Microsurgical thrombectomy: where the ancient art meets the new era.

Mechanical thrombectomy (MT) is the leading treatment for acute large vessel occlusion (LVO). However, surgical thrombectomy (ST) may have a role in well selected LVO patients where MT failed to re-establish flow, the endovascular route is inaccessible, or where MT is a financially prohibitive or absent option (developing and poor countries). We compared the efficacy and efficiency between ST and MT, and described our operative experience and its potential application in the developing world. Clinical outcomes, procedural times, and efficacy of treatment were compared between the MT and ST of acute LVO between 2012 and 2022. Propensity score-matched analysis was also conducted to compare MT and ST. One-hundred nine patients fulfilled the study criteria (77 MTs vs 32 STs). Factors driving outcome were age (aOR: 0.95, 95%CI, 0.91-0.98), hemisphere side (aOR: 0.38, 95%CI, 0.15-0.96), and DWI-ASPECT (aOR: 1.39, 95%CI, 1.09-1.77) at presentation by the multivariate analysis. Times from door-start of procedure (P = 0.45) and start of procedure-recanalization (P = 0.13) were similar between treatment options. Propensity score-matched analysis found no significant difference for 2 treatment methods about time of door to recanalization (P = 0.155) and outcome (P = 0.221). The prognosticators of thrombectomy for acute LVO in patients with successful recanalization were age, affected hemisphere side, and DWI-ASPECT score. Our evidence shows that the efficacy of ST is similar to that of MT. There should be a place of ST for cases of mechanical failure or tandem cervical ICA and MCA occlusion. ST may be a temporizing LVO treatment option in healthcare systems where MT is inexistent or financially prohibitive to patients.

Clinical prediction score for prolonged length of hospital stay in aneurysmal subarachnoid hemorrhage.

BACKGROUND: Length of stay (LOS) is an important indicator of the optimization of health services and hospital financing efficiency in aneurysmal subarachnoid hemorrhage (aSAH) patients. The purpose of this study was to develop a scoring model to predict the LOS of patients with aSAH. METHOD: A clinical scoring was developed based on retrospectively collected data from the cerebral aneurysm registry of the National Brain Center Hospital, Jakarta, from January 2019 to June 2022. Multivariate logistic regression was used to determine the odds ratio for risk-adjusted prolonged LOS. LOS predictors were obtained based on the regression coefficients and converted into a point score model. RESULTS: Of the 209 aSAH patients observed, 117 patients had prolonged LOS (> 14 days of hospital stay). A clinical score was developed with a range of 0-7 points. Four variables were chosen as predictors of prolonged LOS: the presence of high-grade aSAH (1 point), aneurysm treatment (endovascular coiling: 1 point; surgical clipping: 2 points), cardiovascular comorbidities (1 point), and hospital-acquired pneumonia (3 points). The score showed good discrimination with an area under the receiving operating characteristics curve (AUC) of 0.8183 (SE 0.0278) and a p-value for the Hosmer-Lemeshow (HL) goodness-of-fit of 0.9322. CONCLUSION: This simple clinical score reliably predicted prolonged LOS in aneurysmal subarachnoid hemorrhage cases and may aid clinicians in improving patient outcomes and decreasing healthcare costs.

Analyzing the cost-effectiveness of microvascular decompression and percutaneous radiofrequency rhizotomy for trigeminal neuralgia: the role of clinical classification.

Trigeminal neuralgia (TN) is a neuropathic pain that can be treated with microvascular decompression (MVD) or percutaneous radiofrequency rhizotomy (PRR) when medications fail. However, the cost-effectiveness of these interventions is uncertain, and it is unclear whether TN should be considered as a single entity for cost-effectiveness analysis. To address these issues, a prospective cohort study was conducted between 2017 and 2020, documenting Burchiel et al.'s clinical classification, pain-free survival, complications, and costs. Two models of quality-adjusted life years (QALYs) were calculated: pain-specific (PQALY) and pain-complication-specific (PCQALY), based on pain-free survival and complications data, followed by cost-effectiveness analysis. The study included 112 patients, of whom 70 underwent MVD and 42 underwent PRR. Our findings revealed that MVD was less cost-effective in the PCQALY model than PRR, but more cost-effective in the PQALY model and had an incremental cost-effectiveness ratio (ICER) that met the World Health Organization cost-effectiveness threshold in both models. Further clinical classification analysis showed that MVD was only cost-effective in type 1 TN patients, with an ICER of 0.9 and 1.3 times the GDP/capita, based on PQALY and PCQALY, respectively, meeting the cost-effectiveness criteria. Conversely, MVD was economically dominated by PRR for type 2 TN patients based on PQALY. These findings indicate that PRR may be more cost-effective for type 2 TN patients, while MVD remains the cost-effective option for type 1 TN patients. Our study highlights the importance of clinical classification and complication in determining the cost-effectiveness of MVD and PRR for refractory TN.

Bypass Surgery for Vertebral Artery and Posterior Inferior Cerebellar Artery Fusiform Aneurysms: Surgical Technique and Key Lessons.

Fusiform vertebral artery (VA) aneurysms are challenging to treat due to their pathophysiology, morphology, and anatomic location.1,2 Endovascular treatments are considered to be a widely adopted safe option for this pathology.1 Open microsurgical treatment is considered for complex anatomy, important branch involvement, poor collateral flow, or failed endovascular therapy.3-7 This report aims to show the flow-replacement strategy and bypass technique for a VA aneurysm with complex anatomy and branch involvement. A 24-year-old man presented to our clinic with a bilateral fusiform VA aneurysm discovered during workup of progressive headaches. Further investigation revealed that the left-side aneurysm was mostly thrombosed and the posterior inferior cerebellar artery arose from the aneurysm dome with a fusiform enlargement within a few millimeters from the branching point. After evaluating all management options, the patient decided on surgical treatment of the left VA aneurysm. We performed an occipital artery to posterior inferior cerebellar artery end-to-side anastomosis distal to the fusiform enlargement, followed by trapping of the aneurysm and dome resection (Video 1). Antegrade flow to the distal VA was reestablished using a radial artery interposition graft, thus preventing any flow alterations that may cause growth or rupture of the contralateral aneurysm caused by increased hemodynamic stress if the ipsilateral VA flow is not preserved.8 After in-hospital physical rehabilitation, the patient was discharged with a modified Rankin Scale score of 1. The contralateral aneurysm is managed with serial imaging and treatment will ensue if there is clinical-radiologic evolution. The patient consented to the procedure and publication of his image.

Training in Sylvian Arachnoid Dissection: The Art of Using Kamiyama Scissors and a Simple Novel Model for Practice Sylvian Arachnoid Dissection Using Cotton Fiber with Brain Model.

Background Transsylvian approach is one of the main approaches for a variety of vascular, tumor, and skull-base lesions. Sylvian fissure harbors a lot of critical structures including the middle cerebral artery and many venous structures. If not done properly, the transsylvian approach could cause several complications. Up to now, there is no simple training model for practicing Sylvian fissure dissection. In this article, we describe the technique of using microscissors for the sharp dissection of arachnoid trabeculae. We also propose a new model for practicing Sylvian arachnoid dissection using a three-dimensional (3D) brain model with cotton fiber. Materials and Method We inserted cotton fiber into the Sylvian fissure of the brain model (aneurysm box from UpsurgeOn) and covered the Sylvian fissure with a cotton sheet, then sprayed the water over it. We dissected this model under a microscope by using Kamiyama scissors in the right hand and suction in the left hand. Result Under the microscope, our model appears comparable with the real Sylvian fissure. We can use this model for practicing arachnoid dissection with Kamiyama scissors. Conclusion The arachnoid dissection model by using a 3D brain model with cotton fiber is a simplified and novel approach for practicing the Sylvian fissure dissection.

A Practical Guide to Train the Side-to-side Anastomosis: Tips, Tricks and Technical Nuances.

BACKGROUND: Microanastomosis presents a challenge in neurosurgical procedures, requiring specialized skills. Regular practice outside the operating room is crucial. This study aims to provide a detailed description of the side-to-side anastomosis technique and analyze its advantages in preventing failures compared with other variations. METHODS: We examined the technique, characteristics, and outcomes of side-to-side bypass procedures for complex aneurysms in the anterior cerebral artery territory at our institution over the past decade. We compared our technique with those described in the literature by other groups. RESULTS: The Far East Neurosurgical Institute (FENI) technique was used in 15 patients, with 17 side-to-side anastomoses performed. The average anastomosis time was 27.5 minutes, with 100% patency in follow-up. Our technique demonstrated safety and effectiveness in treating intracranial aneurysms, yielding satisfactory short- and long-term functionality outcomes. We highlight the importance of maintaining a curvilinear arteriotomy shape, at least 3 times the diameter of the artery, and utilizing an interrupted suturing technique on the anterior wall. CONCLUSIONS: This paper presents the first comprehensive description of the side-to-side anastomosis technique, supported with images and videos for training and replicability. Our technique enhances flow dynamics and reduces the risk of acute thrombus formation. Training in simulators and microsurgery practice centers outside the operating room is essential for acquiring and refining microsurgical skills.

Risk factors of cerebral aneurysms rupture in an Indonesian population.

BACKGROUND: The demographic, clinical, and angiographic features of ruptured aneurysms compared to unruptured cerebral aneurysms in Indonesia are still limited. This study aims to determine risk factors for rupture according to clinical patterns and morphological features in the Indonesian population. METHOD: We retrospectively reviewed all cerebral aneurysm registries at the largest comprehensive stroke center in Indonesia from January 2019 to January 2022. We compared demographic and vascular risk factors as well as angiographic features between patients with ruptured and unruptured aneurysms with univariate and multivariate analyses. RESULTS: Of 275 patients, 231 (84%) had ruptured cerebral aneurysms. We found a significant difference between the ruptured and unruptured groups in variables such as age, hypertension, dyslipidemia, smoking, location, and type of aneurysm. It was found that only the anterior circulation site (OR 4.91, 95% CI 1.47-16.48; p < 0.01) and saccular type (OR 5.45, 95% CI 1.42-20.93; p = 0.01) were significantly linked to ruptured aneurysms. CONCLUSION: Our findings revealed that anterior location and saccular type were substantially linked with ruptured aneurysms in the Indonesian population.

Adaptative Diploic Vein Bypass of the Superior Sagittal Sinus in a Large Falcine Meningioma.

We describe an adaptative bypass at the posterior third of the superior sagittal sinus (SSS) through the parietal diploe veins related to a large falcine meningioma on a 55-year-old lady with progressive headaches and mild left hemiparesis. Cranial imaging revealed a large tumor at the posterior third of the cerebral falx, compatible with meningioma. Imaging also revealed lack of continuity of the superior sagittal sinus at that region. Large diploic veins were seen bypassing the segment of the SSS affected by the tumor. An "L"-shaped modified posterior interhemispheric craniotomy was performed to avoid traversing the diploic veins. Near-total resection of the meningioma was accomplished. Postoperative imaging revealed a small remnant invading the SSS, which was treated with adjuvant radiotherapy. The patient tolerated the procedure well and was discharged to rehabilitation unit on postoperative day 5 with no neurologic deficits.

Dome Resection and End-to-End Reanastomosis for a Middle Cerebral Artery Fusiform Aneurysm of the M1 Segment: 2-Dimensional Operative Video.

Fusiform aneurysms of the middle cerebral artery (MCA) are both relatively uncommon and challenging to treat given their pathophysiology, morphology, and anatomy (e.g., perforating arteries involvement).1,2 Endovascular treatment of fusiform MCA aneurysms can achieve good outcomes in well-selected cases.3,4 Open microsurgical strategies are effective in a case of fusiform MCA aneurysms with complex anatomy or perforator involvement.2,5,6 We demonstrate the bypass strategy for resection of a fusiform M1 MCA aneurysm (Video 1). A 48-year-old female was referred for the treatment of a growing incidental right M1 MCA fusiform aneurysm. Imaging showed a tortuous M1 segment with no apparent perforator involvement, which we considered a candidate for resection and reanastomosis. A modified minipterional transsylvian approach was performed as described earlier.7,8 A double superficial temporal artery to middle cerebral artery bypass was performed to maintain flow to MCA territory and distal perforators in anticipation of a long temporary flow arrest due to complex aneurysmal dissection and reanastomosis and also to serve as long-term protective insurance. Resection and end-to-end reanastomosis will preserve the antegrade flow and prevent the risk stump thrombosis carried by a simple trapping.9,10 We cover the nuances of this technique including key steps to an efficient aneurysmal resection and complication avoidance. The patient tolerated the procedure well, and postoperative imaging showed no aneurysmal remnant and flow restoration with no evidence of stroke. We discharged the patient home with a modified Rankin scale of 0. The patient consented to the procedure and publication of his or her image.

Clinical and Morphological Factors for Ruptured Anterior Communicating Artery Aneurysms.

Introduction: The anterior communicating artery (ACoA) aneurysm, the most frequent cerebral aneurysm to rupture, carries a significant clinical burden, yet the factors influencing its rupture are limited in Indonesia. This study aims to determine the clinical and morphological features associated with ruptured ACoA compared to non-AcoA aneurysms among Indonesians. Patients and Methods: We retrospectively reviewed our center's aneurysm patient registry from January 2019 to December 2022, and compared the clinical and morphological features between ruptured ACoA aneurysms and ruptured aneurysms elsewhere with univariate and multivariate analyses. Results: Of the 292 patients with 325 ruptured aneurysms, 89 were from ACoA. The mean age of patients was 54.99 years, with female preponderance in the non-ACoA group (non-ACoA: 73.31%, ACoA: 46.07%). On univariate analysis, ages ≥60 [ages 60-69: OR = 0.311 (0.111-0.869), p=0.026; ages ≥70: OR = 0.215 (0.056-0.819), p=0.024], female gender [OR = 0.311 (0.182-0.533), p<0.001], and smoking [OR=2.069 (1.036-4.057), p=0.022] exhibited significant association with ruptured ACoA aneurysm. On multivariate analysis, only the female gender was independently associated with ruptured ACoA aneurysm (aOR 0.355 [0.436-1.961], p=0.001). Conclusion: In our study, ruptured ACoA aneurysm was inversely associated with advanced age, female gender, presence of daughter aneurysm, and directly associated with smoking. After multivariate adjustment, the female gender showed an independent association with ruptured ACoA aneurysm.

Single-surgeon approach in microvascular decompression for trigeminal neuralgia: Lessons from an Indonesian Tertiary-Level Neurological Center.

BACKGROUND: Microvascular decompression (MVD) is effective for refractory trigeminal neuralgia (TN), but its accessibility is often limited in lower-to-middle-income countries (LMICs). This study aims to assess the impact of implementing a single-surgeon policy on MVD for TN in LMICs. METHODS: A prospective cohort study was conducted from 2014 to 2020, comparing outcomes between multi-surgeon and single-surgeon policies. Residents were included in MVD procedures starting in 2019. The Barrow Neurological Institute (BNI) pain scale (P), numbness scale (N), and result conclusion scale (P + N) were used to evaluate outcomes (1 week, 1 month, 1 year, and yearly thereafter). Propensity score matching was performed before comparing the groups. Pain-free survival was assessed using Kaplan-Meier and Cox-regression analysis. RESULTS: We comprehensively analyzed data from 72 patients with a minimum one-year follow-up. The implementation of the single-surgeon policy had several notable impacts. Firstly, it led to an increased referral rate (p < 0.05) and a reduced duration to surgery (p < 0.05). During MVD, there was a significant increase in the identification of complex compression (p < 0.05) and a reduced frequency of internal neurolysis (p < 0.05). After surgery, the single-surgeon group exhibited a superior pain-control profile (RR 1.9, p < 0.001; ARR 26-36%), higher pain-free survival rate (p < 0.001), lower likelihood of pain recurrence (HR 0.2, p < 0.0001), and fewer additional surgical interventions compared to the multi-surgeon group. Moreover, the involvement of residents did not significantly impact surgical outcomes. CONCLUSIONS: Implementing a single-surgeon policy for MVD in LMICs has the potential to improve surgical outcomes, provide social benefits, and offer educational opportunities.

Case report: Teflon granuloma following microvascular decompression manifesting as light-triggered trigeminal neuralgia.

Trigeminal Neuralgia is commonly triggered by stimuli in the area of the trigeminal nerve innervation. We report an exceptionally rare case of a 61-year-old woman who complained of recurrent trigeminal neuralgia, which sole trigger was seeing a bright light. Teflon felt that was placed on the nerve root in the initial surgery was suspected of causing this rare type of trigeminal neuralgia. A reflex circuit linking luminance to trigeminal nerve activity may be implicated in activating a trigeminal nociceptive pathway by a bright light trigger.

Awake Craniotomy in a Low- to Middle-Income Country: A Sustainability Analysis.

OBJECTIVE: This study evaluated the sustainability of teaching awake craniotomy in Indonesia. We explored the factors affecting how awake craniotomy can be taught in a low- to middle-income (LMIC) country and the factors affecting the utilization of awake craniotomy in Indonesia. METHODS: This is a prospective mixed-methods study in Indonesia. A questionnaire was administered to 100 neurosurgeons at a conference on their experience with neuro-oncology, awake craniotomy, and teaching missions. Thirty-three physicians participated in semi-structured interviews elaborating on these topics. Data on tumor caseload and resources were collected. RESULTS: Thirty-three of 88 respondents (41.3%) indicated that they still perform awake craniotomy. Although 87.3% felt that it was beneficial for patients and resource sparing, less than a quarter of them felt they had sufficient exposure/training in awake craniotomy. Almost all of them wanted further training and to maintain a relationship with international mentors. Four themes emerged about the factors that affect how we teach awake craniotomy in an LMIC: 1) the sustainability of a teaching mission is dependent on a culture of information sharing and 2) the support of multiple health care providers; 3) hospital structure affects how changes are implemented; and 4) health care professionals in Indonesia value opportunities for international training. Regarding the uptake of awake craniotomy in Indonesia, there are sociocultural factors that affect patients' receptiveness to surgery and the national insurance plan restricts the provision of neurosurgical care. CONCLUSIONS: Many factors need to be explored when planning a neurosurgical mission in LMICs to ensure its sustainability.