[Role of cranioplasty in the management of decompressive craniectomies: Study of the Adolphe de Rothschild Foundation Hospital cohort over 7 years]. / Place de la cranioplastie dans la prise en charge des crâniectomies décompressives : étude de la cohorte de l'Hôpital Fondation Adolphe de Rothschild sur 7 ans.

OBJECTIVES: The objective of our study is to take stock of the cranioplasty implants used within our establishment. MATERIALS AND METHOD: We analyzed the patients files who underwent craniectomy followed by cranioplasty between 2017 and 2023, with at least 1 year of follow-up after cranioplasty (n=75). The data were extracted from the computerized patient file (DxCare®, Dédalus) and the pharmaceutical management tool for drugs and sterile medical devices (Pharma®, Computer Engineering). The sex ratio, indication for craniectomy, operating time, time between craniectomy and cranioplasty, complications and aesthetic result were statistically analyzed. RESULTS: The main indications are stroke (n=59; 78.5%) and aneurysms (n=7; 9.5%). Among the 75 patients, 52 benefited from the placement of a custom implant (PolyEtherEtherCetone/PEEK or Hydroxyapatite) and 23 from cementoplasty. The operating time was significantly shorter (P<0.05) for custom cranioplasty (1.93±0.61h vs. 1.62±0.53). Only 4 patients (5.3%) were not satisfied with the aesthetic result following the placement of a custom implant. A greater risk of infection was found in the context of cementoplasty (43% for cementoplasties vs. 25% for the custom implant, so χ2 (P=0.1095), this difference not being statistically significant. CONCLUSION: This collaborative work between the pharmacy and the adult neurosurgery department served to establish an initial register for monitoring patients who have undergone cranioplasty for whom the ideal implant remains to be determined.

Clipping Versus Coiling for Ruptured MCA Aneurysms Associated with Intracerebral Hematoma Requiring Surgical Evacuation.

BACKGROUND: Ruptured middle cerebral artery aneurysm (MCAa) can lead to intracerebral hematoma, and surgical evacuation can be performed in these cases. MCAa can be treated by clipping or before by endovascular therapy (EVT). Our objective was to compare the impact on the functional outcome of MCAa in patients with intracerebral hematoma requiring evacuation. METHODS: This is a multicenter, retrospective, cohort study with nine French neurosurgical units from January 1, 2013, to December 31, 2020. All participants were adult patients who required evacuation of an intracerebral hematoma. We looked for risk factors for poor outcomes by comparing the baseline characteristics and treatments performed by using the 6-month modified Rankin scale score. Poor outcomes were defined by an modified Rankin scale score of 3-6. RESULTS: A total of 162 patients were included. A total of 129 (79.6%) patients were treated by microsurgery, and 33 (20.4%) patients were treated by EVT. In multivariate analysis, factors associated with poor outcomes included hematoma volume, realization of a decompressive craniectomy, occurrence of procedure-related symptomatic cerebral ischemia, occurrence of delayed cerebral ischemia, and EVT. In the propensity score matching analysis (n = 33 per group), poor outcomes were observed in 30% of the patients in the clipping group versus 76% in the EVT group (P < 0.001). These differences may have been related to a longer delay between hospital admission and hematoma evacuation in the EVT group. CONCLUSIONS: In the specific subgroup of ruptured MCAa with intracerebral hematoma that requires surgical evacuation, clipping with concomitant hematoma evacuation could provide better functional outcomes than EVT followed by surgical evacuation.

Preservation of frontal white matter tracts in ventricular surgery: favoring an anterior interhemispheric transcallosal approach vs a transcortical transfrontal transventricular approach.

Secondary to the creation of a surgical corridor and retraction, white matter tracts degenerate, causing long-term scarring with potential neurological consequences. Third and lateral ventricle tumors require surgery that may lead to cognitive impairment. Our objective is to compare the long-term consequences of a transcortical transfrontal approach and an interhemispheric transcallosal approach on corpus callosum and frontal white matter tracts degeneration. Surgical patients with ventricular tumor accessible through both approaches were included and clinico-radiological data were retrospectively analyzed. The primary endpoint was the callosotomy length at 3-month post-operative T1 MRI, corrected by the extension of the tumor and the use of neuronavigation. Secondary outcomes included perioperative criteria such as bleeding, use of retractors and duration, FLAIR hypersignal on 3-month MRI, and re-do surgeries. To assess white matter tract interruption, 3-month FLAIR hypersignal was superposed to a tractography atlas. Seventy patients were included, 57 (81%) in the transfrontal group and 13 (19%) in the interhemispheric group. There was no difference in the mean callosotomy length on 3-month MRI (12.3 mm ± 5.60 transfrontal vs 11.7 mm ± 3.92 interhemispheric, p = 0.79) on univariate and multivariate analyses. The callosotomy length was inferior by - 3.13 mm for tumors located exclusively in the third ventricle (p = 0.016), independent of the approach. Retractors were used more often in transfrontal approaches (60% vs 33%, p < 0.001). The extent of frontal FLAIR hypersignal was higher after transfrontal approach (14.1 mm vs 0.525 mm, p < 0.001), correlated to the use of retractors (p < 0.05). After the interhemispheric approach, no tract other than corpus callosum was interrupted, whereas, after the transfrontal approach, frontal arcuate fibers and projections from the thalamus were interrupted in all patients, the cingulum in 19 (33%), the superior fronto-occipital fasciculus in 15 (26%), and the superior longitudinal fasciculus in 2 (3%). Transfrontal and interhemispheric approaches to the third and lateral ventricles both lead to the same long-term damage to the corpus callosum, but the transfrontal approach interrupts several white matter tracts essential to cognitive tasks such as attention and planning, even in the non-dominant hemisphere. These results encourage all neurosurgeons to be familiar with both approaches and favor the interhemispheric approach when both can give access to the tumor with a comparable risk. Neuropsychological studies are necessary to correlate these anatomical findings to cognitive outcomes.

Interhemispheric transcallosal approach: going further based on the vascular anatomy.

Preserving cortical frontal bridging veins draining into the superior sagittal sinus is a factor of good neurological outcome in anterior interhemispheric transcallosal approaches, classically performed to reach intraventricular tumors. Challenging the idea that veins are utterly variable, we propose a statistical analysis of 100 selective cerebral angiographies to determine where to place the craniotomy in order to expose the most probable vein-free area. The mean distance to the first pre-coronal vein was 6.66 cm (± 1.73, 1.80 to 13.00) and to the first post-coronal vein 0.94 cm (± 0.92, 0 to 3.00) (p < 0.001). The probability of absence of bridging veins was 92.0% at 4 cm anterior to the coronal suture versus 37.5% at 1 cm and 12.5% at 2 cm posteriorly. The length of the surgical corridor (distance between the first pre-coronal and post-coronal vein) was 7.60 cm (± 1.72, 3.00 to 14.10). Overall, the ideal centering point of the craniotomy was 2.86 cm (± 1.08, - 0.65 to 6.50) ahead of the coronal suture. The mean number of veins within 6 cm behind the coronal suture was 8.47 (± 2.11, from 3 to 15) versus 0.530 (± 0.82, from 0 to 3) ahead of the coronal suture (p < 0.001). These findings support a purely pre-coronal 5 cm craniotomy for interhemispheric approaches.

Female gender and exogenous progesterone exposition as risk factors for spheno-orbital meningiomas.

OBJECTIVE: The great heterogeneity of meningiomas is challenging and we need to distinguish relevant subgroups. Spheno-orbital osteomeningiomas (SOOM) constitute a clinically specific entity, with slow-growing benign osteo-meningiomatous tumors, which recur after surgery in one fourth of cases. Neurosurgical daily practice, supported by the literature, shows that the vast majority of patients with SOOM are women, and we explored whether their epidemiological and hormonal profiles suggest a progesterone influence. METHODS: We retrospectively documented all radiologically and histologically confirmed cases of SOOM operated in 2005-2019 in our institution. We completed the clinical and hormone history by systematic telephone interviews. RESULTS: In the literature, SOOM occur significantly more often in women than other meningiomas (749/847, 86.4% versus 73.8%, p = 0.002). Among 175 cases, we included 124 patients, 93.5% were women, younger than men (51 ± 5 versus 63 ± 8, p = 0.02). Women' meningiomas showed more progesterone receptors (96.4% versus 50%, p < 0.001). Exogenous hormonal intake, reliable in 82 cases, concerned 83.3% (64/78) of women, with frequent progesterone intake: 13 oestroprogestogenic treatment only, with old-generation progesterone analogs, 41 progesterone analogs (cyproterone acetate, nomegestrol acetate, chlormadinone, promegestone, etonogestrel, levonogestrel), 7 substitutive hormonal therapy for menopause, 3 others. Duration of treatment was 2-40 years, median 10 years. CONCLUSIONS: SOOM develop preferentially in women in their fifties, who often received progesterone analogs, and show progesterone receptors. Progesterone analogs are incriminated in skull base meningiomas, and this is the first report on the prevalence of exogenous hormone therapy specifically in SOOM. Whether SOOM reduce after treatment discontinuation, in particular the osteoma part, needs to be explored. Anti-progesterone treatments may represent an avenue for future research in soom.

Surgical treatment of hemifacial spasms: how to predict failure and complications through a series of 200 patients.

Primary hemifacial spasm (pHFS) is a benign but disabling movement disorder caused by a neurovascular conflict involving the facial nerve. Surgical treatment by microvascular decompression (MVD) is the most effective therapeutic. Predictors of surgical failure and surgical complications are still lacking. The aim of this study is to identify such predictors through the retrospective analysis of a series of 200 consecutive patients. All patients who underwent MVD for pHFS from January 1991 to December 2017 were included. All patients had at least two years follow-up. In addition to the demographic data, the outcome and the complications were collected. The primary outcome analysis showed that 7.5% of patients had a recurrence. Multiple and AICA related neurovascular conflicts were statistically associated to a higher recurrence rate after MVD (respectively p < 0.001 and p = 0.02). Permanent facial palsy occurred in 2.5% of patients, hearing loss in 9.0% (2.0% of complete unilateral impairment) and dizziness in 2.5%. The risk of each of these peripheral neurological impairments was statistically increased by a long duration between the first pHFS symptom and the MVD (p < 0.001). In case of recurrence, a second MDV was offered. Long term follow-up showed that all patients had a complete resolution of the HFS. Post-operative complication rate was not significantly increased after a second MVD. Multiple and AICA related neurovascular conflicts are associated to a higher risk of surgical failure. When a pHFS recurrence occurs, a second surgical procedure is associated with excellent outcome without significant increase of post-operative complications and should therefore be recommended.

Accuracy of external ventricular drainage catheter placement.

BACKGROUND: External ventricular drainage (EVD) is a freehand neurosurgical procedure performed routinely using the anatomical landmarks. OBJECTIVE: The aim of this study was to determine the accuracy of EVD catheter freehand placement. MATERIALS AND METHODS: Pre-operative and post-operative computed tomography scans for 66 consecutive EVDs performed in 56 adult patients (26 men, 30 women) in 2008 were retrospectively reviewed. Etiologies of acute hydrocephalus were subarachnoid or intraventricular haemorrhage (43 cases) or miscellaneous (13 cases). Pre-operative lateral ventricular volume, position of the burr hole, length of the catheter and its sagittal and coronal angular variations from a theoretical trajectory were measured. RESULTS: The EVD was placed on the right (53 cases) or left (13 cases) side. The mean pre-operative lateral ventricular volume was 51 cc (10-118 cc). The average distance from the burr hole to the midline was 28 mm (10-49 mm) and to the supra-orbital ridge was 101 mm (75-125 mm). The mean intracranial catheter length was 60 mm (from 39-102 mm). Only 50% of the EVDs in the coronal plane and 40% in the sagittal plane were placed with an angular variation of ±5° to the target. The tip was placed outside of the ventricles in three cases; 13 catheters crossed the midline, and five intracranial minor haemorrhages were detected. CONCLUSION: Freehand placement of EVDs does not have sufficient accuracy and may lead to drainage dysfunctions. This data suggests that a guidance system for EVD's would be required.

Microsurgical Ligation of a Dural Arteriovenous Fistula of the Petrous Apex-A 2-Dimensional Operative Video.

Dural arteriovenous fistulas are rare acquired vascular lesions that represent 15% of the vascular malformations. While endovascular treatment has recently became the first line of treatment, microsurgical ligation may still be indicated in specific cases. We present the case of a 75-year-old patient who presented a progressive tetraparesis culminating in a spastic paraplegia and urinary retention. Cranial and spinal magnetic resonance imaging showed a T2 hypersignal in the cervical spinal cord and lower brainstem associated with flow voids in the subarachnoid space. Brain angiography demonstrated a dural arteriovenous fistula of the right petrous apex fed by the inferior lateral and meningohypophyseal trunks of the right cavernous internal carotid artery and draining in the lateral vein of the pons and the anterior medullary vein. Given the small size and tortuous feeders, endovascular treatment was considered too risky and microsurgical ligation was offered to the patient. The main issue of the microsurgical ligation of the dural arteriovenous fistula is the precise identification of the fistulous point, and therefore a detailed study of the specific vascular anatomy of the cerebellopontine angle is compulsory. Indocyanine green angiography plays a major role in confirming the location of the fistula and its correct occlusion. We discuss the technical nuances of the fistula ligation through a retrosigmoid approach and present Video 1 illustrating these principles. Given the retrospective nature of this report, informed consent was not required.

Extended Endoscopic Endonasal Approach for a Giant Parasellar Epidermoid Cyst.

Epidermoid cysts are rare lesions which typically grow slowly. For this reason, these lesions are usually discovered when they are already very large. The parasellar location is no exception to this rule and may involve the cavernous sinus or the Meckel cave. We present a 34-year-old female patient without past medical history who was admitted in our tertiary referral center for episodes of diplopia in the right lateral gaze and right trigeminal dysesthesias. Brain magnetic resonance imaging (MRI) showed a large right parasellar mass with mixed intensity signal on the T1 and T2 sequences, without contrast enhancement and a typical hypersignal intensity on diffusion-weighted sequences evoking an epidermoid cyst. We discuss the radiologic criteria which differentiate the lesions originating in the cavernous sinus from those of the Meckel cave ( Figs. 1 and 2 ). Parasellar tumors may be approached through classical transcranial approaches such the epidural temporopolar or the subtemporal approach which involve a significant degree of brain retraction. The last decade witnessed the advent of extended endonasal approaches which offer an interesting alternative and avoid the manipulation of the brain. We used the endoscopic transpterygoid approach in our patient and we were able to achieve an excellent clinical and radiological result. We discuss the nuances of the technique and present the surgical steps of the procedure ( Figs. 3 and 4 ). The endoscopic endonasal approach represents an excellent therapeutic option for parasellar lesions. A thorough knowledge of the anatomy and experience with endoscopic techniques are obvious prerequisite. The link to the video can be found at: https://youtu.be/QonSvHrCwOU .

Multivariate models to predict pain recurrence and sensitive complications after percutaneous balloon compression in trigeminal neuralgia.

OBJECTIVE: Percutaneous balloon compression (PBC) is a popular treatment option for trigeminal neuralgia. However, the efficacy of PBC is widely considered to be associated with the occurrence of sensitive complications, although neither this correlation nor the underlying mechanisms have been established. The objectives of the present study were to identify factors predicting time to pain recurrence after PBC and identify factors predicting a severe sensitive complication. METHODS: The authors conducted a retrospective study on patients who underwent PBC for the first time between 1985 and 2019 in two French hospitals. Data were retrieved from patients' medical records. Potential clinical and radiological predictors for time to pain recurrence and severe sensitive complication were evaluated using a Cox model and a logistic regression, respectively. RESULTS: A total of 131 patients were included in the study, with a median follow-up of 3.0 years. Pain recurrence occurred in 77 patients, and the median time to pain recurrence was 2.0 years. In the multivariate analysis, six independent factors predicting pain recurrence were identified: 1) longer duration of presurgical symptoms; 2) localization of the pain along the mandibular branch of the trigeminal nerve (V3); 3) atypical pain; 4) diagnosis of multiple sclerosis; 5) use of a medical device not specifically adapted for trigeminal neuralgia surgery; and 6) duration of balloon compression > 60 seconds. Regarding the secondary objective, 26 patients presented a severe sensitive complication after PBC, which the authors defined as the development of a new sensitivity disorder of the cornea, deafferentation pain known as anesthesia dolorosa, and/or long-lasting hypoesthesia augmentation characterized by the new appearance or increase in size or intensity of an area of hypoesthesia in the face for at least 3 months. The only predictor associated with a severe sensitive complication in the multivariate analysis was compression duration > 60 seconds. CONCLUSIONS: These results show that the risk of postoperative complications can be assessed at the patient level, the most important modifiable parameter being the time of compression by the balloon. Although this study shows the relevance of a personalized medicine approach, its clinical application remains to be validated.

Microsurgical Clipping of Middle Cerebral Artery Aneurysms: Complications and Risk Factors for Complications.

OBJECTIVE: Middle cerebral artery aneurysms (MCAAs) have been considered good candidates for microsurgery. Our objective was to evaluate the risk of complications and the risk factors for complications with microsurgical treatment of MCAAs to better define the indications for microsurgery. METHODS: We conducted a retrospective cohort study from 3 tertiary neurosurgical units from January 2013 to May 2020. We evaluated the frequency of complications and searched for the risk factors for complications after microsurgery. Complications were defined as a composite criterion with the presence of one of the following: procedural-related death, symptomatic cerebral ischemia, impossible exclusion, incomplete exclusion, or rebleeding of the treated aneurysm and symptomatic surgical site hematoma. RESULTS: A total of 292 MCAAs were treated, with 29 complications (9.9%), including symptomatic cerebral ischemia (4.8%), aneurysm rebleeding (0.3%), surgical site hematoma (1.0%), impossible exclusion (0.3%), and incomplete exclusion (4.1%). Severe complications, defined as death or a modified Rankin scale score of ≥4 at 3 months, were infrequent, occurring in 7 of the 292 patients (2.4%). On multivariate analysis, the risk factors were a ruptured aneurysm, a larger maximum aneurysm size, a larger neck size, and arterial branches passing <1 mm from the aneurysm neck or dome. CONCLUSIONS: Microsurgical management of MCAAs can be performed with very low morbidity rates. In some cases, at least for factors that do not result in significant difficulty for endovascular therapy, such as the presence of an en passage artery or ruptured aneurysm, endovascular therapy can be considered to be as safe and effective as clipping.

Efficacy and Safety of Proton Beam Therapy for Primary Optic Nerve Sheath Meningioma.

PURPOSE: Management of optic nerve sheath meningiomas (ONSM) remains challenging. Photon radiation therapy (PhRT) is the most common treatment for sight-threatening ONSM. Proton beam therapy (PBT) is less commonly used because it is more expensive and because there are questions about its efficacy specifically in relation to ONSM. PBT has the theoretical advantage of reducing radiation exposure to adjacent structures. We report the visual outcome of patients with primary ONSM managed at the Fondation Ophtalmologique Adolphe de Rothschild, Paris, France, and treated with PBT at the Centre de Protonthérapie, Institut Curie, Orsay, France. METHODS: We conducted a retrospective review of all patients with primary ONSM who received PBT (either by itself or following surgery) between January 2006 and January 2019. Neuro-ophthalmic examinations were performed at presentation and after radiotherapy, and, when applicable, after surgery. Meningiomas were measured at the time of diagnosis and at each follow-up MRI examination. RESULTS: Sixty patients (50 women, 10 men; mean age, 45.2±11.1y) were included, of whom 29 underwent surgery. At presentation, 52 (87%) of them had decreased vision (average visual acuity: 0.6 logMAR). Fundus examination showed optic disc swelling (n=27; 46.5%), optic disc pallor (n=22; 37.9%), optic disc cupping (n=2; 3.4%), opto-ciliary shunt (n=8; 13.8%), or choroidal folds (n=5; 8.6%). Otherwise, it was unremarkable (n=7; 12.1%). After treatment, visual function was stable overall. Fundus examination showed pallor (n=47; 83.9%), swelling (n=3; 5.4%), or cupping (n=2; 3.4%) of the optic disc, or was unremarkable (n=5; 8.9%). The visual field of 8 patients worsened, while 3 developed asymptomatic retinal hemorrhages. Tumor shrunk significantly in 8 patients at 1 year after PBT and remained stable in size in all others. Patients with opto-ciliary shunts had significantly worse visual outcome than other patients. Retinal abnormalities were observed in 11 patients during follow-up. CONCLUSION: PBT alone or in association with surgery appears to be a safe and efficient treatment for ONSM, reducing the tumor size and stabilizing visual function. The risk of developing radiation retinopathy seems to be higher when patients had upfront surgery.

Brain ventricular wall movement assessed by a gated cine MR trueFISP sequence in patients treated with endoscopic third ventriculostomy.

The purpose of this study was to investigate the value of brain ventricular wall movement assessment with a gated cine trueFISP MR sequence for the diagnosis of endoscopic third ventriculostomy (ETV) patency. Sixteen healthy volunteers and ten consecutive patients with noncommunicating hydrocephalus were explored with a MR scanner (Siemens, Avanto 1.5 T) before, 1 week and 3 months after ETV. TrueFISP was evaluated qualitatively (ventricular wall movement and CSF flow through ETV) and quantitatively [distance moved (DMLT) during a cardiac cycle by the lamina terminalis]. The third ventricle volume (TVV) was assessed. Statistical analysis was performed using nonparametric tests. There was no motion of the lamina terminalis (LT) detected on preoperative data. A pulsatile motion of the LT was found for patients with a patent ETV and for controls. DMLT and TVV were correlated (r = 0.79, P = 0.006). A transient dysfunction of ETV was successfully diagnosed on the trueFISP sequence with no motion of the LT or CSF flow observed. The trueFISP sequence appears reliable for the diagnosis of ETV patency and provides non-invasive assessment of the movement of the ventricular wall related to CSF pressure changes.

Successful Use of Recombinant Activated Factor VII to Reverse Ticagrelor-Induced Bleeding Risk: A Case Report.

Management of ticagrelor-associated bleeding is challenging, especially in neurosurgery. Platelet transfusion is inefficient and no antidote is currently available. We report here the first case of recombinant activated factor VII (rFVIIa) use to bypass ticagrelor-induced platelet inhibition. A woman treated with ticagrelor and requiring emergent neurosurgery for an intracranial hematoma received preoperative high-dose platelet transfusion and 60 µg/kg rFVIIa. Laboratory monitoring demonstrated that platelet transfusion failed to reverse ticagrelor-induced platelet inhibition while rFVIIa improved hemostasis by shortening the thromboelastometric clotting time. Neurosurgery occurred without any bleeding event but the patient presented with a postoperative pulmonary embolism. In conclusion, rFVIIa may decrease ticagrelor-induced bleeding risk but careful assessment of the benefit-risk balance is warranted before using rFVIIa to reverse ticagrelor effects.