (34% versus 13%, respectively) in aggressively treated patients. Recurrence rates were not substantially different in the two groups after accounting for length of follow-up. Patients with incomplete resection (Simpson grades II-V) or with high histological grade (WHO grade III) had significantly higher recurrence rates. A complete resection achieves higher rates of tumor control, however, without nullifying the risk of recurrence. Moreover, "aggressive" tumor removal is associated with higher rates of venous complications and worsening of preexisting motor deficits.

How I do it: surgical clip reconstruction of a large, partially thrombosed, ruptured middle cerebral artery aneurysm.

BACKGROUND: Ruptured large and partially thrombosed aneurysms are challenging lesions to treat successfully. METHODS: We describe the surgical treatment of a large, ruptured partially thrombosed middle cerebral artery (MCA) aneurysm. Once the Sylvian fissure is dissected, temporary clips are placed, and the clot is evacuated with simple microsuction and ultrasonic aspiration. The aneurysm is then carefully clip reconstructed to avoid compromise of the parent vessels. CONCLUSION: In cases of surgical clipping of large, thrombosed aneurysms, it is important to be aware of a few, but critically important, pitfalls to ensure successful outcome.

Microvascular decompression with partial occipital condylectomy in a case of pediatric spasmodic torticollis.

Spasmodic torticollis is a rare, neurologic disorder that is caused by abnormal nerve compression of the 11th cranial nerve by blood vessels or bony protrusions. It is typically treated pharmacologically and, if necessary, with surgical intervention. We report a unique case of spasmodic torticollis in a 15-year-old female that involved abnormal compression of the left 11th cranial nerve (CN) by the left vertebral artery, displaced by a hypertrophic left occipital condyle. After treatment with Botox was unsuccessful, the patient was treated with microvascular decompression and occipital condylectomy that adequately relieved the abnormal compression of CN XI. Mild symptoms persisted, and the patient underwent a partial section of the sternocleidomastoid muscle 1 year later, after which torticollis symptoms resolved.

Surgical ligation of spinal dural arteriovenous fistula.

BACKGROUND: Spinal dural arteriovenous fistulas (SDAVFs) are abnormal arteriovenous shunts between a radicular artery and the radicular vein, located in the dorsal surface of the dura sleeve, which drains in a retrograde manner into the coronal venous plexus of the spinal cord without an interposed capillary network. This result is a venous hypertension that reduces spinal cord perfusion and leads to ischemia and edema. Spontaneous resolution is extremely rare and, once symptomatic, the typical course is further progression with increased neurological impairment. Therefore, once a fistula is diagnosed, treatment is recommended. METHOD: The fistula is placed at the level of intervertebral foramen and surgical ligation is performed through a laminectomy. After dural opening, the area is inspected, and the arterialized vein is identified and ligated. CONCLUSIONS: Laminectomy and arteriovenous fistula ligation is a safe and reliable approach for accessing and treating spinal dural arteriovenous fistulas.

How I do it: surgical ligation of craniocervical junction dural AV fistulas.

BACKGROUND: Dural arteriovenous fistulas (DAVFs) of the craniocervical junction are uncommon vascular lesions, which often require surgical treatment even in the endovascular era. METHODS: Most commonly, the fistula is placed laterally, and surgical ligation is performed through a lateral suboccipital craniotomy. After dural opening, the area is inspected, and the arterialized vein is identified emerging from the dura, often adjacent to the entry point of the vertebral artery, and ligated. CONCLUSIONS: A far lateral craniotomy is the authors' preferred surgical approach for accessing and treating dural arteriovenous fistulas of the craniocervical junction that cannot be reached endovascularly.

The paramedian supracerebellar infratentorial approach.

BACKGROUND: Lesions of the superior cerebellar surface, pineal region, lateral and dorsal midbrain and mesial temporal lobe are challenging to treat and often require neurosurgical intervention. METHODS: The paramedian variation of the supracerebellar infratentorial approach utilizes the downward slope of the cerebellum to facilitate exposure and the lower density of cerebellar bridging veins away from the midline decreases the need to sacrifice larger venous channels. We also discuss our experiences with the approach, and some of the drawbacks and nuances that we have encountered as it has evolved over the years. CONCLUSIONS: This approach is versatile and effective and the authors' surgical approach of choice for resecting these challenging lesions.

Severe Referred Shoulder Pain Following Revision Fundoplication From a Stich on the Diaphragm.

Complications following fundoplication surgery for hiatal hernias are rare. Herein, we present the case of a 61-year-old woman who underwent a Nissen fundoplication, complicated by dysphagia, and a revision modified Toupet fundoplication for a hiatal hernia, after which she began to experience severe prandial referred left shoulder pain that was refractory to medical management. We hypothesized that a diaphragmatic suture placed during the revision fundoplication could be the source of the pain, and we elected to remove the suture, resulting in resolution of the pain. This pain remained resolved at the most recent follow-up on postoperative week six, and the patient had no further concerns.

#Fake news: a systematic review of mechanical thrombectomy results among neurointerventional stroke surgeons on Twitter.

OBJECTIVE: Twitter is a popular social media platform among physicians. Neurointerventionalists frequently document their lifesaving mechanical thrombectomy cases on Twitter with very favorable results. We fear that there may be some social media publication bias to tweeted mechanical thrombectomy cases with neurointerventionalists being more likely to tweet cases with favorable outcomes. We used these publicly documented cases to analyze post-intervention Twitter-reported outcomes and compared these outcomes with the data provided in the gold standard literature. METHODS: Two reviewers performed a search of Twitter for tweeted cases of acute ischemic strokes treated with mechanical thrombectomy. Data were abstracted from each tweet regarding baseline characteristics and outcomes. Twitter-reported outcomes were compared with the Highly Effective Reperfusion Evaluated in Multiple Endovascular Stroke (HERMES) trial individual patient meta-analysis. RESULTS: When comparing the tweeted results to HERMES, tweeted cases had a higher post-intervention rate of modified Thrombolysis In Cerebral Infarction (mTICI) scale score of 2c/3 (94% vs 71%, respectively; p<0.0001) and rate of National Institutes of Health Stroke Scale (NIHSS) score ≤2 (81% vs 21%, respectively; p<0.0001). There were no reported complications; thus, tweeted cases also had significantly lower rates of complications, including symptomatic intracerebral hemorrhage (0% vs 4.4%, respectively; p<0.0001), type 2 parenchymal hemorrhage (0% vs 5.1%, respectively; p<0.0001), and mortality (0% vs 15.3%, respectively; p<0.0001). CONCLUSIONS: There is a significant difference between social media and reality even within the 'MedTwitter' sphere, which is likely due to a strong publication bias in Twitter-reported cases. Content on 'MedTwitter', as with most social media, should be accepted cautiously.