Spinal Epidural Atypical Meningioma: Case Report and Review of the Literature.

Spinal atypical meningiomas are rare, and those whose main extension is in the epidural space are anecdotal. Here, we report a case of a young woman presenting with sensory disturbances and a radiological diagnosis of a dorsal epidural sleeve-like mass. The surgical resection of the lesion allowed the decompression of the spinal cord and led to the histopathological diagnosis of atypical meningioma. At the 3-month follow-up, her neurological recovery was complete. Because of the gross total removal of the lesion, adjuvant radiotherapy was not performed: At the 2-year follow-up, no recurrence of disease was detected. A comprehensive literature review was performed, and just two more case reports on epidural atypical meningiomas were found in the English literature. Through this case report and literature review, we described a rare manifestation of spinal meningioma that entered into a differential diagnosis for extradural spinal lesions, such as secondary malignancies.

Comparison between rupture/growth risk scores and treatment recommendation scores application to aneurysmal subarachnoid hemorrhage patients: A multicenter cross-reliability assessment study.

BACKGROUND: Two score families were introduced to help clinicians about the decision-making regarding intracranial aneurysms management. The first family estimates the growth/rupture risk (GRS), whereas the second provides straightforward recommendation (RS) for treatment decisions. However, both remain poorly validated and little is known about their agreement. In this paper, we performed a retrospective concordance analysis among the two scores families through their application to a multicenter cohort of SAH patients. METHODS: Demographical, clinical and radiological data were extracted in conformance with the variables included in PHASES, UCAS, ELAPSS, Juvela's growth score (JGS), UIATS and Juvela's treatment score (JTS). Individual patients' score were calculated for both score families, and pooled data were then analyzed. RESULTS: Overall, 146 patients were included. True positive rates were: 51.4% for PHASES; 71.9% for UCAS; between 60.3% and 90.4% for JTS; and between 27.4% and 68.5% for UIATS. In patients showing UIATS unclear recommendation and low JTS score (RS), UCAS outperformed PHASES (GRS) in identifying aneurysms at higher risk of rupture. Same results we found for patients with conservative UIATS recommendation and very low JTS score. Forty-to-sixty percent of aneurysms with unclear or conservative RS recommendation would have been identified as at high risk with GRS. CONCLUSIONS: Retrospectively applied, JTS appeared outperforming UIATS in correctly recommending treatment in a higher percentage of patients. UIATS and JTS appeared agreeing more with UCAS than PHASES predictions. Around 50% of patients with unclear or conservative UIATS/JTS recommendations were been classified as at higher growth risk by ELAPSS and JGS.

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.

Retrospective Application of UIATS Recommendations to a Multicenter Cohort of Ruptured Intracranial Aneurysms: How It Would Have Oriented the Treatment Choices?

BACKGROUND: Decisions to treat unruptured intracranial aneurysms remain challenging, as the risk of rupture needs to be balanced with risk of intervention. In 2015, the Unruptured Intracranial Aneurysm Treatment Score (UIATS) was introduced to assist physicians in the decision making process. As its reliability is still debated, we retrospectively applied UIATS to a multicenter cohort of aneurysmal subarachnoid hemorrhage patients to test its performance in suggesting treatment in patients with known natural history. METHODS: Demographical, clinical, and radiological data of subarachnoid patients admitted in 2 referral cerebrovascular centers were collected. UIATS was individually calculated for each patient, and resulting recommendations were pooled in 3 groups (favor treatment, favor conservative management, unclear indication). RESULTS: One-hundred and forty-six patients were included in this study. In the event of aneurysm discovery previous to their rupture, UIATS calculation revealed that 40 (27.4%) patients would have received an indication-to-treat advice (mean score: 4.58 ± 1.32), 46 (31.5%) would have been suggested a conservative management (mean score: -7.07 ± 4.15), and 60 (41.1%) would have been included in an unclear recommendation group (mean score: 0.07 ± 1.42). UIATS sensitivity ranged between 27% and 68% depending on the inclusion of patients with unclear indication within the conservative or intervention group. CONCLUSIONS: In our study, UIATS would have failed to provide a clear recommendation to treat in up to 72.6% of patients whose aneurysm eventually ruptured. In agreement with previous reports, we provide additional evidence that some unruptured intracranial aneurysms may elude UIATS sensitivity. Further long-term prospective studies are necessary to assess UIATS reliability in real-world clinical practice.

Combined Use of Color Doppler Ultrasound and Contrast-Enhanced Ultrasound in the Intraoperative Armamentarium for Arteriovenous Malformation Surgery.

BACKGROUND: Safety and efficacy in surgical treatment of cerebral arteriovenous malformations (AVMs) are dictated by thorough understanding of angioarchitectural features, intraoperative identification of feeding vessels, and appreciation of surrounding eloquent areas. Our aim was to describe the preliminary results of combined application of color Doppler ultrasound (CDUS) and contrast-enhanced ultrasound (CEUS) in a consecutive surgical series of AVM. We pointed out the tool's efficacy in distinguishing feeding from bystander vessels and in identifying pattern of venous drainage. We examined its role as an adjunct for semiquantitative evaluation of the nidus inflow. METHODS: We used combined CDUS and CEUS in patients surgically treated for cerebral AVMs. We adopted these techniques following a designed protocol to guide safer AVM resection as an adjunct to indocyanine green videoangiography. Intraoperative assessment by ultrasound was performed before, during, and following nidus resection. RESULTS: Four surgically treated cerebral AVMs availed of the ultrasound protocol. Postoperative conventional angiography showed complete resection of the AVMs. CDUS and CEUS proved to be valuable adjunctive tools to indocyanine green videoangiography and micro-Doppler in properly navigating and discerning vascular structures, especially vessel feeders from bystanders. The protocol allows us to identify flow direction, estimate blood velocity within the nidus, and appreciate flow modifications following temporary clipping. Ultimately, it allows us to evaluate the degree of nidus deafferentation, residual flow, restoration of venous drainage and absence of arteriovenous shunts. CONCLUSIONS: The CDUS and CEUS protocol is safe and repeatable and works as real-time imaging, further supporting complete surgical resection of AVMs.

Comparison Between Minipterional Craniotomy Associated With Focused Sylvian Fissure Opening and Standard Pterional Approach With Extended Sylvian Fissure Dissection for Treatment of Unruptured Middle Cerebral Artery Aneurysms.

BACKGROUND: In our institution, standard pterional craniotomy (PC) with an extended Sylvian fissure opening (ESFO) represented the standard approach for unruptured middle cerebral artery (MCA) aneurysm clipping until 2014, when we progressively started to prefer minipterional craniotomy (MPC) associated with a focused Sylvian fissure opening (FSFO). In the present study, we compared our results in terms of the efficacy of clipping and the rate of complications with these 2 different techniques. METHODS: We included patients with small- and medium-size unruptured MCA aneurysms from January 2008 to December 2018 with follow-up of >12 months. The clinical and radiologic data were reviewed from the medical records. The outcomes were measured in terms of efficacy (aneurysmal exclusion rate) and safety (intracranial complication rate). RESULTS: Overall, 134 patients who had presented with unruptured MCA aneurysms <1.5 cm were treated at our institution from January 2007 to December 2018: PC and ESFO were used in 73 patients and MPC and FSFO in 61. The demographics and angioarchitectural features were comparable between the 2 groups, except for age, which was older in the FSFO group. The aneurysm exclusion rate was not different between the 2 groups. The intracranial complication rate was, overall, significantly lower in the FSFO group (P < 0.001), especially for the rate of postoperative seizures. Finally, the FSFO group had had shorter postoperative hospitalization and better short- and long-term clinical outcomes. CONCLUSIONS: The association between MPC and FSFO should represent the standard of treatment of unruptured MCA aneurysms in all referral cerebrovascular centers, allowing for the achievement of the same efficacy of standard PC with ESFO and minimizing the complications.

Reliability and quality of online patient education videos for lateral lumbar interbody fusion.

OBJECTIVE: There is an increasing trend among patients and their families to seek medical knowledge on the internet. Patients undergoing surgical interventions, including lateral lumbar interbody fusion (LLIF), often rely on online videos as a first source of knowledge to familiarize themselves with the procedure. In this study the authors sought to investigate the reliability and quality of LLIF-related online videos. METHODS: In December 2018, the authors searched the YouTube platform using 3 search terms: lateral lumbar interbody fusion, LLIF surgery, and LLIF. The relevance-based ranking search option was used, and results from the first 3 pages were investigated. Only videos from universities, hospitals, and academic associations were included for final evaluation. By means of the DISCERN instrument, a validated measure of reliability and quality for online patient education resources, 3 authors of the present study independently evaluated the quality of information. RESULTS: In total, 296 videos were identified by using the 3 search terms. Ten videos met inclusion criteria and were further evaluated. The average (± SD) DISCERN video quality assessment score for these 10 videos was 3.42 ± 0.16. Two videos (20%) had an average score above 4, corresponding to a high-quality source of information. Of the remaining 8 videos, 6 (60%) scored moderately, in the range of 3-4, indicating that the publication is reliable but important information is missing. The final 2 videos (20%) had a low average score (2 or below), indicating that they are unlikely to be of any benefit and should not be used. Videos with intraoperative clips were significantly more popular, as indicated by the numbers of likes and views (p = 0.01). There was no correlation between video popularity and DISCERN score (p = 0.104). In August 2019, the total number of views for the 10 videos in the final analysis was 537,785. CONCLUSIONS: The findings of this study demonstrate that patients who seek to access information about LLIF by using the YouTube platform will be presented with an overall moderate quality of educational content on this procedure. Moreover, compared with videos that provide patient information on treatments used in other medical fields, videos providing information on LLIF surgery are still exiguous. In view of the increasing trend to seek medical knowledge on the YouTube platform, and in order to support and optimize patient education on LLIF surgery, the authors encourage academic neurosurgery institutions in the United States and worldwide to implement the release of reliable video educational content.

Medical Student Interest and Recruitment in Neurosurgery.

OBJECTIVE: Recent years have witnessed an increase in articles describing factors influencing medical student recruitment in neurosurgery, such as undergraduate preparation, impact of research experience, and selection into residency programs. In this study, we provide a comprehensive review of the literature addressing the relationship of medical students within neurosurgery. METHODS: A search of the literature was conducted on the PubMed/MEDLINE database to October 2018 to screen for studies on medical student interest and recruitment in neurosurgery. Articles were screened for eligibility and reviewed for inclusion and their findings critically discussed. RESULTS: Sixty-nine articles were included. Most research on the relationship of medical students with neurosurgery was conducted in the United States and United Kingdom. Data analysis was categorized into 2 groups: educational and noneducational factors. Eight areas of interest were identified: baseline undergraduate education, early research involvement, attitude toward neuroscience, mentoring, existence of a gender gap, residency program requirements, availability of educational resources, and networking opportunities. CONCLUSIONS: Our study bridges the gap of fragmented knowledge on medical student involvement in neurosurgery with the aim of optimizing existing approaches. We suggest that medical institutions outside the United States and United Kingdom should implement university-based interest groups to stimulate student interest, with reinforced participation of faculty for leading educational initiatives and collaborative research. We advocate the creation of national and international associations to support medical students in approaching neurosurgery early in their education.