An overview of decision-making in cerebrovascular treatment strategies: Part I - unruptured aneurysms.

Introduction: Unruptured intracranial aneurysm treatment has evolved over the last two centuries, starting from the introduction of aneurysm ligation and clipping, up until the inception of endovascular treatment and further advancements in both fields. Research question: The wide variety of aneurysm presentations and possible treatment modalities, complicates the understanding of decision-making for the treatment of a given aneurysm. The goal of this article is to provide an overview of the best available evidence concerning unruptured intracranial aneurysm decision-making and identify insights and hiatuses, as well as providing a scaffold to surpass the subjectiveness of decision-making. Materials and methods: A literature review was performed for the most impactful articles on decision-making in unruptured intracranial aneurysm treatment, to provide an overview on current practice. Results: Two groups of decision-altering factors were identified; patient-related and aneurysm-related factors. A summary is presented of the general evidence, and the influence of age, aneurysmal mass-effect, as well as size, morphological aspects and specific anatomical locations on decision-making. Discussion and conclusion: Decision-making for an unruptured intracranial aneurysm often comes down to combining these different patient- and aneurysm-related factors. In this paper, an evidence-based overview is provided into these different factors which alter management of unruptured saccular aneurysms.

An overview of decision-making in cerebrovascular treatment strategies: Part II - Ruptured aneurysms.

Introduction: Decision-making for the treatment of ruptured aneurysms is an intricate process, which involves several factors. There has been a rapid advancement in endovascular, but also in the surgical treating field of ruptured intracranial aneurysms, with a growing body of evidence for either treatment technique. Research question: As there is a wide variety of treatment possibilities, it can be hard to understand the intricacies which lie behind the decision-making process for a given aneurysm. Materials and methods: An overview of the most relevant literature in decision-making on ruptured intracranial aneurysms is given. Results: Different decision-altering factors were identified, which can be divided into information from the general evidence, to influential factors such as the patient's age, initial presenting status, and aneurysmal factors such as size, morphology and aneurysmal location. Discussion and conclusion: This review provides an evidence-based overview of the most pertinent literature on these different aspects of decision-making in ruptured aneurysm cases and provides some recommendations after each of these segments. As always, all different aspects of the patient and aneurysmal factors should be taken into consideration before coming to a conclusion, as to obtain the best possible result for an individual patient.

Demonstrating the Non-inferiority of a Plastic Surgery Microscopic Technique for Hepatic Artery Anastomosis in Pediatric Liver Transplant: A Single-Institution Study.

INTRODUCTION: Before advancements in liver transplantation, conditions such as acute liver failure, decompensated liver cirrhosis, and hepatocellular carcinoma were associated with poor prognosis. Orthotopic liver transplantation has since emerged as a curative treatment. Despite its benefits, liver transplantation can lead to complications, including hepatic artery thrombosis (HAT), which is especially significant in pediatric patients. This study evaluates the utility of microsurgical anastomosis by plastic surgeons in reducing postoperative HAT compared to standard loupe-assisted anastomosis performed by transplant surgeons. METHODS: This retrospective chart review included pediatric patients who underwent orthotopic liver transplantation at a single institution between September 2015 and September 2023. Patients were divided into two groups: one receiving standard loupe-assisted anastomosis by transplant surgeons (n = 28) and the other receiving microsurgical anastomosis by plastic surgeons (n = 22). The primary outcomes measured were the rates of HAT. Secondary outcomes included graft survival, patient survival, postoperative hospital stay, resistive indices, bleeding, biliary complications, venous complications, transplant rejection, and reoperation rates. RESULTS: In 50 pediatric patients who underwent orthotopic liver transplantation, we compared outcomes between standard anastomosis (n = 28) and microscope-assisted anastomosis (n = 22). Demographic characteristics were similar between the groups. Hemorrhage occurred significantly more frequently in the standard anastomosis group (35.7%) compared to the microscope-assisted group (9.1%), with a p-value of 0.045. Other complications, including HAT (28.6% vs. 13.6%, p = 0.306), biliary leak (14.3% vs. 27.3%, p = 0.302), and organ rejection (21.4% vs. 13.6%, p = 0.713), did not differ significantly between the groups. Additionally, survival rates were comparable, with 71% in the standard group and 86% in the microscope group (p = 0.306). These findings suggest that while microscope-assisted anastomosis may reduce the risk of hemorrhage, other outcomes remain similar between the techniques. CONCLUSION: Our findings suggest that microsurgical anastomosis techniques performed by plastic surgeons are non-inferior to standard loupe-assisted techniques in pediatric liver transplantation and may decrease the rate of postoperative hemorrhage. Microsurgical anastomosis is a viable alternative to standard loupe-assisted techniques in pediatric hepatic artery transplants. Further research with larger sample sizes is warranted to confirm these findings and optimize surgical techniques.

Facial nerve decompression of a PICA vessel loop: A case report.

INTRODUCTION AND IMPORTANCE: Facial nerve palsy is a common condition with various etiologies. However, compression due to a vessel loop is an exceptionally rare cause. This case report highlights the unusual presentation and management of facial nerve palsy caused by vascular compression, emphasizing the importance of considering rare etiologies in persistent cases. CASE PRESENTATION: We describe the case of a young female patient who presented with a history of right blepharospasm and facial muscle twitching for several years. Cranial magnetic resonance imaging (MRI) revealed a posterior inferior cerebellar artery (PICA) vessel loop compressing the exit of the acoustofacial bundle at the level of the brainstem. CLINICAL DISCUSSION: The patient's condition necessitated a microscopic surgical decompression to relieve the compression on the facial nerve. During the procedure, the facial nerve was freed and cushioned using Teflon. This intervention highlights the potential for surgical resolution in cases of facial nerve palsy caused by vascular compression, despite its rarity. CONCLUSION: Postoperatively, the patient was free from blepharospasm and showed significant clinical improvement in facial muscle control. This case underscores the importance of considering vascular compression in the differential diagnosis of persistent facial nerve palsy and demonstrates the efficacy of surgical decompression in such cases.

Development and assessment of case-specific physical and augmented reality simulators for intracranial aneurysm clipping.

BACKGROUND: Microsurgical clipping is a delicate neurosurgical procedure used to treat complex Unruptured Intracranial Aneurysms (UIAs) whose outcome is dependent on surgeon's experience. Simulations are emerging as excellent complements to standard training, but their adoption is limited by the realism they provide. The aim of this study was to develop and validate a microsurgical clipping simulator platform. METHODS: Physical and holographic simulators of UIA clipping have been developed. The physical phantom consisted of a 3D printed hard skull and five (n = 5) rapidly interchangeable, perfused and fluorescence compatible 3D printed aneurysm silicone phantoms. The holographic clipping simulation included a real-time finite-element-model of the aneurysm sac, allowing interaction with a virtual clip and its occlusion. Validity, usability, usefulness and applications of the simulators have been assessed through clinical scores for aneurysm occlusion and a questionnaire study involving 14 neurosurgical residents (R) and specialists (S) for both the physical (p) and holographic (h) simulators by scores going from 1 (very poor) to 5 (excellent). RESULTS: The physical simulator allowed to replicate successfully and accurately the patient-specific anatomy. UIA phantoms were manufactured with an average dimensional deviation from design of 0.096 mm and a dome thickness of 0.41 ± 0.11 mm. The holographic simulation executed at 25-50 fps allowing to gain unique insights on the anatomy and testing of the application of several clips without manufacturing costs. Aneurysm closure in the physical model evaluated by fluorescence simulation and post-operative CT revealed Raymond 1 (full) occlusion respectively in 68.89% and 73.33% of the cases. For both the simulators content validity, construct validity, usability and usefulness have been observed, with the highest scores observed in clip selection usefulness Rp=4.78, Sp=5.00 and Rh=4.00, Sh=5.00 for the printed and holographic simulators. CONCLUSIONS: Both the physical and the holographic simulators were validated and resulted usable and useful in selecting valid clips and discarding unsuitable ones. Thus, they represent ideal platforms for realistic patient-specific simulation-based training of neurosurgical residents and hold the potential for further applications in preoperative planning.

Exploring arterial anatomy of the internal capsule: an analysis of the deep vascular structures and related white matter pathways.

BACKGROUND AND OBJECTIVES: The internal capsule is supplied by perforators originating from the internal carotid artery, middle cerebral artery, anterior choroidal artery and anterior cerebral artery. The aim of this study is to examine the vascular anatomy of the internal capsule, along with its related white matter anatomy, in order to prevent potential risks and complications during surgical interventions. METHODS: Twenty injected hemispheres prepared according to the Klingler method were dissected. Dissections were photographed at each stage. The findings obtained from the dissections were illustrated to make them more understandable. Additionally, the origins of the arteries involved in the vascularization of the internal capsule, their distances to bifurcations, and variations in supplying territories have been thoroughly examined. RESULTS: The insular cortex and the branches of the middle cerebral artery on the insula and operculum were observed. Following decortication of the insular cortex, the extreme capsule, claustrum, external capsule, putamen and globus pallidus structures were exposed. The internal capsule is shown together with the lenticulostriate arteries running on the anterior, genu and posterior limbs. Perforators supplying the internal capsule originated from the middle cerebral artery, anterior cerebral artery, internal carotid artery and anterior choroidal artery. The internal capsule's vascular supply varied, with the medial lenticulostriate arteries (MLA) and lateral lenticulostriate arteries (LLA) being the primary arteries. The anterior limb was most often supplied by the MLA, while the LLA and anterior choroidal artery dominated the genu and posterior limb. The recurrent artery of Heubner originated mostly from the A2 segment. The distance from the ICA bifurcation to the origin of the first LLA on M1 is 9.55 ± 2.32 mm, and to the first MLA on A1 is 5.35 ± 1.84 mm. MLA branching from A1 and proximal A2 ranged from 5 to 9, while LLA originating from the MCA ranged from 7 to 12. CONCLUSION: This study provides comprehensive understanding of the arterial supply to the internal capsule by combining white matter dissection. The insights gained from this study can help surgeons plan and execute procedures including oncological, psychosurgical, and vascular more accurately and safely. The illustrations derived from the dissections serve as valuable educational material for young neurosurgeons and other medical professionals.

Early Penile and Donor Site Sensory Outcomes After Innervated Radial Forearm Free Flap Phalloplasty: A Pilot Prospective Study.

BACKGROUND: Radial forearm free flap phalloplasty (RFFF) is a set of complex reconstructive procedures aimed at creating an aesthetic and functional penis in transgender patients. Sensory recovery in the neophallus and donor site is crucial for optimizing outcomes, but the few prior studies that exist assess neophallus sensation at limited locations and time points. The purpose of this study was to prospectively quantify sensory outcomes in the neophallus and donor site following RFFF phalloplasty. METHODS: Sensation testing occurred prospectively over February 2019-January 2021 on Stage 1 RFFF phalloplasty patients using the Pressure Specified Sensory Device (PSSD). On the neophallus, one-point discrimination (1PS) pressure threshold and lengthwise sensory recovery were measured at six circumferential locations proximally to distally. On the donor site, 1PS was measured at three locations on the donor hand. RESULTS: Nineteen patients were included (average age 34.0 years old, range 18-53 years). Among patients that received neophallus testing (n = 13), eight had at least two follow-up appointments. Six of these patients had sensation as of their most recent measurement (75.0%), with an average of 73 days to regain sensation. There was a significantly greater proportion of patients with sensation at the right ventral (80.0% after 3 months vs. 11.1%-60.0% before 3 months, p = 0.024) and right lateral (100.0% after 3 months vs. 11.1%-60.0% before 3 months, p = 0.004) aspects of the neophallus over time. Pressure required to elicit sensation decreased by 18.0% from 1 week-1 month postoperatively to 3-7.7 months postoperatively in the right ventral neophallus (96.2 g/mm2 ± 11.3 g/mm2 to 56.6 ± 39.9 g/mm2, p = 0.037). Among patients that received donor site testing (n = 11), mixed effects regression analysis with random intercepts demonstrated significant changes in the thumb (3.4 g/mm2 ± 1.4 g/mm2, p < 0.05) and webspace (13.5 g/mm2 ± 4.9 g/mm2, p < 0.01) that returned to baseline at 3 months postoperatively (1.7 g/mm2 ± 1.0 g/mm2, p > 0.05, and 2.3 g/mm2 ± 4.0 g/mm2, p > 0.05, respectively). CONCLUSION: This pilot study demonstrates that quantitative sensory testing can be used to monitor post-phalloplasty sensory changes. Recovery was significantly associated with contralateral (i.e, right side in a left forearm RFF) aspects of the neophallus, suggesting a possible pattern of circumferential sensory innervation via RFFF sensory nerves. Future studies with a larger sample size and longer follow-ups are necessary to fully characterize sensory recovery in phalloplasty patients.

Changes in Testosterone Levels Following Surgical Sperm Retrieval in Men with Non-Obstructive Azoospermia: Systematic Review and Meta-Analysis.

PURPOSE: Surgical sperm retrieval (SSR) is used to extract spermatozoa for use with intracytoplasmic sperm injection in men with obstructive and non-obstructive azoospermia (NOA). The procedure may lead to segmental devascularization, postoperative fibrosis, and atrophy with a subsequent decrease in testosterone. The aim of the study is to investigate the impact of SSR on serum levels of total testosterone (TT), follicle-stimulating hormone (FSH), luteinizing hormone (LH) testicular volume, and sexual function in infertile azoospermic men. MATERIALS AND METHODS: In this systematic review and meta-analysis (SRMA), we searched articles in "PubMed" and "Scopus" exploring the impact of SSR on TT, FSH, LH, and testicular volume. The full-text articles were screened to assess eligibility before data extraction, quality assessment, and meta-analysis. RESULTS: Seventeen studies meeting the inclusion criteria were finally analyzed and included 1,685 infertile, azoospermic men. Patients underwent SSR and were followed in the postoperative period (one week to 32 months). The analysis showed a significant reduction in TT (mean difference [MD] 3.81 nmol/L, 95% confidence interval [CI] 0.55:7.06; p=0.02) compared to pre-SSR values. We also observed insignificant differences in serum FSH (MD 5.08 IU/L, 95% CI -5.6:15.8; p=0.35), LH (MD -2.96 IU/L, 95% CI -6.31:0.39; p=0.08), and no change in testicular volume (MD 0.07 mL, 95% CI -1.92:2.07; p=0.94) after SSR. Sexual dysfunction was associated with hypogonadism, depression, and anxiety, especially in men with unsuccessful SSR and Klinefelter syndrome. CONCLUSIONS: The results of this SRMA indicate a significant reduction in TT after SSR. Sexual dysfunction after testicular sperm extraction and the potential negative impact of future SSR repeat should be considered during preoperative counseling.

Contralateral approach to giant ruptured and unruptured ophthalmic artery aneurysms: patient series.

BACKGROUND: Giant ophthalmic artery (OphA) aneurysms remain surgically challenging despite the progress in endovascular treatments. This study describes the contralateral interoptic corridor in select patients based on imaging criteria suitable for clipping. The aim of this study was to show that despite the growing use of novel endovascular techniques, such as coil embolization and flow diversion, for the treatment of OphA aneurysms, microsurgical clipping may still be preferred for giant ones under certain conditions. OBSERVATIONS: The authors retrospectively reviewed the records of the microsurgical treatment of unruptured and ruptured giant OphA aneurysms at the University Hospital Center "Mother Teresa," Tirana, from 2007 to 2016. Four patients were selected for microsurgery and the contralateral approach using ophthalmic evaluations and coronal imaging on computed tomography, magnetic resonance imaging, and digital subtraction angiography that demonstrated aneurysms with a small neck and an orientation between 11 and 13 on the coronal clock face. A prefixed chiasm was a contraindication to this approach. LESSONS: Giant OphA aneurysms can be safely clipped through a contralateral interoptic corridor without creating new visual deficits or a residual aneurysm. https://thejns.org/doi/10.3171/CASE2473.

Microsurgery resection of giant cervicothoracic spinal ependymoma: Two-dimensional operative video.

Background: Ependymomas, rare glial brain tumors, account for <5% of all brain tumors. Interestingly, over 60% of ependymomas occur in the spinal cord of adults, including those originating from the filum terminale, while the rest are found within the brain. The World Health Organization (WHO) categorizes ependymomas into three grades: subependymomas and myxopapillary ependymomas ([MEPNs]; WHO grade I), classic ependymomas (WHO grade II), and anaplastic ependymomas (WHO grade III). Spinal ependymomas generally exhibit a more favorable prognosis compared to their intracranial counterparts and are primarily treated through gross total resection, which is considered the most effective surgical approach. As such, they are recognized as a distinct clinical entity that demands tailored management strategies. MEPNs, which constitute 13% of ependymomas, typically occur in the cauda equina and sometimes extend into the conus medullaris. Most other spinal ependymomas are of the classic type and predominantly arise in the cervical and thoracic regions of the spine. The mean age at diagnosis is 45 years of age. While prognosis varies based on molecular subtypes, complete resection is associated with improved survival. Case Description: Here, we demonstrate the technical nuances to safely achieve gross total resection of a giant spinal ependymoma in a 29-year-old female with a medical history notable for sept-optic dysplasia, and panhypopituitarism. The patient presented with progressive neck pain, upper and lower extremity weakness, and numbness for 1 year. On physical examination, she demonstrated mild weakness in her left arm. The preoperative magnetic resonance imaging revealed a cervicothoracic intramedullary mass extending from C4 to T2 with an associated syrinx at C4. Under intraoperative neural monitoring (somatosensory evoked potentials, motor-evoked potentials, and epidural direct wave recordings), the patient underwent a C4 - T2 laminectomy. In addition, spinal ultrasonography helped differentiate solid tumor mass from syrinx formation, thus guiding the focus and extent of the decompression . Conclusion: Gross total resection was achieved; at 18 postoperative months, the patient had mild residual motor deficit. The pathological evaluation revealed a WHO grade II ependymoma. Subsequent sequential enhanced MR studies at 3, 6, and 12 months confirmed no tumor recurrence.

Classification of anatomy and treatment approaches for aneurysms originating from the proximal of the A1 segment of the anterior cerebral artery in clinical settings.

Objective: To explore the spatial relationship between A1 segment proximal anterior cerebral artery aneurysms and their main trunks, classify them anatomically and develop targeted treatment strategies. Methods: This single-center retrospective analysis involved 39 patients diagnosed with aneurysms originating from the proximal of A1 segment of the anterior cerebral artery (2014-2023). Classify the patient's aneurysm into 5 types based on the location of the neck involving the carrier artery and the spatial relationship and projection direction of the aneurysm body with the carrier artery, and outcomes from treatment methods were compared. Results: Among 39 aneurysms, 18 cases underwent endovascular intervention treatment, including 6 cases of stent assisted embolization, 1 case of flow-diverter embolization, 5 cases of balloon assisted embolization, and 6 cases of simple coiling. At discharged, the mRS score of all endovascularly treated patients was 0, and the GOS score was 5 at 6 months after discharge. At discharge, the mRS score of microsurgical clipping treated patients was 0 for 15 cases, 3 for 1 case, 4 for 1 case and 5 for 2 cases. Six months after discharge, the GOS score was 5 for 16 cases, 4 for 2 cases, 3 for 2 cases, and 1 for 1 case. GOS outcomes at 6 months were better for endovascularly treated patients (p = 0.047). Conclusion: Results showed better outcomes for the endovascular treatment group compared to microsurgical clipping at 6 months after surgery. The anatomical classification of aneurysms in this region may be of help to develop effective treatment strategies.

An alternative reconstruction for the complex nasal and facial defect with a thinned anterolateral thigh flap.

Reconstructive surgeons often use a free radial forearm flap for nasal reconstruction when a forehead flap is not an option, but this flap has drawbacks. This article presents a series of patients with complex defects who underwent reconstruction with an anterolateral thigh (ALT) flap. Severe burns and cancer resection may lead to the loss of multiple anatomical units, including the entire nose and nearby structures. Multiple materials are required for reconstruction in those with complex total nasal defects involving adjacent areas. In this series of patients, a chimeric ALT flap was harvested and thinned to recreate the three-dimensional nasal structure and cover the adjacent area. Cartilage and alloplastic materials were used as the nasal framework, and the skin flap was folded for the mucosal lining. The results were good with an excellent contour, and no complications or airway obstruction were observed during follow-up. By thinning the ALT flap, this flap can be an alternative for complex reconstructions that require a facial or three-dimensional nasal structure.

Microsurgical lesionectomy for drug-resistant insular cortex epilepsy in focal cortical dysplasia type IIB: a pediatric case report.

Introduction and importance: Focal cortical dysplasia (FCD) is a significant cause of drug-resistant epilepsy, often necessitating surgical intervention. Type IIb FCD poses challenges due to its strong association with drug-resistant seizures. Effective management involves advanced imaging, intraoperative neurophysiological monitoring, and precise surgical techniques. This case study illustrates these strategies in an 11-year-old female with drug-resistant epilepsy attributed to Type IIb FCD. Case presentation: The patient, an 11-year-old female, had drug-resistant seizures despite various anticonvulsant treatments. Preoperative 3 Tesla (3T) MRI revealed an ill-defined lesion in the right frontal operculum. The surgical team used neuro-navigation for intraoperative guidance and electrocorticography for lesionectomy. Pathology confirmed Type IIb FCD with rare concentric calcifications. Clinical discussion: Drug-resistant seizures in FCD often require surgery when medications fail. This case highlights the importance of comprehensive preoperative evaluations and advanced imaging, such as 3T MRI, to accurately identify lesions. Intraoperative neurophysiological monitoring, including electrocorticography, ensures precise resection of the epileptogenic zone. The unusual finding of concentric calcifications in Type IIb FCD is noteworthy, suggesting the need for further research to understand their impact on the disease. Conclusion: Microsurgical lesionectomy is crucial for managing drug-resistant seizures in Type IIb FCD. Combining advanced imaging with intraoperative monitoring improves surgical precision and outcomes. The rare pathological finding of calcifications highlights the diversity of FCD manifestations, warranting further study. These techniques can significantly enhance seizure control and quality of life in patients with drug-resistant epilepsy.

Vascular loops mimicking herniated lumbar discs: fair warning.

The authors report their experience with twenty-one consecutive patients who presented with symptoms and imaging characteristics of a herniated lumbar disc; of whom, at the time of surgery had a vascular loop instead. The procedure was performed on 14 women and seven men with a mean age of 39 years. Clinical complaints included lumbar aching with one limb overt radiculopathy in all patients; with additional sphincter dysfunction in two cases. Symptoms had developed within a mean period of three months. In all patients, the disc was exposed through an L5-S1 (n = 10); L4-L5 (n = 5) and L3-L4 (n = 6) open minimal laminotomy. In 16 patients, rather than a herniated disc they had a lumbar epidural varix, while an arterio-venous fistula was found in the remaining five cases. In all cases, the vascular disorder was resected and its subjacent disc was left intact. One patient had a postoperative blood transfusion. While the radiculopathy dysfunction improved in all patients, four patients reported lasting lumbar pain following surgery. The postoperative imaging confirmed the resolution of the vascular anomaly and an intact disc. The mean length of the follow-up period was 47 months. Either epidural varix or arterio-venous fistula in the lumbar area may mimic a herniated disc on imaging studies. With the usual technique they can be operated safely. Resection of the anomaly can be sufficient for alleviating radiculopathy symptoms.

Lateral compartment of the cavernous sinus from the endoscopic endonasal approach: anatomical considerations and surgical relevance to adenoma surgery.

OBJECTIVE: The cavernous sinus (CS) has 4 compartments: superior, inferior, posterior, and lateral. Among these, the lateral compartment is the most common location for residual tumor, given the risk of neurovascular injury. The authors' study aimed to delineate the anatomical landmarks in this area and illustrate the technical nuances of the lateral transcavernous approach. METHODS: Twenty-two colored silicone-injected specimens were dissected via an endoscopic endonasal approach to the lateral compartment of the CS. The anatomical landmarks and the internal carotid artery (ICA) mobilization technique were investigated. Two illustrative cases are provided. RESULTS: The lateral compartment of the CS is bounded by the carotid-oculomotor membrane (COM) and optic strut as the roof and the petrolingual ligament and lingual process as the floor. It is divided into 2 asymmetrical subcompartments: the upper, larger subcompartment, located superior to the abducens nerve, accommodates the lateral parasellar ligament (LPL), inferolateral trunk (ILT), and branches of the tentorial artery; and the lower, smaller subcompartment, inferior to the abducens nerve, accommodates only the sympathetic nerve branches as they join the abducens nerve. The LPL is a well-defined ligamentous band and was identified in 38 (86%) hemispheres with 2 distinct configurations: 1) robust LPL (59%), with highly compacted ligamentous bands tightly adherent to the ICA; and 2) dispersed LPL (27%), with less compaction and adherence to ICA. The main attachment of the LPL to the cavernous ICA was most commonly observed at the horizontal ICA segment (55%), followed by the anterior (18%) and posterior (14%) genua. The ILT, as the main vessel in the lateral compartment, was identified in 41 (93%) hemispheres and originated from the horizontal ICA segment (80%) or the anterior genu (14%), from either the lateral (52%) or inferior (41%) aspect of the cross-section of the ICA. In 64% of hemispheres, the LPL wrapped the ILT, abducens nerve, and sympathetic nerve to form a broad and firm neurovascular-ligamental complex. Transection of the LPL, ILT, and COM enables medial ICA mobilization and enhances access to the lateral compartment of the CS, potentially increasing the exposure width by 6 ± 1 mm. CONCLUSIONS: This study provides valuable insights into the anatomical intricacies of the lateral compartment of the CS and underscores the potential benefits of the endoscopic endonasal lateral transcavernous approach. Further clinical applications are essential for validating these findings and optimizing surgical outcomes.

Exploring Pathways for Pain Relief in Treatment and Management of Lumbar Foraminal Stenosis: A Review of the Literature.

BACKGROUND: Lumbar foraminal stenosis (LFS) involves the narrowing of neural foramina, leading to nerve compression, significant lower back pain and radiculopathy, particularly in the aging population. Management includes physical therapy, medications and potentially invasive surgeries such as foraminotomy. Advances in diagnostic and treatment strategies are essential due to LFS's complexity and prevalence, which underscores the importance of a multidisciplinary approach in optimizing patient outcomes. METHOD: This literature review on LFS employed a systematic methodology to gather and synthesize recent scientific data. A comprehensive search was conducted across PubMed, Scopus and Cochrane Library databases using specific keywords related to LFS. The search, restricted to English language articles from 1 January 2000 to 31 December 2023, focused on peer-reviewed articles, clinical trials and reviews. Due to the heterogeneity among the studies, data were qualitatively synthesized into themes related to diagnosis, treatment and pathophysiology. RESULTS: This literature review on LFS analyzed 972 articles initially identified, from which 540 remained after removing duplicates. Following a rigorous screening process, 20 peer-reviewed articles met the inclusion criteria and were reviewed. These studies primarily focused on evaluating the diagnostic accuracy, treatment efficacy and pathophysiological insights into LFS. CONCLUSION: The comprehensive review underscores the necessity for precise diagnostic and management strategies for LFS, highlighting the role of a multidisciplinary approach and the utility of a unified classification system in enhancing patient outcomes in the face of this condition's increasing prevalence.

Comparison of clinical characteristics and surgical outcomes in non-vasectomized epididymal obstructive azoospermia patients with or without concurrent vas-deferens obstruction.

BACKGROUND: Microsurgical vasoepididymostomy is an effective surgical method for treating epididymal obstructive azoospermia but the surgical outcomes can be affected in some non-vasectomized epididymal obstructive azoospermia patients with concurrent vas-deferens obstruction. This study aimed to explore the clinical characteristics and surgical outcomes in non-vasectomized epididymal obstructive azoospermia patients with versus without concurrent vas-deferens obstruction. STUDY DESIGN: Retrospective study. OBJECTIVE: To explore the clinical characteristics and surgical outcomes in non-vasectomized epididymal obstructive azoospermia patients with versus without concurrent vas-deferens obstruction, aiming to identify predictive factors for concurrent vas-deferens obstruction and evaluate the efficacy of microsurgical vasoepididymostomy in patients with epididymal obstructive azoospermia and concurrent short-segment vas-deferens obstruction. MATERIALS AND METHODS: A retrospective analysis of 225 epididymal obstructive azoospermia cases was conducted at the First Affiliated Hospital of Fujian Medical University from November 2016 to March 2023. All patients underwent a comprehensive preoperative evaluation. During surgery, the vas deferens were assessed to determine the presence and extent of obstruction. Depending on the obstruction length, either a standard microsurgical vasoepididymostomy was performed, or the obstructed segment was resected followed by microsurgical vasoepididymostomy. If the remaining length post-resection was insufficient for anastomosis, the procedure was discontinued. Data on patient clinical characteristics, operative findings, and outcomes were collected and analyzed. Logistic regression was used to identify predictive factors for concurrent vas-deferens obstruction, and comparative analysis assessed patency and pregnancy rates between patients with and without concurrent vas-deferens obstruction. RESULTS: Of the 225 patients in the study, 77 (34.22%) presented with epididymal obstructive azoospermia and concurrent vas-deferens obstruction. Logistic regression analysis revealed that "the history of epididymitis" was a significant predictive factor for epididymal obstructive azoospermia patients with concurrent vas-deferens obstruction (odds ratio = 9.06, p < 0.001). The average length of vas deferens obstruction amenable to microsurgical vasoepididymostomy post-resection was 1.31 ± 0.54 cm (range from 0.50 to 2.50 cm). In contrast, cases unsuitable for microsurgical vasoepididymostomy presented an average obstruction length of 15.26 ± 5.79 cm (p < 0.001). The patency rates were 82.17% in epididymal obstructive azoospermia patients without concurrent vas-deferens obstruction and 74.14% in those with concurrent vas-deferens obstruction. The pregnancy rates followed a similar trend, at 34.11% and 34.48%, respectively. These differences were not statistically significant (p > 0.05 for both). However, epididymal obstructive azoospermia patients with vas-deferens obstruction exhibited a decreased likelihood of bilateral microsurgical vasoepididymostomy (p < 0.001). DISCUSSION AND CONCLUSION: Our study identifies a noticeable occurrence of concurrent vas-deferens obstruction in non-vasectomized epididymal obstructive azoospermia patients, with approximately one-third of the cases (34.22%) exhibiting vas-deferens obstruction during surgical interventions. Notably, a small fraction (6.67%) of these individuals chose not to proceed with any microsurgical vasoepididymostomy, even on one side, due to the extensive length of the obstruction. Through logistic analysis, we have demonstrated that "the history of epididymitis" is a critical predictive factor for the presence of vas-deferens obstruction, underscoring its significance in preoperative evaluations. Furthermore, our research confirms that microsurgical vasoepididymostomy is still an effective treatment for epididymal obstructive azoospermia patients with concurrent short-segment vas-deferens obstruction, achieving significant patency and favorable pregnancy rates compared to those patients without vas-deferens obstruction. These insights are pivotal for enhancing surgical strategies and improving fertility outcomes in this patient cohort.

A novel subtype classification and corresponding surgical strategies for spinal dural cysts -a report of 104 cases.

BACKGROUND: The nomenclature, classification, and surgical approaches for spinal dural cysts (SDCs) remain a subject of controversy. PURPOSE: The present study proposes a novel subtype classification system and corresponding surgical strategies, with the aim of enhancing comprehension of this entity and standardizing surgical treatment. STUDY DESIGN: A retrospective review. PATIENT SAMPLE: A total of 104 patients with SDCs underwent novel subtype classification and corresponding surgical strategies from January 2015 to December 2021. Fifty-four patients who underwent conventional surgery from January 2012 to December 2014 as the control group for preliminary validation. OUTCOME MEASURES: The outcomes are categorized into 4 levels: excellent, good, unchanged, and deteriorated, based on neurological improvement and pain relief. Grades of excellent and good were identified as improvements. Follow-up magnetic resonance imaging and complications were also evaluated. METHODS: Based on the shared pathogenic factor of dural defects, the dural-associated cysts in the spinal canal are uniformly referred to as SDCs. They are further classified into Type 1 (no nerve roots) and Type 2 (containing nerve roots), with 4 additional subtypes based on the shape of the leak and the flow of leakage. The fissure-shaped leak of Type 1a SDCs is directly sutured, whereas the aperture-shaped leak of Type 1b is repaired using a patch. Low-flow leakage of Type 2a is directly sealed using a combination of adipose tissue and fibrin glue, whereas high-flow Type 2b necessitates suturing at the end of the leak to attenuate cerebrospinal fluid flow prior to sealing. RESULTS: The follow-up period averaged 23.8 months. Excellent or good outcomes were achieved in 100%, 88.9%, 100%, and 97.3% for the 4 subtypes respectively. The overall improvement rate of SDCs was 97.1%, which was significantly higher than that of the conventional surgery group (85.2%, p=.008). MRI follow-up showed a significant reduction in cyst size of 100%, 100%, 97.8%, and 97.3% for the 4 subtypes, respectively. The primary complications included pseudomeningocele in 4 cases (3.8%) and delayed wound healing in 5 cases (4.8%). The complication rate was also significantly lower than that of the control group (8.7% vs 24.1%, p=.008). CONCLUSIONS: Subtyping SDCs based on the variation of leaks and leakage can enable more targeted surgical strategies, which are helpful for improving treatment effectiveness and reducing complications.

Surgical Management of Ipsilateral Internal Carotid Artery Stenosis and Unruptured Intracranial Aneurysm: Case Review and Treatment Considerations.

Introduction The coexistence of carotid artery stenosis and a concomitant downstream ipsilateral unruptured intracranial aneurysm requires unique treatment considerations to balance the risk of thromboembolic complications from carotid artery stenosis and the risk of subarachnoid hemorrhage from intracranial aneurysm rupture. These considerations include the selection of optimal treatment modalities, the order and timing of interventions, and potential management of antiplatelet agents with endovascular approaches. We present strategies to optimize treatment in such a case. Case Report We discuss the case of a 69-year-old woman with 90% stenosis of the right internal carotid artery and an ipsilateral, wide-necked, 4.8-mm, irregular-appearing right A1-2 junction aneurysm with an associated daughter sac. Open, endovascular, and mixed treatment strategies were considered. The patient selected and underwent a staged, open treatment approach with a carotid endarterectomy followed by a right craniotomy for microsurgical clipping of the aneurysm 5 days later. Both procedures were performed on daily full-dose aspirin without complications. On follow-up, the right carotid artery was widely patent, the aneurysm was secured, and the patient remained at her neurologic baseline. Discussion The presented strategy for ipsilateral carotid artery stenosis and an unruptured intracranial aneurysm initially optimized cerebral perfusion to mitigate ischemic risks while permitting timely aneurysm intervention without a need for dual antiplatelet therapy or to traverse an earlier procedure site.