Complex intracranial aneurysms: a DELPHI study to define associated characteristics.

PURPOSE: Intracranial aneurysms present significant health risks, as their rupture leads to subarachnoid haemorrhage, which in turn has high morbidity and mortality rates. There are several elements affecting the complexity of an intracranial aneurysm. However, criteria for defining a complex intracranial aneurysm (CIA) in open surgery and endovascular treatment could differ, and actually there is no consensus on the definition of a "complex" aneurysm. This DELPHI study aims to assess consensus on variables defining a CIA. METHODS: An international panel of 50 members, representing various specialties, was recruited to define CIAs through a three-round Delphi process. The panelists participated in surveys with Likert scale responses and open-ended questions. Consensus criteria were established to determine CIA variables, and statistical analysis evaluated consensus and stability. RESULTS: In open surgery, CIAs were defined by fusiform or blister-like shape, dissecting aetiology, giant size (≥ 25 mm), broad neck encasing parent arteries, extensive neck surface, wall calcification, intraluminal thrombus, collateral branch from the sac, location (AICA, SCA, basilar), vasospasm context, and planned bypass (EC-IC or IC-IC). For endovascular treatment, CIAs included giant size, very wide neck (dome/neck ratio ≤ 1:1), and collateral branch from the sac. CONCLUSIONS: The definition of aneurysm complexity varies by treatment modality. Since elements related to complexity differ between open surgery and endovascular treatment, these consensus criteria of CIAs could even guide in selecting the best treatment approach.

Revitalizing neurosurgical frontiers: The EANS frontiers in neurosurgery committee's strategic framework.

Introduction: The field of neurosurgery faces challenges with the increasing involvement of other medical specialties in areas traditionally led by neurosurgeons. This paper examines the implications of this development for neurosurgical practice and patient care, with a focus on specialized areas like pain management, peripheral nerve surgery, and stereotactic radiosurgery. Research question: To assess the implications of the expanded scope of other specialties for neurosurgical practice and to consider the response of the EANS Frontiers in Neurosurgery Committee to these challenges. Materials and methods: Analysis of recent trends in neurosurgery, including the shift in various procedures to other specialties, demographic challenges, and the emergence of minimally invasive techniques. This analysis draws on relevant literature and the initiatives of the Frontiers in Neurosurgery Committee. Results: We explore a possible decrease in neurosurgical involvement in certain areas, which may have implications for patient care and access to specialized neurosurgical interventions. The Frontiers in Neurosurgery Committee's role in addressing these concerns is highlighted, particularly in terms of training, education, research, and networking for neurosurgeons, especially those early in their careers. Discussion and conclusion: The potential decrease in neurosurgical involvement in certain specialties warrants attention. This paper emphasizes the importance of carefully considered responses by neurosurgical societies, such as the EANS, to ensure neurosurgeons continue to play a vital role in managing neurological diseases. Emphasis on ongoing education, integration of minimally invasive techniques, and multidisciplinary collaboration is essential for maintaining the field's competence and quality in patient care.

Endovascular neurosurgery in Europe: an International Survey and future perspectives.

BACKGROUND: Recent advancements in neurosurgery have transformed patient care through minimally invasive procedures and led to a notable surge in endovascular treatments. However, the regulatory landscape governing these procedures across European countries varies, impacting treatment access and collaboration. This paper discusses the results of a survey on European legislation regarding endovascular neurosurgery, exploring current practices and speculating on the field's future. METHODS: An e-mail survey was distributed to 41 European countries, targeting European member societies within the EANS. Thirty-seven completed questionnaires were returned, providing insights into neuroendovascular treatment legislation and restrictions. RESULTS: Legislation and certification varied across the surveyed countries, with only two countries prohibiting endovascular neurosurgery. Eight countries required specific fellowship programs. Resistance from radiologists was noted in many countries. CONCLUSIONS: Despite growing support for neurosurgeons performing endovascular treatments in Europe, challenges persist. Specialized care, improved access, and a broadening spectrum of treatable conditions contribute to the argument for involvement of neurosurgeons.

Frequency of brain ventricular enlargement among patients with diabetes mellitus.

AIMS: To determine the prevalence of dilated ventricles and concomitant high blood glucose measures. METHODS: We retrieved blood glucose measures from the emergency department database and selected a subgroup of individuals having both the radiological marker Evans' index (EI) values and blood glucose measures. RESULTS: Out of 1221 consecutive patients submitted to axial Computed Tomography scans, a blood glucose measure was detected in 841 individuals. 176 scans (21 %) showed an EI > 0.30. According to the blood glucose categorization, diabetic patients were 104 (12 %), 25 of them (24 %) were dilated (mean EI 0.33). The age difference between dilated and not-dilated ventricles is about ten years in not-diabetic participants, whereas it is five years in diabetic participants. The age difference between dilated and not-dilated ventricles is about 10 years in diabetic men, whereas it zero in diabetic women. CONCLUSIONS: Pathological ventricular enlargement is more frequent in men and in the elderly. In diabetic patients (especially women), the cerebral ventricles enlarge faster than in non-diabetic individuals. Age, sex, and diabetes may interact in determining how cerebral ventricle size changes over time, especially in diabetic women, making routine brain imaging advisable in these patients after the age of 70 years.

Antithrombotic regimen in emergent carotid stenting for acute ischemic stroke due to tandem occlusion: a meta-analysis of aggregate data.

BACKGROUND: The periprocedural antithrombotic regimen might affect the risk-benefit profile of emergent carotid artery stenting (eCAS) in patients with acute ischemic stroke (AIS) due to tandem lesions, especially after intravenous thrombolysis. We conducted a systematic review and meta-analysis to evaluate the safety and efficacy of antithrombotics following eCAS. METHODS: We followed PRISMA guidelines and searched MEDLINE, Embase, and Scopus from January 1, 2004 to November 30, 2022 for studies evaluating eCAS in tandem occlusion. The primary endpoint was 90-day good functional outcome. Secondary outcomes were symptomatic intracerebral hemorrhage, in-stent thrombosis, delayed stent thrombosis, and successful recanalization. Meta-analysis of proportions and meta-analysis of odds ratios were implemented. RESULTS: 34 studies with 1658 patients were included. We found that the use of no antiplatelets (noAPT), single antiplatelet (SAPT), dual antiplatelets (DAPT), or glycoprotein IIb/IIIa inhibitors (GPI) yielded similar rates of good functional outcomes, with a marginal benefit of GPI over SAPT (OR 1.88, 95% CI 1.05 to 3.35, Pheterogeneity=0.31). Sensitivity analysis and meta-regression excluded a significant impact of intravenous thrombolysis and Alberta Stroke Program Early CT Score (ASPECTS). We observed no increase in symptomatic intracerebral hemorrhage (sICH) with DAPT or GPI compared with noAPT or SAPT. We also found similar rates of delayed stent thrombosis across groups, with acute in-stent thrombosis showing marginal, non-significant benefits from GPI and DAPT over SAPT and noAPT. CONCLUSIONS: In AIS due to tandem occlusion, the periprocedural antithrombotic regimen of eCAS seems to have a marginal effect on good functional outcome. Overall, high intensity antithrombotic therapy may provide a marginal benefit on good functional outcome and carotid stent patency without a significant increase in risk of sICH.

Correlation between intravascular pressure gradients and ultrasound velocities in carotid artery stenosis: An exploratory study.

INTRODUCTION: Grading of carotid stenosis is routinely performed with non-invasive techniques, such as carotid ultrasound (CUS) and computerized tomography angiography (CTA), which have limitations in grading definition. Moreover, the actual hemodynamic impact of a stenosis remains poorly defined. Preliminary studies explored the application of the resting full-cycle ratio (RFR), measured with pressure wire (PW), but the correlation between RFR and morphological/hemodynamic parameters is still undefined. This study aims to test the correlation between RFR and CUS-CTA-DSA based degree of stenosis, to define the suitability of RFR as carotid stenosis index. METHODS: We included patients with symptomatic carotid stenosis receiving carotid artery stenting (CAS), between November 2022 and May 2023. We performed CUS and PW measurements before and after stenting, at four different sites (trans-lesion, distal cervical, petrous and supraclinoid internal carotid artery [ICA] segments). We compared CUS and PW parameters by Pearson's or Spearman test for continuous variables. RESULTS: Among 15 patients included the mean stenosis degree was 81.3%. Trans-lesion RFR was significantly higher than other sites (0.72 ± 0.2 trans-lesion vs. 0.69 ± 0.18 distal cervical ICA vs. 0.66 ± 0.2 petrous ICA vs. 0.6 ± 0.2 intracranial ICA, p < 0.05). All RFR values significantly increased after treatment; the highest relative increase was registered at stenosis site (0.72 ± 0.2 pre-stent vs. 1.01 ± 0.1 post-stent, p < 0.01). Trans-lesion RFR was significantly associated with the CTA and DSA stenosis degree and CUS measurements. CONCLUSIONS: Pressure wire in carotid artery stenosis seems safe and suitable. Resting full-cycle ratio has a significant correlation with CUS values and stenosis degree and might be used as carotid stenosis index during CAS.

Growth and rupture of an intracranial aneurysm: the role of wall aneurysmal enhancement and CD68.

Introduction: Intracranial aneurysms occur in 3%-5% of the general population. While the precise biological mechanisms underlying the formation, growth, and sudden rupture of intracranial aneurysms remain partially unknown, recent research has shed light on the potential role of inflammation in aneurysm development and rupture. In addition, there are ongoing investigations exploring the feasibility of employing new drug therapies for controlling the risk factors associated with aneurysms. CD68, a glycosylated glycoprotein and the human homolog of macrosialin, is prominently expressed in monocyte/macrophages within inflamed tissues and has shown potential application in oncology. An observational study was conducted with the aim of comparing the histological characteristics of aneurysm walls with preoperative MRI scans, specifically focusing on CD68 activity. Method: An observational pilot study was conducted to investigate the histological characteristics of the aneurysm wall that could be potentially associated with aneurysm growth and rupture. A total of 22 patients diagnosed with ruptured and unruptured intracranial aneurysms who had undergone conventional clipping between January 2017 and December 2022 were included in the study. Results: A histopathological analysis of the aneurysm wall was performed in all patients, particularly focusing on the presence of CD68. A preoperative MRI with gadolinium was conducted in 10 patients with unruptured aneurysms and six patients with ruptured aneurysms. An emergency clipping was performed in the remaining six patients. The results showed that CD68 positivity and wall enhancement were significantly associated with intracranial aneurysm wall degeneration, growth, and rupture. Conclusion: The histological and radiological inflammatory findings observed in the wall of cerebral aneurysms, as well as the CD68 positivity, are significantly associated with the risk of intracranial aneurysm growth and rupture. This study highlights the crucial importance of considering clinical and medical data when making treatment decisions for intracranial aneurysms. Furthermore, it emphasizes the relevance of evaluating wall enhancement in MRI scans as part of the diagnostic and prognostic process.

Social Media for Global Neurosurgery. Benefits and limitations of a groundbreaking approach to communication and education.

Introduction: Social media have become ubiquitous and their role in medicine is quickly growing. They provide an open platform by which members share educational material, clinical experiences, and collaborate with educational equity. Research question: To characterize the role of social media in neurosurgery, we analyzed metrics of the largest neurosurgical group (Neurosurgery Cocktail), collected relevant data about activities, impact and risks of this groundbreaking technology. Material and methods: We extracted Facebook metrics from 60-day time sample, including users demographics and other platform-specific values such as active members and number of posts within 60 days. A quality assessment of the posted material (clinical case reports and second opinions) was obtained establishing four main quality-criteria: privacy violation; quality of imaging; clinical and follow up data. Results: By December 2022, the group included 29.524 members (79.8% male), most (29%) between 35 and 44 years of age. Over 100 countries were represented. A total of 787 posts were published in 60 days with an average of 12.7 per day. In 173 clinical cases presented through the platform, some issue with privacy was recorded in 50.9%. The imaging was considered insufficient in 39.3%, clinical data in 53.8%; follow up data were missing in 60.7%. Discussion and conclusion: The study provided a quantitative evaluation of impact, flaws and limitations of social medial for healthcare. Flaws were mostly data breach and insufficient quality of case reports. There are actions to correct these flaws that can be easily taken to provide a greater credibility and efficacy to the system.

Neurophysiological monitoring during endovascular treatment of brain arteriovenous malformations: A meta-analysis.

BACKGROUND: Treatment of brain arteriovenous malformations (b-AVM) carries a risk of iatrogenic injury to eloquent brain regions. Intraoperative neuro-monitoring (IONM) has increasingly been used to monitor spontaneous or evoked neural activity during neurosurgery, but its use is not as well characterized in the endovascular treatment (EVT) of b-AVMs. We aimed to provide a systematic review and meta-analysis of studies reporting any neurological deficit after b-AVM embolization with IONM, with or without provocative test (PT), and no-IONM. METHODS: This systematic review followed the PRISMA guidelines. Medline, EMBASE, and Scopus were searched from conception until March 1, 2022 for studies evaluating EVT with IONM and PT. Primary outcome was the rate of postoperative neurological deficits in EVT with IONM versus no-IONM, while secondary outcome was the subanalysis of IONM with or without PT. Meta-analysis was performed using the Mantel-Haenszel method and random effects modeling. RESULTS: Six studies reached synthesis. Out of a total of 192 EVT, 14 events occurred. Results demonstrated a nonsignificant trend favoring IONM compared to no-IONM to prevent neurological deficits (OR 0.09, 95% CI 0-4.68). Among the EVT with IONM, PT was done in 411 branches with 10 events (0.2%) despite a negative PT. There was a nonsignificant trend favoring IONM plus PT compared to IONM without PT (OR 0.16, 95% CI 0.02-1.07). CONCLUSIONS: Our study suggests that b-AVM EVT with IONM plus PT might reduce rates of postprocedural neurological deficits compared with EVT without IONM. Further studies are needed to confirm these results.

Principles, techniques and applications of high resolution cone beam CT angiography in the neuroangio suite.

The aim of this review is to describe the acquisition and reformatting of state of the art high resolution cone beam CT (HR-CBCT) and demonstrate its role in multiple neurovascular conditions as a tool to improve the understanding of disease and guide therapeutic decisions. First, we will review the basic principle of CBCT acquisition, followed by the injection protocols and the reformatting paradigms. Next, multiple applications in different pathological conditions such as aneurysms, arteriovenous malformations, dural arteriovenous fistulas, and stroke will be described. HR-CBCT angiography, widely available, is uniquely useful in certain clinical scenarios to improve the understanding of disease and guide therapeutic decisions. It rapidly is becoming an essential tool for the contemporary neurointerventionalist.AChoAho.

Emergent carotid stenting versus no stenting for acute ischemic stroke due to tandem occlusion: a meta-analysis.

BACKGROUND: Emergent carotid artery stenting (eCAS) is performed during mechanical thrombectomy for acute ischemic stroke due to tandem occlusion. However, the optimal management strategy in this setting is still unclear. OBJECTIVE: To carry out a systematic review and meta-analysis to investigate the safety and efficacy of eCAS in patients with tandem occlusion. METHODS: Systematic review followed the PRISMA guidelines. Medline, EMBASE, and Scopus were searched from January 1, 2004 to March 7, 2022 for studies evaluating eCAS and no-stenting approach in patients with stroke with tandem occlusion. Primary endpoint was the 90-day modified Rankin Scale score 0-2; secondary outcomes were (1) symptomatic intracerebral hemorrhage (sICH), (2) recurrent stroke, (3) successful recanalization (Thrombolysis in Cerebral Infarction score 2b-3), (4) embolization in new territories, and (5) restenosis rate. Meta-analysis was performed using the Mantel-Haenszel method and random-effects modeling. RESULTS: Forty-six studies reached synthesis. eCAS was associated with higher good functional outcome compared with the no-stenting approach (OR=1.52, 95% CI 1.19 to 1.95), despite a significantly increased risk of sICH (OR=1.97, 95% CI 1.23 to 3.15), and higher successful recanalization rate (OR=1.91, 95% CI 1.29 to 2.85). Restenosis rate was lower in the eCAS group than in the no-stenting group (2% vs 9%, p=0.001). Recanalization rate was higher in retrograde than antegrade eCAS (OR=0.51, 95% CI 0.28 to 0.93). Intraprocedural antiplatelets during eCAS were associated with higher rate of good functional outcome (60% vs 46%, p=0.016) and lower rate of sICH (7% vs 11%; p=0.08) compared with glycoprotein IIb/IIIa inhibitors. CONCLUSIONS: In observational studies, eCAS seems to be associated with higher good functional outcome than no-stenting in patients with acute ischemic stroke due to tandem occlusion, despite the higher risk of sICH. Dedicated trials are needed to confirm these results.

Defining activities in neurovascular microsurgery training: entrustable professional activities for vascular neurosurgery.

BACKGROUND: Entrustable professional activities (EPAs) represent an assessment framework with an increased focus on competency-based assessment. Originally developed and adopted for undergraduate medical education, concerns over resident ability to practice effectively after graduation have led to its implementation in residency training but yet not in vascular neurosurgery. Subjective assessment of resident or fellow performance can be problematic, and thus, we aim to define core EPAs for neurosurgical vascular training. METHODS: We used a nominal group technique in a multistep interaction between a team of experienced neurovascular specialists and a medical educator to identify relevant EPAs. Panel members provided feedback on the EPAs until they reached consent. RESULTS: The process produced seven core procedural EPAs for vascular residency and fellowship training, non-complex aneurysm surgery, complex aneurysm surgery, bypass surgery, arteriovenous malformation resection, spinal dural fistula surgery, perioperative management, and clinical decision-making. CONCLUSION: These seven EPAs for vascular neurosurgical training may support and guide the neurosurgical society in the development and implementation of EPAs as an evaluation tool and incorporate entrustment decisions in their training programs.

The Central Cord Syndrome in Patients with Cervical Spinal Cord Tumors: A 19th-Century Vignette from (Karl) Julius Vogel (1814-1880).

Between 1830 and 1850, (Karl) Julius Vogel was one of the most important German pathologists. He received his doctorate in medicine in 1838 from the University of Munich and habilitation in pathology in 1840. In 1846, he moved to the University of Giessen as a full professor of pathology. From 1855, he taught special pathology and therapy at the University of Halle and became director of the internal clinic. Vogel and Heinrich Adolph Karl Dittmar were the first clinicians to describe the symptoms and pathologic findings of the central cord syndrome in a cervical spine tumor.

Flow Diverter Devices in the Treatment of Anterior Communicating Artery Region Aneurysms: Would the Regional Anatomy and the Aneurysm Location Affect the Outcomes?

BACKGROUND: In this study, the authors evaluated the efficacy and the safety of flow diverter devices (FDD) in anterior communicating artery (ACoA) region aneurysms, focusing on anatomical factors that could affect the outcome, such as the location of the aneurysm along the ACoA (centered on ACoA or decentered on the A1-A2 junction) and the anatomy of the ACoA region. METHODS: Clinical, procedural and follow-up data were analyzed. Aneurysms were classified according to the location along the ACoA (centered or decentered on the A1-A2 junction) and on the basis of the anatomical configuration of the ACoA region. Safety was assessed by recording intraprocedural, periprocedural and delayed complications to determine the morbidity and mortality rates. The functional outcome was evaluated with the modified Rankin scale (mRS) prior to and after the endovascular procedure. To assess the efficacy, midterm and long-term clinical, angiographic and cross-sectional imaging follow-ups were recorded. Subgroup analysis according to the different ACoA regional anatomical configurations and the ACoA aneurysm locations were performed. RESULTS: 33 patients (17 males; 16 females) with ACoA region aneurysms were treated with FDDs. 27 aneurysms were located at the A1-A2 junction (82%) while the remaining six aneurysms were centered on the ACoA. No mortality was recorded. The overall morbidity rate was 6% (2/33 procedures). Major complications occurred in 33% (2/6) of ACoA aneurysms and in the 0% of A1-A2 junction aneurysms. Mid-term and long-term neuroimaging follow-ups showed the occlusion of the aneurysm in 28/33 cases (85%). Complete occlusion rates were 93% in the A1-A2 junction aneurysms and 50% in ACoA aneurysms. CONCLUSIONS: The FDD is a safe and effective tool that can be used in the treatment of selected cases of ACoA region aneurysms. The location of the aneurysm along the ACoA and the regional anatomy of the ACoA complex could affect the efficacy and safety.

European Stroke Organisation (ESO) guidelines on management of unruptured intracranial aneurysms.

Unruptured intracranial aneurysms (UIA) occur in around 3% of the population. Important management questions concern if and how to perform preventive UIA occlusion; if, how and when to perform follow up imaging and non-interventional means to reduce the risk of rupture. Using the Standard Operational Procedure of ESO we prepared guidelines according to GRADE methodology. Since no completed randomised trials exist, we used interim analyses of trials, and meta-analyses of observational and case-control studies to provide recommendations to guide UIA management. All recommendations were based on very low evidence. We suggest preventive occlusion if the estimated 5-year rupture risk exceeds the risk of preventive treatment. In general, we cannot recommend endovascular over microsurgical treatment, but suggest flow diverting stents as option only when there are no other low-risk options for UIA repair. To detect UIA recurrence we suggest radiological follow up after occlusion. In patients who are initially observed, we suggest radiological monitoring to detect future UIA growth, smoking cessation, treatment of hypertension, but not treatment with statins or acetylsalicylic acid with the indication to reduce the risk of aneurysm rupture. Additionally, we formulated 15 expert-consensus statements. All experts suggest to assess UIA patients within a multidisciplinary setting (neurosurgery, neuroradiology and neurology) at centres consulting >100 UIA patients per year, to use a shared decision-making process based on the team recommendation and patient preferences, and to repair UIA only in centres performing the proposed treatment in >30 patients with (ruptured or unruptured) aneurysms per year per neurosurgeon or neurointerventionalist. These UIA guidelines provide contemporary recommendations and consensus statement on important aspects of UIA management until more robust data come available.

Cotinine levels influence the risk of rupture of brain aneurysms.

Cotinine, the primary metabolite of nicotine, is currently regarded as the best biomarker of tobacco smoke exposure. We aim to assess whether cotinine levels are associated with (1) intracranial aneurysm and (2) intracranial aneurysm rupture. METHODS: We performed a single-center case-control study. Cases were consecutive patients admitted with diagnosis of brain aneurysm (ruptured or unruptured). We randomly selected controls without intracranial aneurysm from the same source population that produced the cases. Smoking data were collected by questionnaire, and serum levels of cotinine were used as an objective measure of nicotine exposure. Logistic regression models were used to assess the relationship between cotinine levels and aneurysm rupture. RESULTS: We included 86 patients with intracranial aneurysm and 96 controls. Smoking status (p < .001), cotinine levels (p = .009), and female sex (p = .006) were associated with diagnosis of intracranial aneurysm. In the multivariate analysis, controlling for sex, smoker status and age, levels of cotinine were independently associated with aneurysm rupture (OR 1.53, 95% CI 1.10-2.13, p = .012). CONCLUSIONS: Our results suggest that high cotinine levels in smokers with brain aneurysm are significantly associated with high rupture risk, independently of smoker status, age, and sex.

Intrasaccular Flow Disruptor-Assisted Coiling of Intracranial Aneurysms Using the Novel Contour Neurovascular Systems and NEQSTENT: A Single-Center Safety and Feasibility Study.

Background: Intrasaccular flow disruptors (IFD) have been introduced in the treatment of intracranial aneurysms (IAs) to overcome the low aneurysm occlusion rate and the high recanalization rate of the coiling technique. Among them, the Contour Neurovascular System (CNS) and the Neqstent (NQS) were designed to reconstruct the aneurysmal neck and both can be used as assisting coiling devices. We aimed to report our preliminary experience with the flow disruptor-assisted coiling (IFD-AC) technique. Methods: We performed a retrospective analysis of prospectively collected data of all patients with IAs treated with the IFD-AC. Results: Between February 2021 and April 2022, we treated 15 IAs with the IFD-AC: 10 ruptured and 5 unruptured. The IFD-AC was successfully performed in 13 cases, with a post-operative RROC 1 in 12 cases (92.3%) and RROC 2 in 1 case (7.7%). There was one ischemic event (6.7%) and no hemorrhagic complications. Twelve patients underwent a mid-term radiologic follow-up: Ten IAs (83.4%) presented an adequate occlusion, while 2 (16.7%) had a recurrence. Conclusions: The IFD-AC, both with the CNS and the NQS, seems a safe technique with promising efficacy profile. The IFD-AC has proved to be safe without antiplatelet therapy in ruptured cases. Further studies are needed to confirm our preliminary results.

Temporal Horn Enlargements Predict Secondary Hydrocephalus Diagnosis Earlier than Evans' Index.

The aim of this study was to identify early radiological signs of secondary hydrocephalus. We retrieved neuroradiological data from scans performed at various times in patients who underwent surgery for secondary hydrocephalus due to severe traumatic brain injury (TBI), subarachnoid haemorrhage (SAH), or brain tumour (BT). Baseline measurements, performed on the earliest images acquired after the neurological event (T0), included Evans' index, the distance between frontal horns, and the widths of both temporal horns. The next neuroimage that showed an increase in at least one of these four parameters­and that lead the surgeon to act­was selected as an indication of ventricular enlargement (T1). Comparisons of T0 and T1 neuroimages showed increases in Evans' index, in the mean frontal horn distance, and in the mean right and left temporal horn widths. Interestingly, in T1 scans, mean Evans' index scores > 0.30 were only observed in patients with BT. However, the temporal horn widths increased up to ten-fold in most patients, independent of Evans' index scores. In conclusion temporal horn enlargements were the earliest, most sensitive findings in predicting ventricular enlargement secondary to TBI, SAH, or BT. To anticipate a secondary hydrocephalus radiological diagnosis, clinicians should measure both Evans' index and the temporal horn widths, to avoid severe disability and poor outcome related to temporal lobe damage.

Surgical Treatment of Single Pontomedullary Junction Metastasis from Lung Cancer.

Background: When lung cancer develops a solitary metastasis at the pontomedullary junction, due to surgical risk, the current oncologic treatment is radiosurgery and chemotherapy. Case Description. We describe a patient with a single intrinsic metastasis at the pons and medulla. Removal was successful, without complication. Conclusion: Surgery can provide excellent results, and in selected patients, it should be considered a first-line treatment in experienced hands.

Simulation and virtual reality in intracranial aneurysms neurosurgical training: a systematic review.

INTRODUCTION: The recent emphasis on simulation-based training in neurosurgery has led to the development of many simulation models and training courses. We aimed to identify the currently available simulators and training courses for neurovascular surgery and endovascular interventions to assess their validity and determine their effectiveness to suggest widespread applicability in educational curricula. EVIDENCE ACQUISITION: Literature research was performed on academic databases for English language articles that validate simulation or virtual reality intracranial aneurysm models. Studies for neurosurgery and interventional neuroradiology published between January 2011 and January 2021 were included. Each study was assessed according to the Medical Education Research Quality Instrument. EVIDENCE SYNTHESIS: Between January 2011 and January 2021, 44 articles were screened and 12 were identified to be included in our research. The study involved 177 trainers. Participant trainers' characteristics reveal sensible homogeneity between studies. All studies reported a significant improvement in technical outcomes after simulator or virtual reality training. The Medical Education Research Quality Instrument average rate from 12 studies was M=11.7 (range: 8.5-14.5). CONCLUSIONS: Nowadays, the training of a medical doctor in the neurovascular field benefits from modern methods like simulators and virtual reality. With the advent of increasing neurosurgery simulators and training instruments, there is a need for more validity studies. More training tools incorporating full-immersion simulation are recommended to develop a standardized learning curve in neurovascular procedures.