The role of precentral cerebellar vein in neurosurgery: An in-depth review of anatomy, implications, and risks.

Background: The Precentral Cerebellar Vein (PCV) plays a crucial role as an anatomical landmark in neurosurgery, and the possibility of its safe sacrifice is controversial. Understanding its anatomical nuances and clinical implications is fundamental in enhancing neurosurgical practice. Methods: A systematic review following PRISMA guidelines was conducted to consolidate literature on the PCV. PubMed, Scopus, and Web of Science were systematically searched using predefined criteria. Studies providing complete research texts in English, focusing on the PCV's surgical anatomy and neurosurgical implications were included. Results: Fourteen articles met inclusion criteria, exploring the PCV's anatomical variations, trajectory, dimensions, and connections. The PCV's utility in localizing posterior fossa tumors was underscored, aiding in surgical precision. However, sacrifices of the PCV or minor veins for access to quadrigeminal areas posed postoperative risks, emphasizing the need for careful preoperative planning. Additionally, the PCV's diagnostic value in venous malformations and developmental anomalies was highlighted. Conclusions: This comprehensive review accentuates the pivotal role of the PCV in neurosurgery. While serving as a vital guide in procedures, it poses potential risks when manipulated. Understanding its multifaceted significance, from anatomy to clinical implications, is paramount for informed decision-making and minimizing complications in neurosurgical interventions.

Analyzing the relationship between cerebral aneurysms and Non-oculomotor cranial nerve palsies: a systematic review.

OBJECTIVES: This study aimed to investigate the association between intracerebral aneurysms and cranial nerve (CN) palsies, focusing on nerves other than the oculomotor nerve. It sought to determine the prevalence, risk factors, and clinical outcomes of these nerve palsies and compare the effectiveness of microsurgical clipping versus endovascular coiling in restoring nerve function. METHODOLOGY: Following PRISMA guidelines, a comprehensive literature search was conducted using databases like PubMed, Scopus, and Google Scholar, covering studies from 1975 to April 2024. The inclusion criteria targeted patients with non-oculomotor nerve palsies diagnosed with cerebral aneurysms. Studies published before 1975 and non-English studies were excluded. Data extraction included study design, patient characteristics, and intervention outcomes. The Joanna Briggs Institute and Newcastle-Ottawa scales were used to assess study quality. Data were synthesized narratively and statistically analysed using SPSS v27. RESULTS: The analysis included 47 patients (53.2% female, mean age 44.8 years). The internal carotid artery (ICA) was the most common aneurysm site (44.7%), and the abducent nerve (CN VI) was most frequently affected. Ruptured aneurysms had better recovery outcomes (88.9%) than unruptured ones (66.7%). Hypertension was present in 9.2%. Unilateral aneurysms were seen in 80.9%, with 76.6% having a single nerve palsy. Non-ruptured aneurysms accounted for 58.1%, and ruptured for 41.9% of associated cranial nerve palsies. Treatment included microsurgical approaches (42.6%), endovascular approaches (34%), combined approaches (6.4%), and conservative management (17%). Recovery of the palsy was observed in 75.6%, with endovascular procedures showing higher recovery (93.3%) compared to conservative treatment (28.6%). CONCLUSION: Intracerebral aneurysms are significantly associated with non-oculomotor CN palsies. Endovascular procedures yield higher recovery rates than conservative management, particularly in ruptured aneurysms. Timely and appropriate treatment is crucial for improving nerve function recovery in these patients.

Endovascular thrombectomy for ischemic stroke with large infarct, short- and long-term outcomes: a meta-analysis of 6 randomised control trials.

Endovascular Thrombectomy (EVT) as first-line treatment of patients with large core ischemic infarct is a subject of debate. A systematic literature search was conducted in four electronic databases for randomized control trials (RCTs) comparing EVT to best medical treatment (BMT) for large core infarcts (ASPECTS ≤ 5). Relevant studies were added after screening for titles, abstracts, and complete text. Meta-analysis was performed. The continuous outcomes were analyzed using the standardized mean difference (SMD) and 95% CI, while the binary outcomes were analyzed using the risk ratio (RR) and 95% confidence interval (CI). A funnel plot was used to visually evaluate publication bias, and if feasible, Egger's test was used to validate. We included 1918 patients from six RCTs that compared EVT plus BMT and BMT alone in patients with large core infarct due to large vessel occlusion in the anterior circulation. There were 946 patients in the EVT group and 972 patients in the BMT group. The one-year outcomes are available for 314 patients in the EVT group and 292 patents in the BMT group from two RCTs. EVT group had statistically significant higher rate of 90-day mRS 0-1 (RR = 3.1, P-value < 0.0001), mRS 0-2 (RR = 2.64, P-value < 0.0001), mRS 0-3 (RR = 1.80, P-value < 0.0001), lower 90-day mean mRS score (SMD = -0.29, P-value < 0.0001), lower 90-day mortality rate (RR = 0.85, P-value = 0.015), and greater early neurological improvement (RR = 2.16, P-value < 0.00001) compared to the BMT group. However, the rates of symptomatic intracerebral hemorrhage (sICH) (RR = 1.76, P-value = 0.01) and any ICH (RR = 2.18, P-value < 0.00001) were higher in EVT group. Our finding showed that EVT plus BMT led to in an absolute improvement of 5%, 12%, and 16% in 90-day mRS 0-1, 0-2, and 0-3, respectively. In addition, patients in EVT plus BMT group had a 3% increased probability of experiencing sICH and were 32% more susceptible to any ICH. Moreover, the one-year mRS 0-2 (RR = 2.16, P-value < 0.00001) and mRS 0-3 (RR = 1.80, P-value < 0.0001) was significantly favor the EVT plus BMT over BMT alone. Although, the one-year mortality rate was not significantly differed between two groups (RR = 0.91, P-value = 0.31). There was no statistically significant difference observed between the EVT plus BMT group and the BMT group concerning new stroke, decompressive craniectomy, and serious adverse events. Combined data from six RCTs shows that EVT plus BMT provides significantly better short- and long-term functional outcomes with minimal increase in symptomatic hemorrhage over BMT in patient with large core infarcts.

An Adult Case of Medulloblastoma with Multiple Lung Metastatic Lesions-Case Report and Literature Review.

Medulloblastoma (MB) cerebelli is a common brain tumor of the childhood. MB commonly spreads through cerebrospinal fluid; however, there are several reported cases of extracranial spread. The most common sites of extracranial metastasis are bones and bone marrow followed by peritoneum, liver, and lungs. Here, we report a case of pulmonary metastatic lesions of adult cerebellar MB that were discovered 1 year after the primary surgical treatment. We also tried to highlight similar reported cases in the literature.

Subtemporal Approach for the Treatment of Ruptured and Unruptured Distal Basilar Artery Aneurysms: Is There a Contemporary Use?

BACKGROUND AND OBJECTIVES: Distal basilar artery aneurysms (DBAs) are high-risk lesions for which endovascular treatment is preferred because of their deep location, yet indications for open clipping nonetheless remain. The subtemporal approach allows for early proximal control and direct visualization of critical posterior perforating arteries, especially for posterior-projecting aneurysms. Our objective was to describe our clinical experience with the subtemporal approach for clipping DBAs in the evolving endovascular era. METHODS: This was a retrospective, single-institution case series of patients with DBAs treated with microsurgery over a 21-year period (2002-2023). Demographic, clinical, and surgical data were collected for analysis. RESULTS: Twenty-seven patients underwent clipping of 11 ruptured and 16 unruptured DBAs with a subtemporal approach (24 female; mean age 53 years). Ten patients had expanded craniotomies for treatment of additional aneurysms. The aneurysm occlusion rate was 100%. Good neurological outcomes as defined by the modified Rankin Scale score ≤2 and Glasgow Outcome Scale score ≥4 were achieved in 21/27 patients (78%). Two patients died before hospital discharge, one from vasospasm-induced strokes and another from an intraoperative myocardial infarction. CONCLUSION: These results demonstrate that microsurgical clip ligation of DBAs using the subtemporal approach remains a viable option for complex lesions not amenable to endovascular management.

Venous sinus stenting for idiopathic intracranial hypertension: An updated Meta-analysis.

BACKGROUND: Idiopathic intracranial hypertension (IIH) is characterized by elevated intracranial pressure and primarily affects obese women of reproductive age. Venous sinus stenting (VSS) is a surgical procedure used to treat IIH, but its safety and efficacy are still controversial. METHODS: A systematic review and meta-analysis were conducted following PRISMA guidelines. Multiple databases were searched for studies evaluating the safety and efficacy of VSS in IIH patients and meta-analysis was performed to pool the data. RESULTS: A total of 36 studies involving 1066 patients who underwent VSS were included. After VSS, a significant reduction in trans-stenotic gradient pressure was observed. Patients also showed significantly lower cerebrospinal fluid (CSF) opening pressure. Clinical outcomes demonstrated improvement in tinnitus (95%), papilledema (89%), visual disturbances (88%), and headache (79%). However, 13.7% of patients experienced treatment failure or complications. The treatment failure rate was 8.35%, characterized by worsening symptoms and recurrence of IIH. The complications rate was 5.35%, including subdural hemorrhage, urinary tract infection, stent thrombus formation, and others. CONCLUSION: VSS appears to be a safe and effective treatment option for IIH patients who are unresponsive to medical therapy or have significant visual symptoms. However, long-term outcomes and safety of the procedure require further investigation.

Ossifying fibroma of the ethmoid and sphenoid sinuses: A report of a rare case and literature review.

Background: Fibro-osseous lesions include a variety of bone lesions with different clinical and histopathological features. Case Description: We report a case of cemento-ossifying lesion involving the left ethmoid and sphenoid sinus in a 17-year-old male patient. Computed tomography showed an expansile hyperdense lesion with sclerosed peripheral mantle epicentered on the left ethmoid and sphenoid sinus and extending into the left nasal cavity. Magnetic resonance imaging was done for preoperative planning. Transnasal endoscopic resection was performed and histopathological examination confirmed the diagnosis of ossifying fibroma (OF). Conclusion: Involvement of the ethmoid sinus with OF is a rare condition; therefore, we examined the literature for similar cases to highlight the possible clinical presentation and management. Endoscopic management is a safe, effective approach with a low rate of complications.

Tension pneumocephalus as a complication of surgical evacuation of chronic subdural hematoma: case report and literature review.

The management of symptomatic chronic subdural hematoma (CSDH) is surgical evacuation and prognosis in most cases is good. Tension pneumocephalus is the presence of air under pressure in the intracranial cavity. A case of tension pneumocephalus developing as a complication of burr hole evacuation of CSDH is illustrated. In this case, tension pneumocephalus was managed by reopening the wound and saline irrigation with a subdural drain placement. Considering this case report and after a careful review of the literature, the physiopathology, diagnosis, and treatment of this complication are highlighted in the article.

Neurosurgical intervention in an unusual case of extensive acute disseminated encephalomyelitis - A case report and literature review.

Background: The clinical presentations of demyelinating diseases are variable and can range from mild symptoms to fulminant presentations. Acute disseminated encephalomyelitis is one of those diseases which usually follow an infection or vaccination. Case Description: We report a case of extensive acute demyelinating encephalomyelitis (ADEM) with massive brain swelling. A 45-year-old female presented to the emergency room with status epilepticus. Patient has no history of any associated medical problems. Glasgow coma scale (GCS) was 15/15. CT brain was normal. Lumbar puncture was done and cerebrospinal fluid showed pleocytosis and increased protein content. About 2 days after admission, the conscious level rapidly deteriorated and GCS was 3/15, with the right pupil fully dilated and unreactive to light. Computed tomography and magnetic resonance imaging brain were done. We performed an urgent decompressive craniectomy as a life-saving procedure. Histopathological examination was suggestive of ADEM. Conclusion: Few cases of ADEM with brain swelling were reported, but there is no solid consensus about the appropriate management of these cases. Decompressive hemicraniectomy is a possible choice, but further research is needed to evaluate the proper timing, and indication of surgery.

Expression of Anaplastic Lymphoma Kinase (ALK) in glioma and possible clinical correlations. A retrospective institutional study.

BACKGROUND: Glioblastoma is considered the most aggressive primary brain tumor. Recurrence after treatment is a significant problem with a failed response to optimal treatment. The recurrence of GBM is linked to different cellular and molecular pathways. Nationwide, in Egypt, astrocytic tumors are the most commonly diagnosed CNS tumor. Anaplastic Lymphoma Kinase (ALK CD246) is an enzymatic protein (RTK) belonging to the insulin receptors superfamily. METHODS: This is a retrospective study including sixty cases of astrocytic tumors (males = 40, mean age = 31.5), (females = 20, mean age = 37.77) obtained through collecting archived paraffin blocks of astrocytic tumor from the Pathology Department, Cairo University Faculty of Medicine during the period from January 2015 till January 2019. All cases were evaluated for ALK expression trying to find any clinical correlations with the clinical data. RESULTS: Correlations were made using a scatterplot matrix correlogram. There was a significant correlation between tumor recurrence and ALK expression (r = 0.8, P < 0.01), and incidence of postoperative seizures (r = 0.8, P < 0.05), and between mean age and score tumor (r = 0.8, P < 0.05). CONCLUSION: Expression of ALK was found to be abundant among high-grade gliomas and tumor recurrence rate was higher in ALK-positive patients. Further studies are needed to evaluate the potential use of ALK as a prognostic marker in cases of GBM.

Medical Management of Meningiomas.

Meningiomas represent the most common type of benign tumor of the extra-axial compartment. Although most meningiomas are benign World Health Organization (WHO) grade 1 lesions, the increasingly prevalent of WHO grade 2 lesion and occasional grade 3 lesions show worsened recurrence rates and morbidity. Multiple medical treatments have been evaluated but show limited efficacy. We review the status of medical management in meningiomas, highlighting successes and failures of various treatment options. We also explore newer studies evaluating the use of immunotherapy in management.

Spontaneous acute subdural hematoma as a complication of preeclampsia. A case report and literature review.

Background: Acute subdural hematoma (ASDH) is a common form of intracranial bleeding that may be fatal. Trauma is a major cause, while a subset of cases may occur spontaneously. The authors of this article present a case of spontaneous ASDH in the context of preeclampsia and review similar cases in the literature to identify the prognosis. Case Description: A healthy 27-year-old woman presented in her first pregnancy which was complicated with pregnancy-induced hypertension and was sent to a provincial local maternity hospital at 37 weeks of gestation. On day 4 postpartum, the patient complained of severe headache, vomiting and blurred vision. Fundus examination showed papilledema and magnetic resonance imaging showed right acute frontoparietal subdural hematoma. The hematoma was surgically evacuated with decompressive craniotomy. Postoperatively, the patient's symptoms improved. Conclusion: Spontaneous ASDH is a rare event in the context of preeclampsia; however, it should be considered as one of its possible complications. Research should be directed to emphasize on the possibility of spontaneous ASDH as a cause of neurological deterioration in those cases. A proper diagnosis and early intervention for these cases are crucial for both the mother and the fetus.

Recurrent meningioma: When to intervene.

Meningioma occurs most frequently as a benign tumor central nervous system that is common in old females. Radiation exposure and deletion of the NF2 gene are known risk factors. However, there is no consensus about the role of sex hormones. Meningiomas are usually benign tumors, but 6% can be anaplastic or atypical. Most asymptomatic patients do not require treatment, but complete surgical resection is recommended for symptomatic patients. If a tumor returns after being resected previously, it is recommended to be resected, followed by radiotherapy in some cases. Meningiomas (benign, atypical, and malignant) recurring after standard treatment fails could be treated with hormone therapy, chemotherapy, target therapy, and calcium channel blockers.

Systematic Review of Treatment Options and Therapeutic Responses for Lesions of the Sella and Orbit: Evidence-Based Recommendations.

OBJECTIVE: Inflammatory pathologies of the sella and orbit are rare but require prompt diagnosis to initiate effective treatment. Because uniform recommendations for treatment are currently lacking, we performed an evidence-based review to identify recommendations. METHODS: We performed a literature search of the PubMed, Embase, and Web of Science databases to identify papers evaluating treatment of inflammatory pathologies of the sella and orbit. We used PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines to define recommendations, specifically examining aggregated sample sizes, disease-specific patient follow-up, and clinical trials focused on inflammatory diseases of the sella and orbit. RESULTS: A total of 169 studies were included and organized by disease pathology. Treatments for various pathologies were recorded. Treatment options included surgery, radiation, steroids, targeted treatments, immunomodulators, intravenous immune globulin, and plasmapheresis. Steroids were the most often employed treatment, second-line management options and timing varied. Pathological diagnosis was highly associated with treatment used. Most evidence were level 3 without available control groups, except for 13 trials in neuromyelitis optica with level 1 or 2 evidence. CONCLUSIONS: This is the first evidence-based review to provide recommendations on specific treatments for pathologies of the orbit and sella. The reported data may be useful to help guide randomized clinical trials and provide resource for clinical management decisions based on the available evidence.

Traumatic Optic Neuropathy: Update on Management.

Traumatic optic neuropathy is one of the causes of visual loss caused by blunt or penetrating head trauma and is classified as both direct and indirect. Clinical history and examination findings usually allow for the diagnosis of traumatic optic neuropathy. There is still controversy surrounding the management of traumatic optic neuropathy; some physicians advocate observation alone, while others recommend steroid therapy, surgery, or both. In this entry, we tried to highlight traumatic optic neuropathy's main pathophysiologic mechanisms with the most available updated treatment. Recent research suggests future therapies that may be helpful in traumatic optic neuropathy cases.

Carotid endarterectomy versus carotid stenting for asymptomatic carotid stenosis: Evaluating the overlapping meta-analyses of randomized controlled trials.

Background: Asymptomatic carotid stenosis is associated with increased risk of ischemic stroke. The management of asymptomatic carotid stenosis ranges from open surgical approaches, minimally invasive endovascular interventions, and medical therapeutics. However, the research synthesis comparing these interventions, as shown by the scattered and overlapping published meta-analysis, has been inconsistent and non-comprehensive. Methods: Using previously-employed methods, we searched for and compared published meta-analyses comparing carotid endarterectomy and carotid stenting. A comprehensive search was conducted for all relevant studies published until November 13th, 2021, using the following databases: PubMed/MEDLINE, Scopus, Web of Science, Cochrane Library, OVID, and Google Scholar. Results: Five meta-analysis studies were included in this review. In summary, clinical findings were: carotid endarterectomy reduced the rate of ischemic stroke and stroke-related mortality, but led to a higher rate of intraoperative cranial nerve injury. There was no significant difference between carotid endarterectomy and carotid stenting in ipsilateral stroke and myocardial infarction events. Conclusions: The clinical findings favor the carotid endarterectomy over the carotid stenting in terms of stroke incidence (overall and minor events) and stroke-related mortality rates. However, the carotid stenting was superior to the carotid endarterectomy in the events of cranial nerve injury during the intervention.

Factors associated with hearing outcomes after a middle fossa approach in 131 consecutive patients with vestibular schwannomas.

OBJECTIVE: The middle fossa approach is an effective option for the treatment of small (Koos grade I and II) vestibular schwannomas (VSs) when the goal is hearing preservation. The authors evaluated the rates of hearing preservation and examined the factors associated with improved hearing outcomes after the middle fossa approach for VSs. METHODS: In this retrospective, single-center cohort study evaluating the clinical outcomes after resection of small VSs using the middle fossa approach, consecutive adult patients (> 18 years) who underwent surgery between January 2000 and December 2021 were included. Clinical and imaging characteristics were analyzed, including baseline hearing status, duration of surgery, anesthetic parameters, and imaging characteristics of the surgically treated tumors. RESULTS: Among the 131 included patients, 102 had valid and discoverable pre- and postoperative audiology assessments. The mean follow-up was 26 months (range 1-180 months). There were 85 patients with serviceable hearing preoperatively, defined as American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) class A or B, of whom 78% retained class A or B hearing at the last follow-up. Binary logistic regression demonstrated that preoperative hearing AAO-HNS class (OR 0.19, 95% CI 0.05-0.77; p = 0.02), overlap between fundus and cochlea (OR 0.32, 95% CI 0.11-0.96; p = 0.04), and duration of anesthesia (OR 0.98, 95% CI 0.97-0.99; p = 0.03) were independent predictors of hearing outcomes. Additionally, 75% of patients with high diffusion-weighted imaging signal in the tumor (p = 0.009) and 67% of patients with the tumor originating at the modiolus of the cochlea (p = 0.004) had poor hearing outcomes. CONCLUSIONS: The hearing preservation rates after microsurgical resection of small VSs using the middle fossa approach are high, with 78% of patients maintaining AAO-HNS class A or B hearing. Poor hearing status at baseline, longer duration of anesthesia, and large overlap between the fundus of the internal auditory canal and the cochlea were independently associated with unfavorable hearing outcomes. Imaging characteristics can be used to stratify patients' risk of hearing loss.

Evaluating pituitary adenomas using national research databases: systematic review of the quality of reporting based on the STROBE scale.

The use of national research databases has become more prevalent for studying various neurosurgical diseases. Despite the advantages of using large databases to glean clinical insight, variation remains in the methodology and reporting among studies. Using STROBE and RECORD guidelines, we evaluated the quality of reporting of the database literature investigating surgical management of benign pituitary adenomas. In this systematic review of the PubMed/MEDLINE database, we identified studies employing large national research databases of patients who underwent surgery for benign pituitary adenoma. We evaluated each of these studies using the STROBE-RECORD reporting guideline criteria to assess their quality. A total of 42 studies from 2003 to 2020 were identified for inclusion. The two raters demonstrated a κ = 0.228 with 84% overall agreement. Commonly underreported criteria included bias (discussed in 56% of studies), main result reporting (70%), subgroup analysis (69%), generalizability (68%), and funding (57%). These factors, in addition to the data sources/measurement criteria, also had the largest discrepancies between reviewers. About 20% of administrative database reviews did not accurately address bias or control for confounding variables. We found frequent underreporting of crucial information and criteria that can be challenging to identify may limit large database studies of pituitary adenomas. Improved reporting of certain criteria is critical to optimize reader understanding of large database studies. This would allow better dissemination and implementation of study findings, especially as the use of these research tools increases.

UPDATE ON MANAGEMENT OF DURAL ARTERIOVENOUS FISTULAS.

Dural Arteriovenous Fistulas (AVF) represent about 10% of all intracranial vascular lesions. Although they seem benign in nature, the presence of retrograde venous makes them aggressive, with a high risk of complications. Patients may be clinically asymptomatic or experience symptoms ranging from mild to severe hemorrhage, depending on their location. Different treatments are available, but recently, the development of catheter intervention allows most patients to be cured with transcatheter embolization. Stereotactic radiosurgery achieves excellent rates of obliteration for low-grade lesions. In this review, we try to highlight the recent advances in the management of dural AVF.