Infratentorial Cerebral Cavernous Malformation May be a Risk Factor for Symptomatic Bleeding and Precocity of Symptoms: A Multicenter, Propensity Score Matched, Case-Control Study.

BACKGROUND: Cerebral Cavernous Malformation (CCM) is one of the most common types of vascular malformation of the central nervous system. Intracerebral hemorrhage, seizures, and lesional growth are the main clinical manifestations. Natural history studies have tried to identify many risk factors; however, the clinical course remains highly unpredictable. OBJECTIVE: Here, we have analyzed a multicenter CCM cohort looking for the differential clinical data regarding the patients harboring supra and/or infratentorial cavernous malformations in order to better understand risk factors involved in the anatomical location of the unique neurosurgical disease. METHODS: We have presented a multicenter, Propensity Score Matched (PSM), case-control study including 149 consecutive CCM cases clinically evaluated from May 2017 to December 2022 from three different neurosurgical centers. Epidemiological data were defined at each clinical assessment. Logistic regression was used to identify the independent contribution of each possible risk factor to the bleeding risk. To balance baseline covariates between patients with and without symptoms, and specifically between those with and without symptomatic bleeding, we used a PSM strategy. The Kaplan-Meier curve was drawn to evaluate if patients with infratentorial lesions had a greater chance of bleeding earlier in their life. RESULTS: The presence of infratentorial lesions was a risk factor in the multivariate analysis comparing the bleeding risk with pure asymptomatic individuals (OR: 3.23, 95% CI 1.43 - 7.26, P = 0.005). Also, having an infratentorial CCM was a risk factor after PSM (OR: 4.56, 95% CI 1.47 - 14.10, P = 0.008). The presence of an infratentorial lesion was related to precocity of symptoms when the time to first bleed was compared to all other clinical presentations in the overall cohort (P = 0.0328) and in the PSM group (P = 0.03). CONCLUSION: Here, we have provided some evidence that infratentorial cerebral cavernous malformation may have a more aggressive clinical course, being a risk factor for symptomatic haemorrhage and precocity of bleeding.

Unilateral pterional approach to bilateral aneurysms of the middle cerebral artery.

BACKGROUND: The aim of the present study was to evaluate the technical viability of the unilateral pterional approach to simultaneously treat symmetrical bilateral aneurysm (mirror image) of the middle cerebral arteries (SBAMCA) and to determine the morbidity and mortality rates of this approach. METHODS: Forty-six patients with SBAMCA underwent unilateral pterional craniotomy within a period of 9 years. Most patients were women (24, 80.0%) and mean age was 40.7 years. RESULTS: Obliteration of the contralateral aneurysm was not possible in 16 patients (34.8%) because of brain edema in 8 patients operated on during the acute phase, lateral projection of the aneurysm in 3, a very long contralateral M1 segment in 4, and the presence of atheromatous plaques at the MCA bifurcation and aneurysm neck in 1. The remaining 30 patients (65.2%) were submitted to the proposed treatment. Final evaluation showed that 26 patients (86.7%) were Glasgow Outcome Scale (GOS) V, 1 patient (3.3%) was GOS IV, 2 patients (6.6%) were GOS III, and 1 patient (3.3%) was GOS I. CONCLUSIONS: The unilateral pterional surgical approach to treat SBAMCA is a technically viable procedure associated with low morbidity and mortality. However, it requires a neurosurgeon experienced in cerebral aneurysm surgery and the appropriate technical conditions.

Superficial vs combined cervical plexus block for carotid endarterectomy: a prospective, randomized study.

BACKGROUND: The present study compares combined and superficial cervical plexus block in patients submitted to carotid endarterectomy (CEA) in terms of anesthetic efficacy, satisfaction of the patient and surgeon, complications resulting from the type of anesthesia, and final outcome. METHODS: A total of 125 patients submitted to elective CEA were randomized into 2 groups: the first group was submitted to superficial cervical block and the second group to combined (superficial plus deep) cervical block. RESULTS: No significant difference in anesthetic quality was observed between the 2 types of blocks. Complications related to the anesthetic method were observed in only 1 (1.6%) patient of the superficial block group and in 5 (7.4%) patients of the combined block group (P > .05). Anesthetic supplementation by the surgeon was necessary in 50 (81.96%) patients, with no significant difference between the 2 groups. The surgical conditions were closely similar in the 2 groups, showing no significant difference. The final morbidity and mortality in the present series was 1.6%. CONCLUSIONS: Superficial cervical anesthetic block shows the same efficacy as combined block, with the surgical conditions being closely similar. The incidence of complications related to the anesthetic technique is higher for combined block. The type of block does not influence the final outcome of the patients.