Clipping of Anterior Circulation Aneurysms: Operative Instructions and Safety Rules for Young Cerebrovascular Surgeons.

INTRODUCTION: Due to the constant development of the technique, in the last 30 years, the endovascular treatment of the intracranial aneurysms (IAs) has gradually superseded the traditional surgery in the majority of centers. However, clipping still represents the best treatment for some anterior circulation IAs according to their angioarchitectural, topographical, and hemodynamic characteristics. Thus, the identification of residual indications for clipping and the maintenance of training programs in vascular neurosurgery appear nowadays more important than ever. MATERIALS AND METHODS: We reviewed our last 10-year institutional experience of ruptured and unruptured IAs clipping. We appraised in detail all technical refinements we adopted during this time span and analyzed the difficulties we met in teaching the aneurysm clipping technique to residents and fellows. Then, we described the algorithm of safety rules we used to teach young neurosurgeons how to surgical approach anterior circulation IAs and develop a procedural memory, which may intervene in all emergency situations. RESULTS: We identified seven pragmatic technical key points for clipping of the most frequent anterior circulation IAs and constructed a didactic approach to teach young cerebrovascular surgeons. In general, they concern craniotomy; cisternostomy; obtaining proximal control; cranial nerve, perforator, and vein preservation; necessity of specific corticectomy; aneurysm neck dissection; and clipping. CONCLUSION: In the setting of an IA clipping, particularly when ruptured, the young cerebrovascular surgeon needs to respect an algorithm of safety rules, which are essential not only to avoid major complications, but they may intervene during the difficulties helping to manage potentially life-tethering conditions.

Surgery versus endovascular treatment for spinal dural arteriovenous fistulas: a multicenter experience and systematic literature review.

Surgery and endovascular therapy are the primary treatment options for spinal dural arteriovenous fistula (SDAVF). Due to the absence of a consensus regarding which therapy yields a superior outcome, we conducted a comparative analysis of the surgical and endovascular treatment of SDAVF through a multicenter case series and a systematic literature review. Patients with SDAVF, surgically or endovascularly treated at four neurosurgical centers from January 2001 to December 2021, were included in this study. Level of SDAVF, primary treatment modality, baseline and post-procedural neurological status were collected. The primary outcomes were failure, complication rates, and a newly introduced parameter named as therapeutic delay. A systematic review of the literature was performed according to PRISMA-P guidelines. The systematic review identified 511 papers, of which 18 were eligible for analysis, for a total of 814 patients, predominantly male (72%) with a median age of 61 and mainly thoracic SDAVFs (65%). The failure rate was significantly higher for endovascular therapy (20%) compared to surgery (4%) (p < 0.01). Neurological complications were generally rare, with similar rates among the two groups (endovascular 2.9%; surgery 2.6%). Endovascular treatment showed a statistically significantly higher rate of persistent neurological complications than surgical treatment (2.9% versus 0.2%; p < 0.01). Both treatments showed similar rates of clinical improvement based on Aminoff Logue scale score. The multicenter, retrospective study involved 131 patients. The thoracic region was the most frequent location (58%), followed by lumbar (37%). Paraparesis (45%) and back pain (41%) were the most common presenting symptoms, followed by bladder dysfunction (34%) and sensory disturbances (21%). The mean clinical follow-up was 21 months, with all patients followed for at least 12 months. No statistically significant differences were found in demographic and clinical data, lesion characteristics, or outcomes between the two treatment groups. Median pre-treatment Aminoff-Logue score was 2.6, decreasing to 1.4 post-treatment with both treatments. The mean therapeutic delay for surgery and endovascular treatment showed no statistically significant difference. Surgical treatment demonstrated significantly lower failure rates (5% vs. 46%, p < 0.01). In the surgical group, 2 transient neurological (1 epidural hematoma, 1 CSF leak) and 3 non-neurological (3 wound infections) complications were recorded; while 2 permanent neurological (spinal infarcts), and 5 non-neurological (inguinal hematomas) were reported in the endovascular group. According to the literature review and this multicenter clinical series, surgical treatment has a significantly lower failure rate than endovascular treatment. Although the two treatments have similar complication rates, endovascular treatment seems to have a higher rate of persistent neurological complications.

Post-operative segmental cerebral venous sinus thrombosis: risk factors, clinical implications, and therapeutic considerations.

Cerebral venous sinus thromboses (CVSTs) are rare complications of neurosurgical interventions and their management remains controversial as most of cases appear clinically silent. Here, we analyzed our institutional series of patients with CVSTs evaluating clinical and neuroradiological characteristics, risk factors, and outcome. From the analysis of our institutional PACS, we collected a total of 59 patients showing postoperative CVSTs after supratentorial or infratentorial craniotomies. For every patient, we collected demographics and relevant clinical and laboratory data. Details on thrombosis trend were retrieved and compared along the serial radiological assessment. A supratentorial craniotomy was performed in 57.6% of cases, an infratentorial in 37.3%, while the remaining were a single cases of trans-sphenoidal and neck surgery (1.7%, respectively). A sinus infiltration was present in almost a quarter of patients, and in 52.5% of cases the thrombosed sinus was exposed during the craniotomy. Radiological signs of CVST were evident in 32.2% of patients, but only 8.5% of them developed a hemorrhagic infarct. CVST-related symptoms were complained by 13 patients (22%), but these were minor symptoms in about 90%, and only 10% experienced hemiparesis or impaired consciousness. The majority of patients (78%) remained completely asymptomatic along the follow-up. Risk factors for symptoms occurrence were interruption of preoperative anticoagulants, infratentorial sinuses involvement and evidence of vasogenic edema and venous infarction. Overall, a good outcome defined mRS 0-2 was observed in about 88% of patients at follow-up. CVST is a complication of surgical approaches in proximity of dural venous sinuses. CVST usually does not show progression and courses uneventfully in the vast majority of cases. The systematic use of post-operative anticoagulants seems to not significantly influence its clinical and radiological outcome.

Has intraoperative neuromonitoring changed the surgery for unruptured middle cerebral artery aneurysms? A retrospective comparative study.

Intraoperative neurophysiological monitoring (IONM) represents one of the available technologies able to assess ischemia and aimed to improve surgical outcome reducing the treatment related morbidity in surgery for intracranial aneurysms. Many studies analyzing the impact of IONM are poised by the heterogeneity bias affecting the cohorts. We report our experience with IONM for surgery of unruptured middle cerebral artery (MCA) aneurysm in order to highlight its influence on functional and radiological outcome and surgical strategy. We retrospectively reviewed all MCA unruptured aneurysms treated between January 2013 and June 2021 by our institutional neurovascular team. Patients were divided into 2 groups according to the use of IONM. A total of 153 patients were included in the study, 52 operated on without IONM and 101 with IONM. The groups did not differ preoperatively regarding clinical status and aneurysm characteristics. Patients operated with IONM had better functional outcomes at discharge as well as at follow-up (p= 0.048, p=0.041) due to lower symptomatic ischemia and better radiological outcome due to lower rate of unexpected aneurysmal remnants (p= 0.0173). The introduction of IONM changed the use of temporary clipping (TeC), increasing its average duration (p= 0.01) improving the safety of dissecting and clipping the aneurysm. IONM in surgery for unruptured MCA aneurysm could improve the efficacy and safety of clipping strategy in the way it showed a role in changing the use of TeC and was associated to the reduction of unexpected aneurysmal remnants' rate and improvement in both short- and long-term patient's outcome.

Role of Mediterranean diet in the development and recurrence of meningiomas: a narrative review.

Several studies through the years have proven how an unhealthy nutrition, physical inactivity, sedentary lifestyle, obesity, and smoking represent relevant risk factors in cancer genesis. This study aims to provide an overview about the relationship between meningiomas and food assumption in the Mediterranean diet and whether it can be useful in meningioma prevention or it, somehow, can prevent their recurrence. The authors performed a wide literature search in PubMed and Scopus databases investigating the presence of a correlation between Mediterranean diet and meningiomas. The following MeSH and free text terms were used: "Meningiomas" AND "Diet" and "Brain tumors" AND "diet." Databases' search yielded a total of 749 articles. After duplicate removal, an abstract screening according to the eligibility criteria has been performed and 40 articles were selected. Thirty-one articles were excluded because they do not meet the inclusion criteria. Finally, a total of 9 articles were included in this review. It is widely established the key and protective role that a healthy lifestyle and a balanced diet can have against tumorigenesis. Nevertheless, studies focusing exclusively on the Mediterranean diet are still lacking. Thus, multicentric and/or prospective, randomized studies are mandatory to better assess and determine the impact of food assumptions in meningioma involvement.

Spinal Dural Arteriovenous Fistulas: A Retrospective Analysis of Prognostic Factors and Long-Term Clinical Outcomes in the Light of the Recent Diagnostic and Technical Refinements.

Spinal dural arteriovenous fistulas (dAVFs) are abnormal connections between the meningeal branches of segmental arteries and a radiculomedullary veins that result in a progressive myelopathy thanks to perimedullary coronal venous plexus congestion. Usually, dAVFs show nonspecific symptoms, thus leading to late clinical suspicion and a difficult MRI diagnosis.Several authors have tried to identify prognostic factors before treatment, but published studies results are often inconsistent and sometimes contradictory.In this study, we reviewed our recent experience of 30 dAVF patients where we collected all demographic, clinical and angioarchitectural features as well as radiological and treatment-related characteristics. The thoracic spine was the most common location, constituting 53.3% of cases, followed by the lumbar roots, comprising 30%. About 83% of patients showed motor deficits, urinary disturbances were present in 70%, and bowel symptoms in 50%.We treated 86.7% of patients with microsurgery and 13.3% with endovascular occlusion with a mean interval between clinical onset and intervention of 10.8 ± 14.2 months.A significant clinical improvement was observed at follow-up in 80% of patients, with a significant reduction in mean G-score, U-score and F-score at a mean follow-up of 105.89 ± 191.9 months.However, none among the principal demographic, clinical and radiological characteristics showed significant prognostic value to the clinical improvement observed at follow-up.

Bleeding risk evaluation in cerebral cavernous malformation, the role of medications, and hemorrhagic factors: a case-control study.

OBJECTIVE: Cerebral cavernous malformations (CCMs) are vascular lesions with an overall risk of rupture from 2% to 6% per year, which is associated with significant morbidity and mortality. The diagnostic incidence is increasing, so it is of paramount importance to stratify patients based on their risk of rupture. Data in the literature seem to suggest that specific medications, particularly antithrombotic and cardiovascular agents, are associated with a reduced risk of bleeding. However, the effect of the patient coagulative status on the cumulative bleeding risk remains unclear. The aim of this study was to assess the impact of different radiological, clinical, and pharmacological factors on the bleeding risk of CCMs and to assess the predictive power of an already validated scale for general bleeding risk, the HAS-BLED (hypertension, abnormal renal/liver function, stroke, bleeding history or predisposition, labile international normalized ratio, elderly, drugs/alcohol concomitantly). METHOD: This was a multicenter retrospective observational study. The authors collected imaging, clinical status, and therapy data on patients with bleeding and nonbleeding CCMs. Univariate analysis and subsequent multivariate logistic regression were performed between the considered variables and bleeding or nonbleeding status to identify potential independent predictors of bleeding. RESULTS: The authors collected data on 257 patients (46.7% male, 25.3% with bleeding CCMs). Compared with patients with nonbleeding lesions, those with bleeding CCMs were younger, less frequently had hypertension, and less frequently required antiplatelet drugs and beta-blockers (all p < 0.05). Bleeding lesions, however, had significantly higher median volumes (1050 mm3 vs 523 mm3 , p < 0.001). On multivariate analyses, after adjusting for age, history of hypertension and diabetes, and use of antiplatelet drugs or beta-blockers, lesion volume ≥ 300 mm3 was the only significant predictor of bleeding (adjusted OR 3.11, 95% CI 1.09-8.86). When the diagnostic accuracy of different volume thresholds was explored, volume ≥ 300 mm3 showed a limited sensitivity (36.7%, 95% CI 24.6%-50.0%), but a high specificity 78.2% (95% CI 71.3%-84.2%), with an area under the curve of 0.57 (95% CI 0.51-0.64). CONCLUSIONS: This study supports previous findings that the CCM volume is the only factor influencing the bleeding risk. Antithrombotic agents and propranolol seem to have a protective role against the bleeding events. A high HAS-BLED score was not associated with an increased bleeding risk. Further studies are needed to confirm these results.

Widening or narrowing inequalities? The equity implications of digital tools to support COVID-19 contact tracing: A qualitative study.

BACKGROUND: As digital tools are increasingly used to support COVID-19 contact tracing, the equity implications must be considered. As part of a study to understand the public's views of digital contact tracing tools developed for the national 'Test and Protect' programme in Scotland, we aimed to explore the views of groups often excluded from such discussions. This paper reports on their views about the potential for contact tracing to exacerbate inequalities. METHODS: A qualitative study was carried out; interviews were conducted with key informants from organizations supporting people in marginalized situations, followed by interviews and focus groups with people recruited from these groups. Participants included, or represented, minority ethnic groups, asylum seekers and refugees and those experiencing multiple disadvantage including severe and enduring poverty. RESULTS: A total of 42 people participated: 13 key informants and 29 members of the public. While public participants were supportive of contact tracing, key informants raised concerns. Both sets of participants spoke about how contact tracing, and its associated digital tools, might increase inequalities. Barriers included finances (inability to afford smartphones or the data to ensure access to the internet); language (digital tools were available only in English and required a degree of literacy, even for English speakers); and trust (many marginalized groups distrusted statutory organizations and there were concerns that data may be passed to other organizations). One strength was that NHS Scotland, the data guardian, is seen as a generally trustworthy organization. Poverty was recognized as a barrier to people's ability to self-isolate. Some participants were concerned about giving contact details of individuals who might struggle to self-isolate for financial reasons. CONCLUSIONS: The impact of contact tracing and associated digital tools on marginalized populations needs careful monitoring. This should include the contact tracing process and the ability of people to self-isolate. Regular clear messaging from trusted groups and community members could help maintain trust and participation in the programme. PATIENT AND PUBLIC CONTRIBUTION: Our patient and public involvement coapplicant, L. L., was involved in all aspects of the study including coauthorship. Interim results were presented to our local Public and Patient Involvement and Engagement Group, who commented on interpretation and made suggestions about further recruitment.

Timing and outcome of bystanders treatment in patients with subarachnoid hemorrhage associated with multiple aneurysms.

In case of subarachnoid hemorrhage (SAH) associated with multiple intracranial aneurysms (MIAs), the main goal of acute treatment is securing the source of bleeding (index aneurysm). Indications and timing of bystanders treatment are instead still debated as the risk of new SAHs in patients harboring MIAs is not yet established. However, even if technically feasible, a simultaneous management of all aneurysms remains questionable, especially for safety issues. We retrospectively reviewed our last 5-year experience with SAH patients harboring MIAs entered in a clinic-radiological monitoring for bystanders follow-up in order to evaluate the occurrence of morphological changes, bleeding events, and safety and efficacy of a delayed treatment. We included 39 patients with mean age of 59.5 ± 12.2 years who survived a SAH. Among them, 14 underwent treatment, whereas 25 continued follow-up. The mean time between index and bystanders treatment was 14.3 ± 19.2 months. Patients undergoing bystanders treatment were mainly female and in general younger than patients undergoing observation. No cases of growth or bleeding were observed among bystanders within the two groups during the follow-up, which was longer than 1 year for the intervention group, and almost 40 months for the observation group. No major complications and mRS modifications were observed after bystanders treatment. Our data seem to suggest that within the short follow-up, intervention and observation seem to be likewise safe for bystander aneurysms, showing at the same time that a delayed management presents a similar risk profile of treating unruptured aneurysms in patients with no previous history of SAH.

Machine learning model prediction of 6-month functional outcome in elderly patients with intracerebral hemorrhage.

Spontaneous intracerebral hemorrhage (ICH) has an increasing incidence and a worse outcome in elderly patients. The ability to predict the functional outcome in these patients can be helpful in supporting treatment decisions and establishing prognostic expectations. We evaluated the performance of a machine learning (ML) model to predict the 6-month functional status in elderly patients with ICH leveraging the predictive value of the clinical characteristics at hospital admission. Data were extracted by a retrospective multicentric database of patients ≥ 70 years of age consecutively admitted for the management of spontaneous ICH between January 1, 2014 and December 31, 2019. Relevant demographic, clinical, and radiological variables were selected by a feature selection algorithm (Boruta) and used to build a ML model. Outcome was determined according to the Glasgow Outcome Scale (GOS) at 6 months from ICH: dead (GOS 1), poor outcome (GOS 2-3: vegetative status/severe disability), and good outcome (GOS 4-5: moderate disability/good recovery). Ten features were selected by Boruta with the following relative importance order in the ML model: Glasgow Coma Scale, Charlson Comorbidity Index, ICH score, ICH volume, pupillary status, brainstem location, age, anticoagulant/antiplatelet agents, intraventricular hemorrhage, and cerebellar location. Random forest prediction model, evaluated on the hold-out test set, achieved an AUC of 0.96 (0.94-0.98), 0.89 (0.86-0.93), and 0.93 (0.90-0.95) for dead, poor, and good outcome classes, respectively, demonstrating high discriminative ability. A random forest classifier was successfully trained and internally validated to stratify elderly patients with spontaneous ICH into prognostic subclasses. The predictive value is enhanced by the ability of ML model to identify synergy among variables.

Clipping versus coiling for treatment of middle cerebral artery aneurysms: a retrospective Italian multicenter experience.

Endovascular treatment has emerged as the predominant approach in intracranial aneurysms. However, surgical clipping is still considered the best treatment for middle cerebral artery (MCA) aneurysms in referral centers. Here we compared short- and long-term clinical and neuroradiological outcomes in patients with MCA aneurysms undergoing clipping or coiling in 5 Italian referral centers for cerebrovascular surgery. We retrospectively reviewed 411 consecutive patients admitted between 2015 and 2019 for ruptured and unruptured MCA aneurysm. Univariate and multivariate analyses of the association between demographic, clinical, and radiological parameters and ruptured status, type of surgical treatment, and clinical outcome at discharge and follow-up were performed. Clipping was performed in 340 (83%) cases, coiling in 71 (17%). Clipping was preferred in unruptured aneurysms and in those showing collateral branches originating from neck/dome. Surgery achieved a higher rate of complete occlusion at discharge and follow-up. Clipping and coiling showed no difference in clinical outcome in both ruptured and unruptured cases. In ruptured aneurysms age, presenting clinical status, intracerebral hematoma at onset, and treatment-related complications were significantly associated with outcome at both short- and long-term follow-up. The presence of collaterals/perforators originating from dome/neck of the aneurysms also worsened the short-term clinical outcome. In unruptured cases, only treatment-related complications such as ischemia and hydrocephalus were associated with poor outcome. Clipping still seems superior to coiling in providing better short- and long-term occlusion rates in MCA aneurysms, and at the same time, it appears as safe as coiling in terms of clinical outcome.

Stem Cell Strategies in Promoting Neuronal Regeneration after Spinal Cord Injury: A Systematic Review.

Spinal cord injury (SCI) is a devastating condition with a significant medical and socioeconomic impact. To date, no effective treatment is available that can enable neuronal regeneration and recovery of function at the damaged level. This is thought to be due to scar formation, axonal degeneration and a strong inflammatory response inducing a loss of neurons followed by a cascade of events that leads to further spinal cord damage. Many experimental studies demonstrate the therapeutic effect of stem cells in SCI due to their ability to differentiate into neuronal cells and release neurotrophic factors. Therefore, it appears to be a valid strategy to use in the field of regenerative medicine. This review aims to provide an up-to-date summary of the current research status, challenges, and future directions for stem cell therapy in SCI models, providing an overview of this constantly evolving and promising field.

Dissecting Stemness in Aggressive Intracranial Meningiomas: Prognostic Role of SOX2 Expression.

Meningiomas are mostly benign tumors that, at times, can behave aggressively, displaying recurrence despite gross-total resection (GTR) and progression to overt malignancy. Such cases represent a clinical challenge, particularly because they are difficult to recognize at first diagnosis. SOX2 (Sex-determining region Y-box2) is a transcription factor with a key role in stem cell maintenance and has been associated with tumorigenesis in a variety of cancers. The purpose of the present work was to dissect the role of SOX2 in predicting the aggressiveness of meningioma. We analyzed progressive/recurrent WHO grade 1−2 meningiomas and WHO grade 3 meningiomas; as controls, non-recurring WHO grade 1 and grade 2 meningioma patients were enrolled. SOX2 expression was evaluated using both immunohistochemistry (IHC) and RT-PCR. The final analysis included 87 patients. IHC was able to reliably assess SOX2 expression, as shown by the good correlation with mRNA levels (Spearman R = 0.0398, p = 0.001, AUC 0.87). SOX2 expression was an intrinsic characteristic of any single tumor and did not change following recurrence or progression. Importantly, SOX2 expression at first surgery was strongly related to meningioma clinical behavior, histological grade and risk of recurrence. Finally, survival data suggest a prognostic role of SOX2 expression in the whole series, both for overall and for recurrence-free survival (p < 0.0001 and p = 0.0001, respectively). Thus, SOX2 assessment could be of great help to clinicians in informing adjuvant treatments during follow-up.

Retrospective application of risk scores to ruptured intracranial aneurysms: would they have predicted the risk of bleeding?

As the incidental diagnosis of unruptured intracranial aneurysms has been increasing, several scores were developed to predict risk of rupture and growth to guide the management choice. We retrospectively applied these scores to a multicenter series of patients with subarachnoid hemorrhage to test whether they would have predicted the risk of bleeding in the event of aneurysm discovery previous to its rupture. Demographical, clinical, and radiological information of 245 adults were retrieved from two neurovascular centers' database. Data were pooled and PHASES, UCAS, and ELAPSS scores were retrospectively calculated for the whole population and their performances in identifying aneurysms at risk of rupture were compared. Mean PHASES, UCAS, and ELAPSS scores were 5.12 ± 3.08, 5.09 ± 2.62, and 15.88 ± 8.07, respectively. Around half (46%) of patients would have been assigned to the low- or very low-risk class (5-year rupture risk < 1%) in PHASES. Around 28% of patients would have been in a low-risk class, with a probability of 3-year rupture risk < 1% according to UCAS. Finally, ELAPSS score application showed a wider distribution among the risk classes, but a significant proportion of patients (45.5%) lie in the low- or intermediate-risk class for aneurysm growth. A high percentage of patients with ruptured aneurysms in this multicenter cohort would have been assigned to the lower risk categories for aneurysm growth and rupture with all the tested scores if they had been discovered before the rupture. Based on these observations, physicians should be careful about drawing therapeutic conclusions solely based on application of these scores.

Treatment and outcome of thrombosed aneurysms of the middle cerebral artery: institutional experience and a systematic review.

Thrombosed aneurysms of the middle cerebral artery (MCA) usually show large dimension and complex morphology with neck sclerosis and perforating vessels originating from the sac. Only limited experiences from case reports or small mixed series including thrombosed aneurysms in different locations are available in literature. To systematically review all the pertinent literature, a comprehensive literature review with the search terms "MCA, aneurysm, and thrombosis" and a pooled analysis including our institutional series were performed. We evaluated demographics, ruptured status, aneurysm morphology, topography and size, thrombosis extension, treatment, complications, final occlusion rate, and clinical outcome at follow-up. Data were individually extracted for each patient and included in a pool for the statistical analysis. Forty-two articles published between 1992 and 2016 were selected, including a total of 115 patients. Most of thrombosed aneurysms were saccular (67.6%), large or giant (86.7%), and located at the MCA bifurcation (67.3%). The treatment of choice was surgery in more than 80% of cases compared with the endovascular techniques, though the overall percentage of complications reported in the two groups was similar and around 20% of cases. Clinical outcome was favorable in more than 85% of patients after treatment. This is the first systematic review focusing on treatment and outcome of thrombosed MCA aneurysms. Our data depict their main angioarchictectural and clinical characteristics, proving the feasibility of their treatment with good prognosis in a high percentage of patients. However, complication and mortality rates of about 20 and 3.5%, respectively, are not negligible.

Secondary coiling after incomplete surgical clipping of cerebral aneurysms: a rescue strategy or a treatment option for complex cases? Institutional series and systematic review.

Residual and recurrent intracranial aneurysms after surgical clipping present a persistent risk of bleeding. Secondary coiling after incomplete clipping represents a strategy to occlude the residual sac: feasibility, bleeding risk and outcome were evaluated through a systematic review of literature along with the series of two tertiary referral neurovascular centres. Demographics, ruptured status, aneurysm morphology, topography, exclusion at surgery, timing of secondary coiling, complications, occlusion rate and outcome were analysed. Percentage of incidence and 95% CI were calculated for all variables. T test was used for continue variables, whereas Fisher's test (two-sided) is for categorical ones. Overall, 102 patients (92 cases from literature and 10 cases from institutional series) were included. Mean age at diagnosis was 52.94 ± 12.17 years, and male/female ratio 0.5; 3/4 of aneurysms involved the anterior circulation, whereas » the posterior circulation. An aneurysmal neck remnant was described in 58.43% of cases, an aneurysmal sac remnant in 29.21% and a regrowth in 12.36%. Residual aneurysm rupture was reported in 22% of cases. Complete/near-complete occlusion after secondary coiling was observed in 70% of cases, a partial in 25.56% and a failure in 4.44%. Only one case of perforation was reported. Complications were comparable to standard endovascular procedures. Aneurysms remnants after clipping are often observed in cases difficult anatomical locations. Their bleeding risk is not negligible. Secondary coiling is a rescue strategy to effectively and safely secure the aneurysm remnant. Only in a minority of cases, it is a staged treatment after 'remodelling' of the aneurysm neck.

Improving the Accuracy of Neuronavigation in Cerebral Cavernous Malformation: A Technical Note on 68 Cases.

Cavernous malformations (CM) are benign, low-flow vascular lesions that account for 5% - 13% of all cerebrovascular malformations. Surgery remains the most important treatment strategy, and many different approaches have been developed. We present here our institutional experience with 68 cases using a transcortical neuronavigation approach with some technical nuances to improve navigation accuracy during resection. The technique and clinical outcomes are discussed, with a specific focus on seizure sequels. Demographic data were collected, along with information on clinical and seizure characteristics at presentation, localization and size of CM, presence of multiple localizations, evidence of recent CM-related bleeding on MRI, intervention features, postoperative complications, prescription of anti-epileptic drugs at discharge and seizure outcome. We assume that surgery through a narrow well-defined working corridor would limit brain exposure and manipulation, and hence could significantly affect not only general complications, but also seizure control. The technique is feasible and associated with relatively low rates of minor and major procedure-related complications. It is also a valid method for surgeons in training since the trajectory is planned preoperatively with a senior consultant and the working corridor always follows the catheter, which directly leads to the cavernoma.

Surgical approach to posterior inferior cerebellar artery aneurysms.

BACKGROUND: The far-lateral is a standardised approach to clip aneurysms of the posterior inferior cerebellar artery (PICA). Different variants can be adopted to manage aneurysms that differ in morphology, topography, ruptured status, cerebellar swelling and surgeon preference. METHOD: We distinguished five paradigmatic approaches aimed to manage aneurysms that are: proximal unruptured; proximal ruptured requiring posterior fossa decompression (PFD); proximal ruptured not requiring PFD; distal unruptured; distal ruptured. CONCLUSIONS: Preoperative planning in the setting of PICA aneurysm surgery is of paramount importance to perform an effective and safe procedure, to ensure an adequate PFD and optimal proximal control before aneurysm manipulation.

Minipterional Craniotomy for Treatment of Unruptured Middle Cerebral Artery Aneurysms. A Single-Center Comparative Analysis with Standard Pterional Approach as Regard to Safety and Efficacy of Aneurysm Clipping and the Advantages of Reconstruction.

Pterional craniotomy (PT) has long been the standard approach for the treatment of middle cerebral artery (MCA) aneurysms, even though it may cause temporalis muscle atrophy, facial nerve injury, and masticatory difficulties. Minipterional craniotomy (MPT) is an alternative approach that may provide the same surgical corridor, limiting the risk of postoperative esthetic and functional complications. From January 2011 to December 2014 we consecutively performed 68 craniotomies for surgical treatment of unruptured MCA aneuryms: 37 were standard PT and 31 were MPT. There were no significant differences in mean age, sex, and aneurysm topography between the two groups. The mean skin incision length was 14 cm in the PT group and 6 cm in the MPT group. According to the Glasgow Outcome Scale (GOS) and modified Rankin Scale (mRS), there were no significant differences in clinical outcome at discharge or follow-up between the two groups. Also, the rates of complete aneurysm exclusion were comparable. However, the number of patients complaining of masticatory disorders was higher among those treated with PT. Finally, the number of complications observed in the PT group was higher than that in the MPT group, but only the differences in mean hospitalization length and necessity for a dural patch for reconstruction were statistically significant. In conclusion, the MPT approach is a safe and effective alternative to the standard PT for the treatment of unruptured MCA aneurysms.