Open Microsurgical Cerebral Aneurysm Treatment After Failed Endovascular Therapy: An Evaluation of Aneurysm Treatment Frequencies in All Neurovascular Centers Across Austria and the Czech Republic Over 20 Years.

BACKGROUND AND OBJECTIVES: Endovascular treatment of cerebral aneurysms has tremendously advanced over the past decades. Nevertheless, aneurysm residual and recurrence remain challenges after embolization. The objective of this study was to elucidate the portion of embolized aneurysms requiring open surgery and evaluate whether newer endovascular treatments have changed the need for open surgery after failed embolization. METHODS: All 15 cerebrovascular centers in Austria and the Czech Republic provided overall aneurysm treatment frequency data and retrospectively reviewed consecutive cerebral aneurysms treated with open surgical treatment after failure of embolization from 2000 to 2022. All endovascular modalities were included. RESULTS: On average, 1362 aneurysms were treated annually in the 2 countries. The incidence increased from 0.006% in 2005 to 0.008% in 2020 in the overall population. Open surgery after failed endovascular intervention was necessary in 128 aneurysms (0.8%), a proportion that remained constant over time. Subarachnoid hemorrhage was the initial presentation in 70.3% of aneurysms. The most common location was the anterior communicating artery region (40.6%), followed by the middle cerebral artery (25.0%). The median diameter was 6 mm (2-32). Initial endovascular treatment included coiling (107 aneurysms), balloon-assist (10), stent-assist (4), intrasaccular device (3), flow diversion (2), and others (2). Complete occlusion after initial embolization was recorded in 40.6%. Seventy-one percent of aneurysms were operated within 3 years after embolization. In 7%, the indication for surgery was (re-)rupture and, in 88.3%, reperfusion. Device removal was performed in 16.4%. Symptomatic intraoperative and postoperative complications occurred in 10.2%. Complete aneurysm occlusion after open surgery was achieved in 94%. CONCLUSION: Open surgery remains a rare indication for cerebral aneurysms after failed endovascular embolization even in the age of novel endovascular technology, such as flow diverters and intrasaccular devices. Regardless, it is mostly performed for ruptured aneurysms initially treated with primary coiling that are in the anterior circulation.

Hydrocephalus Caused by Primary Fourth Ventricle Outlet Obstruction: Our Experience and Literature Review.

OBJECTIVE: Primary fourth ventricle outlet obstruction (PFVOO) is a rare cause of hydrocephalus with an unclear etiopathogenesis, and thus, consensus regarding the recommended treatment protocol is lacking. This study aims to summarize current knowledge of this condition in the light of our own treatment experience. METHODS: Retrospective analysis was carried out of all patients treated for noncommunicating tetraventricular hydrocephalus between 2006 and 2019, from which a subgroup of patients with PFVOO was created. A literature review of PFVOO cases was also carried out. RESULTS: A total of 62 patients with PFVOO were discovered, of whom 8 were treated at our institution, representing 3.8% of our patients with noncommunicating hydrocephalus. Patients most commonly presented with headaches, gait disturbance, or symptoms of intracranial hypertension. The mean follow-up duration was 75.4 months among our patients and 29.9 months in the literature. Most patients (54.8%) were treated by endoscopic third ventriculostomy (ETV), with the remainder undergoing suboccipital craniotomy alone (17.7%) or in combination with shunt surgery (9.7%), or endoscopic magendieplasty (12.9%). Treatment failure was noted in 28.6% of ETVs and 9% of craniotomies. No failures were recorded after endoscopic magendieplasty. The risk of treatment failure was found to be significantly higher with ETV compared with other treatment modalities (P < 0.0005). CONCLUSIONS: Despite the fact that PFVOO can be defined as an obstructive hydrocephalus, there seems to be a higher risk of ETV failure in such cases. The alternative treatment modalities presented are still recommended. Confirmation of these findings requires a larger multicenter study.

Brain abscess and pyocephalus: our experience with treatment.

INTRODUCTION: Pyocephalus always presents serious complications in the treatment of brain abscesses, and is associated with high rates of mortality and morbidity. This study aimed to comprehensively evaluate this understandably feared complication from a purely medical perspective by using an evidence-based approach and drawing comparisons from the available literature, which mostly comprises case reports. METHODS: This was a prospective monocentric study of all patients treated for brain abscesses at the Neurosurgery Clinic of the University Hospital Ostrava between 2012 and 2017. The cohort was divided into two groups for statistical comparison; one group comprised those in which pyocephalus occurred before or during treatment, while the other group comprised patients without this complication. Particular consideration was given to the effect of pyocephalus on morbidity and mortality rates and C-reactive protein levels, as well as to the identification of risk factors, and to its possible therapeutic influence. Patients were followed up for six months. RESULTS: A total of 43 patients were treated for a brain abscess. An unequivocal diagnosis of pyocephalus was established via CT and MRI brain scans in five cases (11.6%). In the cohort as a whole, mortality and morbidity rates were 23.3% and 48.8% respectively. Among patients with pyocephalus the incidence of mortality and morbidity was 40% and 66.6% respectively. The presence of pyocephalus is not a significant predictor of either morbidity (p 0.575) or mortality (p 0.664). In patients with pyocephalus, we determined elevated CRP levels on the day of surgery (p 0.038). The occurrence of epileptic seizures in the acute phase of the disease is associated with a poor outcome (p 0.039). CONCLUSIONS: Pyocephalus will continue to be a serious complication in the treatment of brain abscesses, although we were unable to determine its utility as a prognostic factor. Patients with this complication have elevated CRP levels on the day of operation.