Quality of Life of Patients with Unruptured Intracranial Aneurysms Before and After Endovascular Coiling: A HEAT Trial Secondary Study and Systematic Review of the Literature.

BACKGROUND: The study of quality of life (QOL) in patients with asymptomatic diseases receiving interventional treatment provides an essential metric for the assessment of procedural benefits in the surgical patient population. In this study, we analyzed QOL data collected from patients with unruptured intracranial aneurysms (UIAs) before and after endovascular coiling in the HEAT Trial, alongside a systematic review on QOL in unruptured brain aneurysms. METHODS: HEAT was a randomized controlled trial comparing recurrence rates in aneurysms treated with either bare platinum coils or hydrogel coils. Patients enrolled in this trial completed a short form-36 (SF-36) QOL questionnaire before treatment and at the 3- to 12- and 18- to 24-month follow-ups. The change in QOL before and after treatment was assessed. Regression analysis evaluated the effect of select baseline characteristics on QOL change. RESULTS: A total of 270 patients were eligible for analysis. There was an increase in the role physical (P = 0.043), vitality (P = 0.022), and emotional well-being (P < 0.001) QOL components at the 18- to 24-month follow-up compared with baseline scores. Regression analysis showed that age younger than 60 and absence of serious adverse events were associated with improved social functioning and vitality. The literature review showed a mixed effect of intervention on QOL in patients with UIAs. CONCLUSIONS: Our analysis has revealed that patients with 3- to 14-mm UIAs had improvements in some physical and emotional components of QOL at 18-24 months following aneurysm coiling in the HEAT study. The literature remains indeterminate on this issue. Further studies are needed to better understand the effects of the diagnosis of UIAs and their treatment on QOL.

Superficial Temporal Artery-Middle Cerebral Artery Bypass Ex Vivo Hybrid Simulator: Face, Content, Construct, and Concurrent Validity.

BACKGROUND: Cerebrovascular bypass surgical procedures require highly developed dexterity and refined bimanual technical skills. To attain such a level of prowess, neurosurgeons and residents have traditionally relied on "flat" models (without depth of field), such as chicken wings, live rats, silicone vessels, and other materials that stray far from the reality of the operating room, albeit more accessible. We have explored the use of a hybrid ex vivo simulator that takes advantage of the availability of placenta vessels and retains the complexity of surgery performed on a human skull to create a more realistic method for the development of cerebrovascular bypass surgical skills. METHODS: Twelve ex vivo simulators were constructed using 3 human placentas and 1 synthetic human skull for each. Face, content, construct, and concurrent validity were assessed by 12 neurosurgeons (6 trained vascular surgeons and 6 general neurosurgeons) and compared with those of other bypass models. RESULTS: The fidelity grade was ranked as low (Linkert scale score, 1-2), medium (score, 3), and high (score, 4-5). The face and content validity of the model showed high fidelity to superficial temporal artery-middle cerebral artery bypass surgery. Construct validity showed that cerebrovascular neurosurgeons had better performance, and concurrent validity highlighted that all surgical steps were present. CONCLUSION: The simulator was found to have strong face and content, construct, and concurrent validity for microsurgical cerebrovascular training, allowing for simulation of all surgical steps of the bypass procedure. The hybrid simulator seems to be a promising method for shortening the bypass surgery learning curve. However, more studies are required to evaluate the predictive validity of the model.

Surgical Outcomes with Midline versus Lateral Approaches for Cranial Base Chordomas: A Systematic Review and Meta-Analysis.

BACKGROUND: Cranial base chordomas are complex lesions centered on the clivus that surgically can be approached from either a midline or a lateral corridor. OBJECTIVE: To compare the surgical outcomes from midline versus lateral approaches by conducting a meta-analysis of the literature. METHODS: Studies were identified between 2000 and 2018. The primary outcome was gross total resection (GTR) rate. The secondary outcomes were recurrence rate and rates of cerebrospinal fluid (CSF) leak and new cranial nerve palsy. Odds ratios were calculated with a random-effect model using studies describing both approaches. An indirect (proportion) meta-analysis was performed pooling studies describing either of the approaches. Individual patient data were analyzed for differences in GTR or recurrence rate with different tumor extensions. RESULTS: Thirty-three studies were found suitable for indirect meta-analysis and 10 studies for direct meta-analysis. The overall odds of GTR with a midline approach compared with a lateral approach was 0.83 (95% confidence interval [CI], -0.43 to 1.62). The odds ratios for recurrence, CSF leak, and new cranial nerve palsy were 0.82 (95% CI, 0.26-2.56), 1.49 (95% CI, 0.14-15.5), and 0.14 (95% CI, 0.04-0.56), respectively. With individual patient data analysis, no statistically significant difference was observed in GTR or recurrence rates between the 2 approaches with different tumor extensions. CONCLUSIONS: The meta-analysis did not show any significant difference in GTR or recurrence rates between the midline versus lateral approaches. Tumor extension to different compartments did not affect the GTR or recurrence rates with either approach. In terms of complications, CSF leak rate was higher in midline approaches and cranial nerve palsy was higher in lateral approaches.

Extended Lateral Orbital Craniotomy: Anatomic Study and Initial Clinical Series of a Novel Minimally Invasive Pterional Approach.

Background Of the minimally invasive "keyhole" alternatives to the pterional region, the supraorbital eyebrow approach is the most widely adopted. Yet it can prove disadvantageous when a more direct lateral microsurgical trajectory of attack to the Sylvian fissure and anterior middle fossa are needed. Objective The extended lateral orbital (XLO) approach was designed to be direct and minimally invasive, with the sphenoid ridge at the center of exposure. Methods Five injected cadaver heads were used for anatomic study of the XLO approach. The anatomic course of the frontalis branch of facial nerve was studied in relation to the XLO incision. Following XLO incision, the bone exposure was measured. The intracranial microsurgical exposure was assessed subjectively. Application of the technique in representative clinical operative cases is provided. Results The frontalis nerve was protected in the subgaleal fat pad, with an average minimum distance of 2.3 cm from the XLO incision. The mean calvarial area exposure was 4.95 cm 2 and consistently centered on the sphenoid ridge. Excellent access to ipsilateral Sylvian's fissure, perisylvian regions, and supra-/parasellar structures was possible. The main limitations related to exposure of the posterior Sylvian fissure and the expected limitations of microsurgical instrument manipulation from a smaller craniotomy. Conclusions The XLO approach is a minimally invasive keyhole approach to the pterional region that affords a unique lateral trajectory via a craniotomy centered on the sphenoid ridge. Excellent exposure to properly selected lesions is possible. The incision is at a safe distance from the frontalis branch and shows excellent cosmetic healing.

Use of Pheno Room, Augmented Reality, and 3-Rod Technique for 3-Dimensional Correction of Adolescent Idiopathic Scoliosis.

This is a surgical video that showcases the surgical repair of a young male patient with idiopathic scoliosis in a hybrid operating room with the utilization of a new imaging modality Advanced Radar Target Identification System (ARTIS) PHENO (Siemens Medical Solutions, Pennsylvania, USA) and augmented reality (Video 1). A 17-year-old male patient with idiopathic scoliosis underwent scoliosis repair in a hybrid operating room with segment reality surgical planning. The use of augmented reality helped in visualization of proper screw trajectory, and the use of ARTIS PHENO helped in identification of correct screw placement and rod fixation. Intraoperative use of new imaging modalities as augmented reality imaging and ARTIS PHENO can decrease surgical complication and time.

Surgical correction of proximal junctional kyphosis.

This 3D video showcases the surgical techniques for patients with proximal junctional kyphosis. The surgical repair for patients with proximal junctional kyphosis is an individualized approach depending on patient history and imaging with adequate surgical measurements. This video will shed light on two cases with proximal junctional kyphosis and the method taken for their repair. The first case is of an 11-year-old female known to have osteogenesis imperfecta and status post T5-L3 posterior spinal fusion with segmental instrumentation. The patient underwent change of older instruments and scoliosis repair, with full correction on postoperative x-ray. The second patient is a 16-year-old male known to have cerebral palsy and kyphoscoliosis status post spinal fusion. The patient underwent scoliosis repair surgery with replacement of old instrumentation and scoliosis correction. The video can be found here: https://youtu.be/f5iLwqbU26Q.

The Use of 5-Aminolevulinic Acid in Low-Grade Glioma Resection: A Systematic Review.

BACKGROUND: For optimizing high-grade glioma resection, 5-aminolevulinic acid is a reliable tool. However, its efficacy in low-grade glioma resection remains unclear. OBJECTIVE: To study the role of 5-aminolevulinic acid in low-grade glioma resection and assess positive fluorescence rates and the effect on the extent of resection. METHODS: A systematic review of PubMed, Google Scholar, and Cochrane was performed from the date of inception to February 1, 2019. Studies that correlated 5-aminolevulinic acid fluorescence with low-grade glioma in the setting of operative resection were selected. Studies with biopsy only were excluded. Positive fluorescence rates were calculated. The quality index of the selected papers was provided. No patient information was used, so Institutional Review Board approval and patient consent were not required. RESULTS: A total of 12 articles met the selection criteria with 244 histologically confirmed low-grade glioma patients who underwent microsurgical resection. All patients received 20 mg/kg body weight of 5-aminolevulinic acid. Only 60 patients (n = 60/244; 24.5%) demonstrated visual intraoperative 5-aminolevulinic acid fluorescence. The extent of resection was reported in 4 studies; however, the data combined low- and high-grade tumors. Only 2 studies reported on tumor location. Only 3 studies reported on clinical outcomes. The Zeiss OPMI Pentero microscope was most commonly used across all studies. The average quality index was 14.58 (range: 10-17), which correlated with an overall good quality. CONCLUSION: There is an overall low correlation between 5-aminolevulinic acid fluorescence and low-grade glioma. Advances in visualization technology and using standardized fluorescence quantification methods may further improve the visualization and reliability of 5-aminolevulinic acid fluorescence in low-grade glioma resection.

Vascular Transposition of the Superior Cerebellar Artery Using a Fenestrated Clip and Fibrin Glue in Trigeminal Neuralgia: 2-Dimensional Operative Video.

This is the case of an 86-yr-old gentleman who presented with left facial pain exacerbated by eating, drinking, chewing, and shaving (distribution: V2, V3). The patient was diagnosed with trigeminal neuralgia and was refractory to medications. Imaging showed a superior cerebellar artery (SCA) loop adjacent to the trigeminal nerve root entry zone and a decision to perform a microvascular decompression of the fifth nerve was presented to the patient. After patient informed consent was obtained, a standard 3 cm × 3 cm retrosigmoid craniotomy was performed with the patient in a supine head turned position and in reverse Trendelenburg. The arachnoid bands tethering the SCA to the trigeminal nerve were sharply divided. A slit was then made in the tentorium and a 3 mm fenestrated clip was then used to secure the transposed SCA away from the trigeminal nerve. The SCA proximal to this was slightly patulous in its course so a small amount of a fibrin glue was also used to secure the more proximal SCA to the tentorium. The patient was symptom-free postoperatively and no longer required medical therapy. Additionally, imaging was consistent with adequate separation of the nerve from adjacent vessels.1-5.

Microvascular Decompression and Transposition of the 8th Cranial Nerve Using a Fenestrated Clip.

Neurovascular compression is a potential, yet rare cause of vertigo and unilateral tinnitus. Despite the high success rate of microvascular decompression (MVD) in other vascular compression syndromes, the outcome reported after MVD of the vestibulocochlear nerve is variable.1,2 The presence of combined symptoms of tinnitus and vertigo treated by MVD has demonstrated a higher predictive value for success.3 In this video, we present the case of a 68-year-old male who presented with vertigo and tinnitus refractory to medical management and vestibular therapy. Audiologic evaluation was normal apart from mild sensorineural hearing loss. Vestibular testing was suggestive of uncompensated right peripheral vestibulopathy. Magnetic resonance imaging with fast imaging employing steady-state acquisition sequences revealed vascular compression by the right anteroinferior cerebellar artery (AICA) at the cisternal component of vestibulocochlear nerve. After a multidisciplinary discussion, a microvascular decompression was performed through a right retrosigmoid craniotomy. The AICA was mobilized off the vestibulocochlear nerve and was secured to the petrous dura using a fenestrated clip. Indocyanine green angiography with Glow-800 was conducted before and after AICA transposition to confirm adequate flow through the mobilized vessel. Postoperatively, the patient's vestibular symptoms improved significantly. This case demonstrates that microvascular decompression can provide a satisfactory outcome in patients with unilateral tinnitus and vertigo associated with vascular compression in appropriately selected cases (Video 1).

Utility of Augmented Reality Imaging (GLOW800) in Resection of Hemangioblastoma.

This is a surgical video that sheds light on the utility of a new imaging modality GLOW800 (Leica Microsystems, Wetzlar, Germany) in resection of vascular tumors. We describe the surgical resection of posterior fossa hemangioblastoma in 2 different patients after informed consent was obtained. In the first case no intraoperative angiographic imaging was used, while in the second case GLOW800 was used. Because of its ability to overlay the augmented reality view on the surgical field, it allowed for localization of highly vascular tumors as seen in the second patient. In addition, it helped in the confirmation of complete resection of the lesion. Another advantage of GLOW800 was that it allowed safe resection of the lesion in and around highly eloquent areas with a narrow surgical corridor (Video 1).

Roberts Bartholow: the progenitor of human cortical stimulation and his contentious experiment.

Roberts Bartholow, a physician, born and raised in Maryland, was a surgeon and Professor in Medicine who had previously served the Union during the Civil War. His interest in scientific research drove him to perform the first experiment that tested the excitability of the human brain cortex. His historical experiment on one of his patients, Mary Rafferty, with a cancerous ulcer on the skull, was one of his great accomplishments. His inference from this experiment and proposed scientific theory of cortical excitation and localization in humans was one of the most critically acclaimed topics in the medical community, which attracted the highest commendation for the unique discovery as well as criticism for possible ethical violations. Despite that criticism, his theory and methods of cortical localization are the cornerstone of modern brain mapping and have, in turn, led to countless medical innovations.

Tulip Giant Aneurysm Amputation and "Shingle Clip Cut Clip" Technique for Microsurgical Reconstruction of a Giant Thrombosed Middle Cerebral Artery Aneurysm.

In this video, we present the case of a 61-year-old female who was brought to the emergency department after she had partial complex seizures. Computed tomography and magnetic resonance imaging of the brain revealed a right temporal lobe mass, which was initially thought to be a tumor. The patient was therefore referred to us for further management. The round nature of the lesion raised suspicion for an aneurysm. Computed tomography angiography was performed, followed by a diagnostic conventional cerebral angiogram, and confirmed the presence of a giant thrombosed aneurysm. Giant aneurysms represent 3%-5% of all cerebral aneurysms.1 They are more common in females with a ratio of 2:1 to 3:1.1 They have a high risk of rupture up to 50% in the posterior circulation and 40% in the anterior circulation over 5 years according to the International Study of Unruptured Intracranial Aneurysms Investigators.2,3 Their treatment can be complex and treacherous. Treatment options vary widely from parent artery sacrifice in select cases to clip reconstruction to an array of endovascular approaches such as flow diversion. In some cases a combination of both open and endovascular approaches might be necessary.4-8 In our case, we opted for an open surgical clip reconstruction. A superior temporal artery-middle cerebral artery bypass was attempted to allow for trapping of the aneurysm without risking ischemic complication distal to it. Unfortunately, the patient's vessels were too atherosclerotic to maintain patency. A strategy was then devised, which consisted of cutting the dome of the aneurysm and clearing the distal two thirds of the clot ("tulip technique") and then completing thrombus resection under temporary occlusion. Once clot removal was completed, the aneurysm was clipped using the "shingle clip cut clip" technique (Video 1). The patient's postoperative course was uneventful, and the patient remained seizure free.

Lateral supracerebellar infratentorial approach for pontomesencephalic cavernous malformations.

Cavernomas at the posterolateral pontomesencephalic surface can be approached from a lateral infratentorial supracerebellar corridor. In this surgical video, we demonstrate two cases of brainstem cavernomas resected through a lateral supracerebellar infratentorial approach. A supine position with lateral turn of the head was used along with significant reverse Trendelenburg to allow the cerebellum to fall away with gravity from the tentorium. After exposure of the posterior surface of the brainstem between the tentorium and the superior cerebellar surface with aid of neuronavigation, the cavernomas were safely resected. The video can be found here: https://youtu.be/fUDdaprg26Y.

Treatment Strategy of a Patient With a Brain Arteriovenous Malformation and Cranial Dural Fistula: 2-Dimensional Operative Video.

We present the case of a 56-yr-old right-handed male, after informed consent was obtained, who presented with acute confusion and agitation, on the background of a remote history of an uncomplicated resection of a left parietal grade 2 glioma. Imaging revealed a large, acute right temporal intracerebral hemorrhage (ICH). Standard vascular workup for the cause of the ICH included catheter angiography. No direct cause of the hemorrhage was revealed; however, a high grade parasagittal dural arteriovenous fistula (DAVF) with cortical venous reflux was noted close to the prior craniotomy site. The venous reflux was towards the left hemisphere, but it was hypothesized that similar reflux on the right side may have been present and was not presently evident due to thrombosis. The DAVF was embolized by endovascular means, followed by evacuation of the hematoma. Follow-up angiogram 7 mo later revealed a high-flow, right superior temporal cortical arteriovenous malformation (AVM). The DAVF unfortunately had also progressed. Endovascular occlusion of both lesions was attempted but was not successful. Subsequently, microsurgical resection for both the vascular malformations was performed with careful pre- and intraoperative planning to obtain a successful clinical and angiographic result. In this video, we summarize diagnostic and therapeutic nuances that have broad implications for the workup of ICH and the strategic management of a unique scenario involving a brain AVM and high-grade cranial dural fistula in the same patient. Prior to each procedure, informed consent was obtained from the patient, which includes consent for publication.