Haemorrhagic Complications After Microsurgical Treatment for Intracranial Aneurysms Under Acetylsalicylic Acid: An Impact Analysis.

BACKGROUND: Patients with intracranial aneurysms often have comorbidities that require them to take acetylsalicylic acid (ASA). In recent years, many patients with aneurysms have been prescribed ASA to prevent aneurysm enlargement. ASA is also prescribed to patients with intracranial aneurysms in preparation for surgical revascularization. METHODS: From 2016 to 2021, 64 patients underwent microsurgical aneurysm clipping without revascularization, and an additional 20 patients underwent extracranial to intracranial (EC-IC) bypass. The following parameters were analysed: the frequency of hemorrhagic complications, the blood loss volume, the duration of surgery and inpatient treatment, the change in hemoglobin level (Hb), hematocrit (Ht), erythrocytes, and clinical outcomes according to the modified Rankin scale (mRS). RESULTS: At the time of surgery, laboratory-confirmed effect of the ASA was registered in 22 patients (main group). In 42 patients, the ASA was not functional on assay (control group). Hemorrhagic complications were noted in two patients in the ASA group. In both cases, the hemorrhagic component did not exceed 15 ml in volume and did not require additional surgical interventions. Statistical analysis showed no significant differences in hemorrhagic postoperative complications. CONCLUSION: Taking low doses of acetylsalicylic acid during planned microsurgical clipping of cerebral aneurysms does not affect intraoperative blood loss volume, risk of postoperative hemorrhagic complications, length of stay in the hospital, or functional outcomes.

A Systematic Review and Case Illustrations of Misdiagnosing Intracranial Aneurysms.

Modern neuroimaging methods do not completely rule out false diagnoses of intracranial aneurysms which can lead to an unwarranted operation associated with risks of complications. However, surgical interventions for falsely diagnosed aneurysms are quite rare. The purpose of this study is to demonstrate two clinical cases of false-positive aneurysms and a systematic review of the literature dedicated to the incidence and etiology of false-positive aneurysms, identifying risk factors associated with false-positive aneurysms. A literature search in two databases (PubMed and Web of Science) using keywords "mimicking an intracranial aneurysm", "presenting as an intracranial aneurysm", "false positive intracranial aneurysms", and "neurosurgery" was conducted. A total of 243 papers were found in the initial search in two databases. Sixteen papers (including 20 patients) were included in the final analysis. There were 10 women and 10 men. The most common location of false-positive aneurysms was the bifurcation of the middle cerebral artery (MCA). In the posterior circulation, false-positive aneurysms were identified either on the basilar artery, or at the vertebro-basilar junction. The main causes of false intracranial aneurysm diagnosis included artery occlusion with vascular stump formation, infundibular widening, fenestration, arterial dissection, contrast extravasation, and venous varix. In conclusion, summarizing the results of our analysis, we can say that surgical interventions for false-positive aneurysms are an underestimated problem in vascular neurosurgery. Despite extremely rare published clinical observations, the actual frequency of erroneous surgical interventions for false-positive aneurysms is unknown.

One-step orbit reconstruction using PMMA implants following hyperostotic sphenoid wing meningioma removal: Evolution of the technique in short clinical series.

Purpose: To report our experience with patient specific implants for one-step orbit reconstruction following hyperostotic SWM removal and to describe the evolution of the technique through three surgical cases. Methods: Three cases of one-step SWM removal and orbit reconstruction are described. All cases are given consecutively to describe the evolution of the technique. Hyperostotic bone resection was facilitated by electromagnetic navigation and cutting guides (templates). Based on a 3D model, silicone molds were made using CAD/CAM. Then PMMA implant was fabricated from these molds. The implant was adjusted and fixed to the cranium with titanium screws after tumor removal. Results: Following steps of the procedure changed over these series: hyperostotic bone resection, implant thickness control, implant overlay features, anatomic adjustments, implant fixation. The proptosis resolved in all cases. In one patient the progressive visual acuity deterioration was recognized during the follow-up. No oculomotor disturbances and no tumor regrowth were found at the follow-up. Conclusion: CAD/CAM technologies enable creation of implants of any size and configuration, and thereby, to increase the extent of bony resection and lower the risk of tumor progression. The procedure is performed in one step which decreases the risk of postoperative morbidity.

Microsurgical Clip Reconstruction of a True Posterior Communicating Artery Aneurysm.

Approximately 25% of intracranial aneurysms originate at the internal carotid artery and posterior communicating artery (PCoA) junction.1 In contrast to typical PCoA aneurysms, which are usually saccular, a subset known as true PCoA aneurysms arise directly from the PCoA. These represent about 1.3% of all intracranial aneurysms and 6.8% of PCoA aneurysms.1 The first report of a true PCoA aneurysm was in 1979.2Video 1 illustrates the microsurgical clipping of a true PCoA aneurysm in a 27-year-old man with subarachnoid hemorrhage and left-sided ophthalmoplegia. Computed tomography angiography revealed a large true patient consent, Our surgical strategy included 1) an extended pterional approach, 2) early brain relaxation through basal cisterns and third ventricle opening, 3) Sylvian fissure dissection, 4) partial uncus resection, 5) tracing the PCoA to the aneurysm, 6) pilot clipping and thrombectomy, and 7) careful aneurysm dissection and definitive clipping. The patient had an uncomplicated recovery and was discharged on postoperative day 5 with resolved third nerve dysfunction. A literature review from 2022 documented only 47 cases of true PCoA aneurysms, predominantly manifesting with rupture.3 Some studies suggest that these aneurysms may have a higher rupture risk than typical internal carotid artery-PCoA junction aneurysms.4 Microsurgical clipping is a primary treatment, often in cases associated with a fetal posterior cerebral artery variant.5 Ensuring the patency of the PCoA and thalamoperforating arteries is crucial, with careful visualization of the clip's distal ends to avoid impacting nearby neurovascular structures.

Reconstruction of orbital walls after resection of cranioorbital meningiomas: a systematic review and meta-analysis of individual patient data.

Following meningioma removal, there are numerous methods available for reconstructing the orbital wall. This systematic review seeks to summarize the published data on the surgical treatment of cranioorbital meningiomas, and to analyze the effectiveness and safety of various techniques and materials used for the reconstruction of bony orbital walls. We conducted a search of the two databases and included original articles with a series of 10 or more cases. Descriptive statistics and meta-analysis of individual patient date were performed. The analysis included a total of 858 patients from 29 sources. No reconstruction of the orbital walls was performed in 525 patients (61.2%), while 333 observations (38.8%) involved resection followed by reconstruction. A relative improvement in eye position was achieved in 94.4% of cases with a 95% CI of (88.92%; 97.25%). However, normalization of eye position, regardless of reconstruction technique, was only present in 6.22% of cases with a 95% CI of (1.24%; 25.9%). The best results were observed with the use of autologous bone implants (64%, 95% CI [33.35%; 86.33%]) and titanium implants (55.78%, 95% CI [2.86%; 98.18%]). In cases of endoscopic resection and microsurgical resection without reconstruction, symmetrical eye position accounted for only 1.94% (95% CI [0%; 96.71%]) and 2.35% (95% CI [0.13%; 31.23%]), respectively. The frequency of normalization of eye position differed significantly (p < 0.01) among the subgroups. A total of 49 postoperative complications were registered, with wound infection (1.52%, 95% CI [0.86%; 2.65%]) and wound cerebrospinal fluid leak (1.32%, 95% CI [0.6%; 2.91%]) being the most frequent. No significant differences were found in the rates of complications among the different subgroups. One of the primary objectives of cranioorbital meningioma surgery is to correct the position of the eye. Simultaneous reconstruction of the bony orbital leads to better cosmetic outcomes. Postoperative complications did not depend on the reconstructive technique or the materials.

Optochiasmatic cavernoma: Surgical treatment and outcomes.

OBJECTIVE: Optochiasmatic cavernoma is an extremely rare cerebral lesion. They account for approximately 1% of all cavernomas of the central nervous system. Reports on this pathology are limited. Abrupt visual deterioration is a common symptom of the disease. Treatment strategy and visual outcomes after different treatment approaches remain a subject for discussion. METHODS: Patients operated in a period 2005-2021 were analyzed in this study. All patients preoperatively underwent computed tomography (CT) scan, CT-angiography, and magnetic resonance imaging (MRI). Visual function of the patients was assessed pre-op, post-op and at the follow-up. Duration of visual dysfunction was noted as well. Surgical details were also extracted from medical notes. All patients were followed up, and control MRI was performed one month after operation. We assessed surgical series of optochiasmatic cavernomas published for last 10 years. Further comparative analysis with our data was performed. RESULTS: Five patients were included into this study. There were four men and one woman. Mean age comprised 33.8 years (range 20-48 years). Most patients were admitted to our hospital due to visual disturbances (80%). Visual function improved in four patients. Visual function was unchanged in one patient, lacking visual disturbancies pre-op. Complication developed in one patient. CONCLUSIONS: Optochiasmatic cavernomas are encountered extremely rare. Despite the use of contemporary diagnostic options, differential diagnosis remains challenging. Full diagnostic work-up is mandatory. After the diagnosis is made, surgical treatment should be considered first. Total microsurgical or endoscopic transsphenoidal removal of the optochiasmatic cavernoma is a relatively safe and effective treatment method facilitating improvement of visual function.

"Unshaved Intradermal Running Suture for Elective Cranial Neurovascular Surgeries".

OBJECTIVE: In this paper, we analyze the experience and propose a method of incision and stitching of the postoperative scalp wound without shaving hair in elective neurosurgical interventions. METHODS: Between January 2021 and May 2022, 44 patients with various neurovascular pathologies were included in the study. The age of the patients varied from 28 to 58 years. All patients underwent elective surgical interventions with intradermal cosmetic sutures without shaving hair. The results of published observational series of neurosurgical patients with unshaved hair were also analyzed. RESULTS: Treatment of the surgical field, scalp, and incision were performed without shaving hair in 44 cases. The technique of intradermal suture without shaving hair was used in 31 cases of the classical pterional approach, in 11 cases of minipteronal, in 1 case of parasagittal, and in 1 case of retrosigmoid suboccipittal approaches. The mean age of the patients was 47.5 years (±8.82). The average length of stay in the clinic was 8.02 days (±2.04). The sutures were removed on the fifth-eighth day. All cases were operated on for elective neurovascular interventions: aneurysms without rupture (95.4%), arteriovenous malformations (2.3%), and cavernous angiomas (2.3%). All but one patient (2.3%) had no wound complications-the suture ruptured at the stage of its removal from the skin. CONCLUSIONS: Our results also show that the use of a nonresorbable intradermal suture combined with hair preservation does not affect the risk of infection.

Laser Speckle Contrast Imaging in Neurosurgery: A Systematic Review.

BACKGROUND: Intraoperative study of blood flow in the brain vessels is among the most critical topics of modern neurosurgery. One of the promising methods for intraoperative monitoring of blood flow is laser speckle contrast imaging (LSCI). This systematic review aims to analyze the experience of using intraoperative LSCI in neurosurgical interventions. METHODS: The literature search was carried out in the PubMed and Web of Science databases using the keywords "Laser-Speckle," "Laser Speckle," "Laser speckle contrast imaging," and "LSCI." We allowed the search to include the following criteria: 1) publication in the English language, 2) full access to the article, 3) information about the method of treatment, and 4) the results presented for at least one patient. RESULTS: The initial search resulted in the detection of 508 publications, of which 476 were eliminated during the initial assessment of titles and abstracts. Two more articles were excluded due to the lack of data in the English language. Twenty articles were found to be focused on nonhuman studies and therefore were excluded. In three more studies treatment of non-neurosurgical patients was reported. The final analysis included 8 articles with 102 patients overall. CONCLUSIONS: LSCI is a promising intraoperative method for intraoperative cerebral blood flow assessing. This method offers several advantages over other modalities. The experience of use is limited to a small number of case series. Further investigation of the method and its implementation in clinical practice is needed.

Surgical Treatment of Large and Giant Anterior Cerebral Artery Aneurysms in the Endovascular Era: Analysis of Large Clinical Series.

OBJECTIVE: Analysis of results of surgical treatment of 112 patients with large and giant anterior cerebral artery (ACA) aneurysms. METHODS: This is the largest clinical series of large and giant ACA aneurysms ever reported. Retrospective analysis of medical charts, radiographic studies, and intraoperative videos was performed. Univariate and multivariate analysis of relations among 3 types of outcomes (complete aneurysm occlusion, ischemic complications, and clinical outcomes) and predicting factors was performed. RESULTS: Most aneurysms were communicant (84.8%). Aneurysms of the A1 segment and distal segments (A2-A5) were encountered rarely. Complete aneurysm occlusion (class I) was shown in 95 cases (90.5%). In 4 patients, only exploration and wrapping were performed because of severe atherosclerosis and chronic intraluminal thrombi. Partial occlusion (class III) was shown in 2 patients, and neck residual (class II) in 4 patients. Cerebral ischemia developed in 29 patients postoperatively. Occlusion or injury of the A1 segment and anterior communicating artery perforators and recurrent branch of Heubner were the most common reason for ischemic complications. At follow-up, 97 patients (86.6%) had favorable outcomes. Ten patients (8.9%) had unfavorable outcomes because of postoperative complications. CONCLUSIONS: Microsurgery provides effective and relatively safe occlusion of complex ACA aneurysms. Direct clipping can be applied in most cases independent of their precise location. In certain cases, alternative methods can be safely used. According to multivariate analysis, giant aneurysm size, aneurysm-related mass effect, involvement of large arterial branches in the aneurysm wall, and intraoperative complications were significant predicting factors for ischemic complications.

Analysis of a Novel Entry Point for Freehand Ventriculostomy Using Computerized Tomography Scans.

Background External ventricular drain (EVD) placement is one of the most common procedures in neurosurgery. Neurosurgeons generally prefer to access the ventricles via Kocher's point since it is the most common point of entry to this area; however, this point is used to describe different anatomic landmarks and is not well-defined. Objective The present study aims to describe and provide an anatomical assessment of a novel ventriculostomy access point developed by the authors using computerized tomography (CT) scans performed on 100 patients. Materials and methods Data were collected from 100 randomly selected patients with normal ventricular anatomy found on their 1.0 mm-slice CT scans performed at the Burdenko Neurosurgical Center from March 2019 to June 2021. The CT inclusion criteria were: CT slices < or = to 1 mm and absence of brain herniation. Patients with brain mass lesions, severe brain edema, and pneumocephalus were excluded. Age, gender, and ventricular size were not exclusion criteria. Results The mean patient age was 43.58 years (range 4-73), with 50 men and 50 women. The mean Evan's index was 25.7 % (SD=4.38 %, range 10.2-41.0 %). No differences were found between the angles of EVD placement on either side (89.50±1.22 degrees on the right and 89.60±1.14 degrees on the left). Hence, nearly all EVD cases had been placed perpendicularly to the skull surface at a pinpoint location. Conclusion The proposed point of successful ventriculostomy placement in this study was 3 cm from the bregma along the coronal suture. The angle of EVD placement was approximately 90 degrees in almost all patients and was independent of the patient's age and the side of the head that was entered. Little correlation was found between the value of the entry angle and Evan's index. The point is simply identifiable, and its entry is easily accessible in practice.

Surgical Treatment Efficacy of CSF-Venous Fistulas: Systematic Review.

BACKGROUND: Cerebrospinal fluid (CSF)-venous fistula presents a pathologic connection between spinal subarachnoid space and adjacent epidural vein or veins. It is one of the 3 main causes of spontaneous intracranial hypotension along with dural defects and meningeal diverticulum. We performed a systematic review of the literature and analyzed individual participants' data focusing on clinical outcomes after different treatment modalities of CSF-venous fistula. METHODS: Systematic review was conducted according to PRISMA recommendations. Literature search was performed in PubMed and Web of Science databases with following key phrases: "CSF-venous fistula", "Spontaneous intracranial hypotension". Overall, 97 articles were found during the initial search; 15 were included for the final analysis, with a total number of 137 patients. RESULTS: Epidural blood patch (EBP) was performed as a first-line treatment in 37.1% of patients in individual data group, often not combined with fibrin glue (61.5%). Either partial (69.2%) or no resolution (30.8%) of symptoms was achieved after EBP injection. Nerve root ligation was the most common method of exclusion of CSF-venous fistula. Complete resolution of symptoms was achieved in 69.0% of patients, in 21.4% it was partial and in 9.5% no regress was found. Endovascular treatment was described only in 1 study. CONCLUSIONS: Surgical ligation of fistula is a treatment of choice. In approximately 70% of patients complete long-term resolution of symptoms is achieved after surgery. Endovascular treatment and fibrin glue injections are prospective and evolving options, which require further investigation.

Surgical treatment of ruptured right middle cerebral artery mycotic aneurysm and central nervous system aspergillosis: Clinical case and literature review.

BACKGROUND: Central nervous system (CNS) aspergillosis is more often met in patients with expressed immune suppression. Still, in 50% of cases of meningitis caused by Aspergillus spp., it is observed in patients without expressed immune suppression. The prognosis of CNS aspergillosis is unfavorable with the general rate of lethality around 70%. CASE DESCRIPTION: Clinical case of a 58-year-old man who developed an Aspergillus abscess in the chiasmosellar region and an associated mycotic aneurysm of the right middle cerebral artery (MCA) and intracerebral hemorrhage. Microsurgical clipping of the fusiform-ectatic aneurysm of the right MCA in the conditions of rupture was performed. An extra-intracranial micro anastomosis was formed on the right. An open biopsy of the neoplasm in the chiasmosellar region was made. The neoplasm was yellow and destroyed the bone plate of the skull base. Biopsy results: Mycotic lesion (aspergillosis). The analysis of surgical treatment for mycotic aneurysms in the acute period of hemorrhage in patients with aspergillosis revealed a high rate of lethality. The issue of the feasibility and effectiveness of complicated revascularization interventions in the patients with hemorrhage and aspergillosis remains unsolved. CONCLUSION: The lack of generally accepted tactics of the treatment of this pathology requires further studies and systemic analysis. A high risk of the lethal outcome in patients with invasive mycotic infection and rupture of mycotic aneurysm highlight the importance of timely diagnostics and the beginning of antimycotic therapy. WThe issue of the evaluation of the revascularization methods effectiveness in patients after surgical treatment of a mycotic aneurysm associated with cerebral aspergillosis remains poor.