Management of spinal aneurysms associated with arteriovenous malformations: systematic literature review and illustrative case.

PURPOSE: Spinal aneurysms are rare vascular malformations, commonly associated with spinal AVMs. AVM-associated spinal aneurysms are burdened by significant morbidity. The purpose of our study is to evaluate the best treatment strategy for these uncommon vascular lesions and to report an illustrative case. METHODS: We reviewed clinical and radiological data of a patient surgically treated at our institution for a spinal AVM with an associated prenidal aneurysm. According to PRISMA guidelines, a systematic literature review has been performed in order to discuss the best management AVM-associated prenidal aneurysms. RESULTS: In the reported case, the aneurysm showed spontaneous regression at follow-up after surgical removal of the AVM. Only 6 articles reported management of spinal prenidal AVM-associated aneurysms. Basing on our experience and data from literature, surgical treatment of the aneurysm may be indicated along with the resection of the AVM if the aneurysm is close to the nidus. Conversely, if the aneurysm is far away from the nidus or in an unfavorable position, resection of the nidus only may lead to aneurysm regression as in the reported case. CONCLUSIONS: The treatment strategy for AVM-associated spinal aneurysms should be tailored on the single patient. In presence of large aneurysms that cause mass-effect symptoms, when rupture of the aneurysm is suspected or when treatment of the AVM is not proposable, direct treatment of the aneurysm should be considered. Otherwise, when complete resection of the nidus is performed, the eventually associated unruptured aneurysms located in challenging positions can be safely managed conservatively.

The role of external ventricular drainage for the management of posterior cranial fossa tumours: a systematic review.

Posterior cranial fossa tumours frequently develop hydrocephalus as first presentation in up to 80% of paediatric patients and 21.4% of adults, although it resolves after tumour removal in 70-90% and 96%, respectively. New onset hydrocephalus is reported in about 2.1% of adult and 10-40% of paediatric patients after posterior fossa surgery. There is no consensus concerning prophylactic external ventricular drainage (EVD) placement that is frequently used before posterior fossa lesion removal, as well in those cases without clear evidence of hydrocephalus. The aim of the study was to define the most correct management for patients who undergo posterior fossa tumour surgery, thus identifying cohorts of patients who are at risk of persistent hydrocephalus prior to surgery. A systematic review of literature has been performed, following PRISMA guidelines. Most of the studies reported CSF shunt only in the presence of hydrocephalus, whereas only a few authors suggested its prophylactic use in the absence of signs of ventricular dilatation. Predictive factors for postoperative hydrocephalus has been identified, including young age (< 3 years), severe symptomatic hydrocephalus at presentation, EVD placement before surgery, FOHR index > 0.46 and Evans index > 0.4, pseudomeningocele, CSF leak and infection. The use of pre-resection CSF shunt in case of signs and symptoms of hydrocephalus is mandatory, although it resolves in the majority of cases. As reported by several studies included in the present review, we suggest CSF shunt also in case of asymptomatic hydrocephalus, whereas it is not indicated without evidence of ventricular dilatation.

Escalation therapy in severe traumatic brain injury: how long is intracranial pressure monitoring necessary?

Traumatic brain injury frequently causes an elevation of intracranial pressure (ICP) that could lead to reduction of cerebral perfusion pressure and cause brain ischemia. Invasive ICP monitoring is recommended by international guidelines, in order to reduce the incidence of secondary brain injury; although rare, the complications related to ICP probes could be dependent on the duration of monitoring. The aim of this manuscript is to clarify the appropriate timing for removal and management of invasive ICP monitoring, in order to reduce the risk of related complications and guarantee adequate cerebral autoregulatory control. There is no universal consensus concerning the duration of invasive ICP monitoring and its related complications, although the pertinent literature seems to show that the longer is the monitoring maintenance, the higher is the risk of technical issues. Besides, upon 72 h of normal ICP values or less than 72 h if the first computed tomography scan is normal (none or minimal signs of injury) and the neurological exam is available (allowing to observe variations and possible occurrence of new-onset pathological response), the removal of invasive ICP monitoring can be justified. The availability of non-invasive monitoring systems should be considered to follow up patients' clinical course after invasive ICP probe removal or for substituting the invasive monitoring in case of contraindication to its placement. Recently, optic nerve sheath diameter and straight sinus systolic flow velocity evaluation through ultrasound methods showed a good correlation with ICP values, demonstrating their potential role in place of invasive monitoring or in the early weaning phase from the invasive ICP monitoring.

An Early Increase of Blood Leukocyte Subsets in Aneurysmal Subarachnoid Hemorrhage Is Predictive of Vasospasm.

Objective: Vasospasm is a severe complication in patients with aneurysmal subarachnoid hemorrhage (aSAH) and cannot be reliably predicted. Its pathophysiology remains elusive with the current body of evidence suggesting inflammation as one of the main driving forces. We here aimed to analyze circulating immune cell subsets over time in patients with aSAH with or without vasospasm. Methods: We performed a prospective observational study recruiting patients with spontaneous aSAH. Peripheral blood withdrawn at pre-specified time-points after aSAH, day 0, days 3-4, 6-8, 10-11, 13-15, and 18-21. Flow cytometry analysis, cell blood counts, and laboratory and diagnostic parameters were performed. Patients were monitored by transcranial Doppler for vasospasm as well as by advanced imaging and divided into a group with (VS) and without vasospasm VS (NVS). Results: We included 42 patients for study analysis, 21 VS and 21 NVS. An early significant increase at day 0 in platelet, leukocyte, neutrophil, lymphocyte, NK lymphocyte, monocyte, and CD 14++ CD16- DR+ monocyte counts was found in patients with later ensuing vasospasm. The early differences in platelets, leukocytes, lymphocytes, and NK lymphocytes remained significant on multivariate analysis. Conclusions: An early increase of immune cellular subsets in aSAH may contribute to predict VS.

Acute Occlusion of Descending Thoracic Aorta.

Acute aortic occlusion is a rare but potentially devastating clinical event, which requires a prompt diagnosis and emergency treatment. Only 5 cases of native thoracic aorta acute occlusion have so far been reported with different pathologic causes. The clinical features depend on the level of occlusion. Sometimes the diagnosis could be misinterpreted as a stroke or other diseases of the central nervous system. This could lead to a delay in the diagnosis and revascularization procedure, followed by a morbidity or mortality increase. Open surgery has been considered the first-line approach. This study is of a female patient suffering from acute descending thoracic aorta occlusion undergoing, for the first time to our knowledge, endovascular surgical treatment.

Spinal Dural Arteriovenous Fistulas: Clinical Results and Quality of Life Assessment with Surgical Treatment as a Crucial Therapy. The Joint Experience of Two Centers.

OBJECTIVE: Dorsal intradural arteriovenous fistulas (AVFs) consist of a direct connection between a radicular feeding artery and the coronal venous plexus; this direct connection leads to arterialization of the venous plexus, venous congestion, and myelopathy. Controversy still exists regarding the best treatment modality of spinal dural AVFs. Surgical disconnection of spinal dural AVFs is a straightforward procedure with a high success rate and virtually no risk of recurrence or incomplete treatment. To identify factors associated with the clinical progression of dorsal intradural AVFs and quantify the range of surgical outcomes in terms of neurologic improvement as well as patients' perception of quality of life (QOL). METHODS: A retrospective observational study of 19 consecutive patients treated with surgery over a 10-year period was carried out. We analyzed surgical results and clinical outcomes. We also evaluated the impact of this disease and its sequelae on the patients' postoperative health-related QOL. RESULTS: The surgical procedure showed good results in terms of neurologic improvement as well as patients' perception of QOL. CONCLUSIONS: Our series confirmed that surgical obliteration of dorsal intradural AVFs is an effective and safe procedure. The results of this retrospective analysis make us believe that surgery, given its low morbidity and high success rate, represents a safe and effective first therapeutic option for these spinal vascular malformations. It could be considered to avoid unsuccessful endovascular attempts that could delay the definitive treatment of this disease. The surgical procedure showed good results in terms of neurologic improvement as well as patients' perception of QOL.

Pituicytomas: radiological findings, clinical behavior and surgical management.

BACKGROUND: Pituicytomas are rare low-grade glial neoplasms originating in the neurohypophysis or infundibulum that appear as solid, noninfiltrative masses occupying the sella turcica, the suprasellar space or both. Due to their high tendency to bleed and the possible firmness and adhesion to surrounding structures, preoperative diagnosis of pituicytoma is a goal for the surgeon, but it is actually a challenge because of the absence of distinctive clinical or neuroradiological findings. METHODS: We report the new cases of three patients who underwent transsphenoidal surgery for suspected pituitary adenomas, which were determined to be pituicytomas at histological and immunohistochemical analysis. We also review previously reported cases of pituicytoma in the literature. RESULTS: To date, 51 cases of pituicytoma have been reported in addition to our own cases. The natural history and clinical characteristics of this rare tumor are outlined. CONCLUSIONS: Macroscopic aspects are variable, and final diagnosis is made from the typical histological and immunohistochemical pattern. The therapy of choice is gross total surgical resection since subtotal removal can lead to local regrowth, but the time to recurrence is unpredictable and highly variable. The role of adjuvant therapy is currently undefined.