Time trends in the risk of delayed cerebral ischemia after subarachnoid hemorrhage: a meta-analysis of randomized controlled trials.

OBJECTIVE: Delayed cerebral ischemia (DCI) contributes to morbidity and mortality after aneurysmal subarachnoid hemorrhage (aSAH). Continuous improvement in the management of these patients, such as neurocritical care and aneurysm repair, may decrease the prevalence of DCI. In this study, the authors aimed to investigate potential time trends in the prevalence of DCI in clinical studies of DCI within the last 20 years. METHODS: PubMed, Embase, and the Cochrane library were searched from 2000 to 2020. Randomized controlled trials that reported clinical (and radiological) DCI in patients with aSAH who were randomized to a control group receiving standard care were included. DCI prevalence was estimated by means of random-effects meta-analysis, and subgroup analyses were performed for the DCI sum score, Fisher grade, clinical grade on admission, and aneurysm treatment method. Time trends were evaluated by meta-regression. RESULTS: The search strategy yielded 5931 records, of which 58 randomized controlled trials were included. A total of 4424 patients in the control arm were included. The overall prevalence of DCI was 0.29 (95% CI 0.26-0.32). The event rate for prevalence of DCI among the high-quality studies was 0.30 (95% CI 0.25-0.34) and did not decrease over time (0.25% decline per year; 95% CI -2.49% to 1.99%, p = 0.819). DCI prevalence was higher in studies that included only higher clinical or Fisher grades, and in studies that included only clipping as the treatment modality. CONCLUSIONS: Overall DCI prevalence in patients with aSAH was 0.29 (95% CI 0.26-0.32) and did not decrease over time in the control groups of the included randomized controlled trials.

Minimal exposure maximal precision ventriculoperitoneal shunt: how I do it.

BACKGROUND: Ventriculoperitoneal shunt is among the most frequent neurosurgical procedures, complicated by infection and obstruction. The first is influenced by number of skin incisions, catheter exposure and manipulation, and the latter by catheter position. METHOD: Presenting our neuronavigated laparoscopic-assisted minimal exposure shunt technique performed on 40 consecutive adults. No patient presented infection or distal catheter migration (mean follow-up 12 months). Ventricular catheter malpositioning associated with electromagnetic neuronavigation inaccuracy occurred in two patients with slit ventricles. CONCLUSION: This technique demonstrates low infection/malfunction rate, postoperative pain, and cosmetic advantages. Limiting factors are availability of laparoscopic surgeons and neuronavigation if not familiar with the approach.

The endoscope-assisted contralateral paramedian approach to large falcine meningiomas.

BACKGROUND: Resection of large falcine meningiomas can be challenging as overlaying cortical brain is endangered during the surgical approach. METHOD: We describe the endoscope-assisted contralateral paramedian approach to large left-falcine meningiomas to avoid retraction of the ipsilateral thin layer of eloquent brain cortex. CONCLUSIONS: The contralateral paramedian approach enables complete tumor resection with endoscopic-assisted removal of tumor remnants in the superior aspect of the resection cavity, sparing any manipulation of ipsilateral brain tissue.

Operating room waste: disposable supply utilization in neurointerventional procedures.

BACKGROUND: Operating rooms account for 70% of hospital waste, increasing healthcare costs and creating environmental hazards. Endovascular treatment of cerebrovascular pathologies has become prominent, and associated products highly impact the total cost of care. We investigated the costs of endovascular surgical waste at our institution. METHODS: Data from 53 consecutive endovascular procedures at the Radboud UMC Nijmegen from May to December 2016 were collected. "Unused disposable supply" was defined as one-time use items opened but not used during the procedure. Two observers cataloged the unused disposable supply for each case. The cost of each item was determined from the center supply catalog, and these costs were summed to determine the total cost of unused supply per case. RESULTS: Thirteen diagnostic cerebral digital subtraction angiographies (DSA) (24.5%) and 40 endovascular procedures (75.5%) were analyzed. Total interventional waste was 27,299.53 € (mean 515.09 € per procedure). While total costs of unused disposable supply were almost irrelevant for DSAs, they were consistent for interventional procedures (mean 676.49 € per case). Aneurysm standard coiling had the highest impact on total interventional waste (mean 1061.55 €). Disposable interventional products had a very high impact on the surgical waste costs in the series of the neurointerventional procedures (95% of total waste). CONCLUSIONS: This study shows the impact of neurointerventional waste on the total care costs for cerebrovascular patients. This might reflect the tendency to anticipate needs and emergencies in neurointervention. Responsible use of disposable material can be achieved by educating operators and nurses and creating operator preference cards.

Anterior subtemporal approach for posterolateral brainstem cavernomas: report of ten cases.

BACKGROUND: The neuronavigation-assisted anterior subtemporal approach is proposed in this article as an alternative to surgery of posterolateral brainstem cavernomas. Brainstem cavernomas represent a neurosurgical challenge because of the high morbidity and mortality rate related to their surgical removal. Several nerve nuclei, ascending and descending fibers make this region at high risk of serious postoperative deficits. METHODS: Between 1998 and 2010, 24 patients underwent surgical removal of brainstem cavernomas in our institution. Ten of these patients presented a cavernous malformation in the posterolateral region of the brainstem and underwent surgical removal by means of a neuronavigation-assisted anterior subtemporal approach. RESULTS: Lesion removal was complete for all patients. There were no cases of surgery-related death. Neurological status improved or remained unchanged after surgery in all cases. All patients presented good outcomes at 12 to 154 months' follow-up (mean 70 months; GOS = 5 in 8/10 patients, 4 in 2/10 patients; mRS = 0-1 in all patients). Only one patient presented transient confusion, aphasia and seizures related to temporal lobe swelling, which resolved completely within a few days. One patient developed cranial nerve III palsy and left hemiparesis with gradual recovery. CONCLUSIONS: This approach represents a valid alternative to the "more classical" approaches for the surgery of posterolateral cavernomas of the pontomesenchephalic junction reaching the tentorial incisura, reducing the risk of damaging the vein of Labbé, temporal lobe swelling, cerebellar swelling, ophtalmoparesis, fourth ventricle cranial nerve nuclei lesions. Skeletonization of sigmoidal sinus provides with good outcomes, low morbidity and mortality.

Endoscopic-Assisted Resection of Anterior Foramen Magnum Meningiomas through a Midline Suboccipital Subtonsillar Approach.

Objective This study was aimed to demonstrate the resection of anterior foramen magnum meningiomas through an endoscopic-assisted posterior midline suboccipital subtonsillar approach. Design This study was designed with illustration of the surgical steps and safety of this approach. Setting Evidence of cerebrospinal fluid (CSF) cleft between the tumor and brainstem on MRI was studied ( Fig. 1A and B ). Preoperative tracheotomy was considered in cases of preoperative dysphagia to prevent any further neurological deterioration due to the bilateral access through the lower cranial nerves corridors. Semisitting position with extensive electrophysiological neuromonitoring and transesophageal echocardiogram was adopted. A standard midline incision with bilateral suboccipital craniotomy and C1-laminotomy was performed ( Fig. 2A ). After partial resection and elevation of the tonsils, tumor was debulked unilaterally around the lower cranial nerves and the vertebral artery, devascularized from the clival dura and then dissected from the brainstem ( Fig. 2B, C ). Endoscopic-assisted removal of its anterior portion followed. The same procedure was repeated from the opposite site for the contralateral portion, before approaching the purely anterior part with endoscope assistance ( Fig. 2D ). Participants Four consecutive patients were included in the study. Main Outcome Measures Grade of tumor resection and outcome (mRS) were primary measurement of this study. Results Clinical outcome and grade of resection are comparable to other series of patient treated with other foramen magnum approaches ( Fig. 1C and D ). Conclusion Anterior foramen magnum meningiomas can be safely removed through this relatively faster midline suboccipital approach with bilateral exposure of lower cranial nerves (CNs) and vertebral arteries and lower approach-related morbidity (no condyle drilling). The surgical corridor is created by the tumor during debulking reducing need for brain retraction and the removal of the anterior dural attachment coagulated under the microscope is verified and completed endoscopically with pituitary curettes (Simpson's grade II) ( Fig. 1C and D ). The link to the video can be found at: https://youtu.be/9eACAJVwQBs .

Limitations of Flow Diverters in Posterior Communicating Artery Aneurysms.

BACKGROUND: Treatment of intracranial aneurysms with flow diverters (FDs) showed promising results. However, a subset of patients treated for posterior communicating artery (PComA) aneurysms has variable occlusion rates. Especially the fetal type-associated PComA aneurysms seemed to respond differently to treatment. We analyze our series of fetal type PComA aneurysms treated with a FD. The literature on this subject is reviewed. METHODS: Data from patients treated with FD for all PComA aneurysms at the RadboudUMC Nijmegen were retrospectively analysed. Primary end-point was complete aneurysm occlusion at six months. Secondary end-points were clinical outcome, treatment safety, and results of secondary treatment after non-closure. The results for the fetal PComA aneurysms were compared to the literature. RESULTS: Nineteen consecutive patients harboring 21 PComA aneurysms were treated. Three aneurysms had ipsilateral fetal type PCA (14.3%). Overall, none of the fetal type PcomA aneurysm showed complete occlusion versus 77.8% of the others (p = 0.03). Mortality and permanent morbidity rates were respectively 5.3% and 0%. CONCLUSIONS: FD treatment for PComA aneurysm with fetal type circulation seemed to be less effective compared to other types of PComA aneurysms. Flow characteristics at the PComA bifurcation are thought to be causative Alternative strategies should be considered as first line treatment.

Factors Associated with Subsequent Subarachnoid Hemorrhages in Patients with Multiple Intracranial Aneurysms.

BACKGROUND: Detection of multiple intracranial aneurysms (MIAs) in patients with aneurysmal subarachnoid hemorrhage (aSAH) is common and the optimal management of the additional unruptured intracranial aneurysms (UIA) is often a matter of debate. We calculate the incidence and the factors associated with subsequent aSAHs from untreated additional aneurysms in a single-center group of patients with aSAH and MIAs. METHODS: Charts of patients with MIAs admitted to our neurosurgery department for aSAH between January 2000 and March 2020 were retrospectively reviewed. Incidence rate and factors associated with subsequent aSAHs were calculated with univariable and multivariable analyses. RESULTS: Of the unruptured aneurysms, 50% were preventively treated. During a median follow-up of 3 years, 20 of 174 patients (11.5%) presented with a second aSAH. Incidence of rupture of an additional untreated aneurysm was 18.05 per 1000 person/years (confidence interval, 10.69-30.47). Rupture incidence of an additional aneurysm located in the anterior circulation was 32.70 per 1000 person/years and 40.73 per 1000 person/years in the posterior circulation. Presence of untreated mirror and de novo aneurysms increased the risk of overall subsequent aSAHs by 16.9-fold and 7.6-fold, respectively. Most untreated additional aneurysms causing a subsequent aSAH were smaller than 7 mm (73.3%), with middle cerebral artery being the most frequent location (40.0%). CONCLUSIONS: Incidence of subsequent aSAHs is high in patients with aSAH-MIA. Untreated mirror and de novo aneurysms are associated with higher rupture risk. Longer follow-up and prophylactic treatment of asymptomatic aneurysms at higher rupture risk are recommended to prevent the significant poor outcome of subsequent aSAHs.

Endoscope-assisted resection of a brainstem cavernoma.

Procedures on cavernous malformations of the brainstem are challenging due to their eloquent location. This accounts especially for recurrent cavernomas as surgical scars, adhesions, and functional shift might have occurred since primary surgery. We report on a 38-year-old female patient with a large recurrent brainstem cavernoma, who underwent previous successful surgery and experienced recurrent bleeding about 2 years later. She harbored a large associated developmental venous anomaly (DVA) traversing the cavernoma through the midline of the brainstem. In order to visualize complete resection and preservation of the DVA at the same time, endoscopic-assisted resection within the brainstem after decompression in the semisitting position was performed. The video can be found here: https://youtu.be/K1p-Sx7jUpA.

An overview of endoscopy in neurologic surgery.

Endoscopy allows neurosurgeons to reach regions in the brain and spine through minimally invasive approaches. Such areas were previously accessible only by extensive and invasive approaches that limited the ability to see the areas of interest. Physicians are increasingly caring for patients who have undergone these procedures (eg, for pituitary tumors, hydrocephalus, and other intracranial, peripheral nerve, and spinal problems). This article familiarizes nonneurosurgeons with these techniques.

Anterior cervical discectomy and interbody fusion with porous tantalum implant. Results in a series with long-term follow-up.

Few papers have been published about the anterior cervical discectomy and fusion (ACDF) with implant of porous tantalum cages. These studies included patients submitted to operation at a single level. To our knowledge, we report the results of the largest series of ACDF with implant of porous tantalum cages. Our series included patients operated at a single or double level with a long follow-up (FU). We also discuss the pertinent literature. Clinical and outcome data of 99 consecutive patients (47 men, 52 women) submitted to ACDF with implant of porous tantalum cages (Trabecular Metal TM-S Cervical Fusion Device, Zimmer Spine, Minneapolis, MN) from June 2007 to September 2012, were retrospectively reviewed. Mean FU was 67.47±19.63months. The changes in pain were assessed using the Visual Analogue Scale (VAS). Patients were evaluated pre-operatively and at FU with the Short Form-36 Score Health Survey Version 2.0 (SF-36v2) for Physical Health and Mental Health Scores and the Neck Disability Index. We globally found a statistically significant improvement of all evaluated scores. Patients operated at two levels experienced a statistically significant improvement of all scores, with no statistical difference compared to patients operated at one level. No major complications occurred post-operatively and at FU. Only one patient (operated at two level) experienced an infection during FU. We conclude that ACDF with porous tantalum cages is a safe procedure, with long term clinical benefits (also in patients operated at two levels) and a very low rate of complications.

Petrosectomy and Topographical Anatomy in Traditional Kawase and Posterior Intradural Petrous Apicectomy (PIPA) Approach: An Anatomical Study.

OBJECTIVE: To compare the anatomical exposure and petrosectomy extent in the Kawase and posterior intradural petrous apicectomy (PIPA) approaches. METHODS: Kawase and PIPA approaches were performed on 4 fixed cadaveric heads (3 alcohol-fixed, 1 formaldehyde-fixed silicone-injected; 4 Kawase and 4 PIPA approaches). The microsurgical anatomy was examined by means of Zeiss Opmi CS/NC-4 microscopes. HD Karl Storz Endoscopes (AIDA system) were used to display intradural exposure. Petrosectomy volumes was assessed by comparing pre- and postoperative thin-slice computed tomography scans (Analyze 12.0; AnalyzeDirect Mayo Clinic). RESULTS: The Kawase approach exposed the rhomboid fossa with Meckel's cave extradurally, the upper half of the clivus, superior cerebellopontine angle, ventrolateral brainstem, the intrameatal region, basilar apex, and the preganglionic root of cranial nerve (CN) V, CN III-IV-VI intradurally. The PIPA approach exposed the cerebello-pontine angle with CN VI-XII, Meckel's cave, CN III-V, and the middle and lower clivus intradurally from a posterior view. The area of surgical exposure is wide in both approaches; however, the volume of petrosectomy, the working angle, and surgical corridor differ significantly. CONCLUSIONS: The Kawase approach allows wide exposure of the middle cranial fossa (MCF) and posterior cranial fossa, requiring extradural temporal lobe retraction and an extradural petrosectomy with preservation of the internal acoustic meatus and cochlea. No temporal lobe retraction and direct control of neurovascular structures make the PIPA approach a valid alternative for lesions extending mostly in the Posterior cranial fossa with minor extension in the MCF. The longer surgical corridor, cerebellar retraction, and limited exposure of the anterior brainstem make this approach less indicated for lesions with major extension in the MCF and the anterior cavernous sinus.

Selective Patch Angioplasty and Intraoperative Shunting in Carotid Endarterectomy: A Single-Center Review of 141 Procedures.

OBJECTIVE: Open surgical treatment of carotid artery stenosis, namely, carotid endarterectomy (CEA), has evolved since its inception in 1953. Despite improvements in the treatment of carotid occlusive disease through technological and surgical innovations, the use of patch grafting in CEA's remains controversial. We evaluate the durability of the primary closure and the safety of selective shunting during carotid endarterectomy (CEA) as determined by intraoperative EEG and postoperative outcomes. METHODS: A consecutive series of CEA's performed by the senior author at a single academic medical center from 2001 to 2012 were reviewed. All cases were performed under continuous intraoperative electroencephalography (EEG). Patch angioplasty was used in cases where there was tortuosity of the vessel within the region of the endarterectomy and narrow vessel diameter at the distal end of the arteriotomy. Shunting was used when intraoperative EEG showed a > 50% reduction in a waveform in any lead. Patients were evaluated for restenosis via imaging or ultrasound at six months and subsequently annual follow-up. RESULTS: One hundred and forty-one CEA's were performed on 132 (76 male, 56 female) patients with an average age of 71 years (range: 40-95 years). Four (3%) cases required patch angioplasty and three (2%) required intraoperative shunts. The cross-clamp time ranged from 22 to 74 minutes, and the duration increased with the use of shunts and patches. Complications were rare and included recurrent stenosis (n=2), postoperative transient ischemic attack (n=1), ischemic stroke in (n=1), temporary hypoglossal nerve weakness (n=2), temporary marginal mandibular nerve weakness (n=6), and neck hematoma (n=1). CONCLUSION: Intraoperative EEG data suggests that primary closure and selective shunting in CEA can result in outcomes comparable with routine patch angioplasty and shunting.

Endoscopic-Assisted Posterior Intradural Petrous Apicectomy in Petroclival Meningiomas: A Clinical Series and Assessment of Perioperative Morbidity.

OBJECTIVE: To describe the clinical feasibility and outcome of the endoscopic-assisted posterior intradural petrous apicectomy approach (PIPA) for petroclival meningiomas extending into the supratentorial space. METHODS: From 2005-2013, 29 patients with a petroclival meningioma underwent tumor removal through a PIPA approach. The approach consists of a retrosigmoid approach, intradural anterior resection of the petrous apex and microsurgical removal of the tumor, followed by endoscopic-assisted visualization and removal of tumor parts in the middle fossa or anterior to the brainstem. RESULTS: Patients consisted of 7 men and 22 women; the mean age of patients was 52.7 years. In 24 patients, surgery was performed with the patient in a semisitting position; in 5 patients, surgery was performed with the patient in a supine position. A total resection was achieved in 19 patients (66%). A Karnofsky performance scale score >60% was recorded in 27 patients (93%), with surgical complications that involved a cerebrospinal fluid leak in 3 patients, bleeding in the surgical cavity in 2 patients, and pneumocephalus in 1 patient. The most frequent postoperative neurologic deficit was facial palsy (34%), which disappeared or improved consistently in all but 1 patient, who required a cranial nerve VII-cranial nerve XII anastomosis. CONCLUSIONS: For petroclival meningiomas extending into the middle fossa, the endoscopic-assisted PIPA approach is safe and straightforward. The principal advantages of the PIPA approach are familiarity with the retrosigmoid route; the absence of temporal lobe retraction; and early control of the cranial nerves, vessels, and brainstem. However, careful patient selection regarding tumor extension is fundamental to obtaining optimal outcomes.

Optic Nerve Decompression through a Supraorbital Approach.

Objective We propose a stepwise decompression of the optic nerve (ON) through a supraorbital minicraniotomy and describe the surgical anatomy of the ON as seen through this approach. We also discuss the clinical applications of this approach. Methods Supraorbital approaches were performed on 10 preserved cadaveric heads (20 sides). First, 3.5-cm skin incisions were made along the supraciliary arch from the medial third of the orbit and extended laterally. A 2 × 3-cm bone flap was fashioned and extradural dissections were completed. A 180-degree unroofing of the ON was achieved, and the length and width of the proximal and distal portions of the optic canal (OC) were measured. Results The supraorbital minicraniotomy allowed for identification of the anterior clinoid process and other surgical landmarks and adequate drilling of the roof of the OC with a comfortable working angle. A 25-degree contralateral head rotation facilitated visualization of the ON. Conclusion The supraorbital approach is a minimally invasive and cosmetically favorable alternative to more extended approaches with longer operative times used for the management of ON decompression in posttraumatic or compressive optic neuropathy from skull base pathologies extending into the OC. The relative ease of this approach provides a relatively short learning curve for developing neurosurgeons.

The Pterional Port in Dual-Port Endoscopy: A 2D and 3D Cadaveric Study.

Objective We propose a novel dual-port endonasal and pterional endoscopic approach targeting midline lesions of the anterior cranial fossa with lateral extension beyond the optic nerve. Methods Ten dual-port approaches were performed on five cadaveric heads. All specimens underwent an endoscopic transtuberculum/transplanum approach followed by placement of a pterional port. The endonasal port was combined with an endoscopic extradural pterional keyhole craniectomy. The pterional port was placed at the intersection of the sphenoparietal and coronal sutures. The extradural space was explored using two-dimensional and three-dimensional endoscopes. Results The superolateral access provided by the pterional port may improve the ability to achieve a gross total resection of tumors with lateral extensions. The complete opening of the optic canal achieved through the dual-port approach may enable resection of the intracanalicular portion of a tumor, a crucial step in improvement of visual function and reduction of tumor recurrence. Conclusion The pterional port may enhance control of midline anterior skull base lesions with lateral extension beyond the optic nerve and optic canal. Dual-port endoscopy maintains minimally invasiveness and dramatically increases the working limits and control of anatomical structures well beyond what is attainable through single-port neuroendoscopy.

Magnetic resonance image findings of primary intradural Ewing sarcoma of the cauda equina: case report and review of the literature.

BACKGROUND CONTEXT: Involvement of the cauda equina in Ewing sarcoma (ES) is extremely rare, and only few cases are reported in literature. However, ES of cauda equina shares some neuroradiological features with other neoplasms that can involve the intradural space. Therefore, differential diagnosis with other tumors of cauda equina should be considered by neuroradiologists and neurosurgeons to provide appropriate treatment. PURPOSE: To present a rare case of intradural extramedullary primary ES. STUDY DESIGN: Case report. METHODS: We report a case of a 44-year-old woman presenting with the rapid onset of cauda equina syndrome. Radiological analysis showed multiple intradural masses, extending from L1 to S3 level. After radical surgery, lesions were histologically defined as ES. We present a literature review, analyzing magnetic resonance image (MRI) features of primary intradural ES of the cauda equina. RESULTS: Four cases of primitive ES arising from the cauda equina have been reported in the literature. CONCLUSIONS: Because of the low number of reported cases, it is not possible to describe pathognomonic MRI findings for intradural ES of the cauda equina. However, few tumors show similar MRI features. Therefore, despite its rarity, intradural ES should be taken into account in the differential diagnosis of spinal tumors involving cauda equina.

Dual-Port 2D and 3D Endoscopy: Expanding the Limits of the Endonasal Approaches to Midline Skull Base Lesions with Lateral Extension.

Objective To investigate a novel dual-port endonasal and subtemporal endoscopic approach targeting midline lesions with lateral extension beyond the intracavernous carotid artery anteriorly and the Dorello canal posteriorly. Methods Ten dual-port approaches were performed on five cadaveric heads. All specimens underwent an endoscopic endonasal approach from the sella to middle clivus. The endonasal port was combined with an anterior or posterior endoscopic extradural subtemporal approach. The anterior subtemporal port was placed directly above the middle third of the zygomatic arch, and the posterior port was placed at its posterior root. The extradural space was explored using two-dimensional and three-dimensional endoscopes. Results The anterior subtemporal port complemented the endonasal port with direct access to the Meckel cave, lateral sphenoid sinus, superior orbital fissure, and lateral and posterosuperior compartments of the cavernous sinus; the posterior subtemporal port enhanced access to the petrous apex. Endoscopic dissection and instrument maneuverability were feasible and performed without difficulty in both the anterior and posterior subtemporal ports. Conclusion The anterior and posterior subtemporal ports enhanced exposure and control of the region lateral to the carotid artery and Dorello canal. Dual-port neuroendoscopy is still minimally invasive yet dramatically increases surgical maneuverability while enhancing visualization and control of anatomical structures.