Applicability of Bosniak 2019 for renal mass classification on portal venous phase at the era of spectral CT imaging using rapid kV-switching dual-energy CT.

OBJECTIVES: To evaluate the applicability of Bosniak 2019 criteria on a monophasic portal venous phase using rapid kilovoltage-switching DECT (rsDECT). MATERIALS AND METHODS: One hundred twenty-seven renal masses assessed on rsDECT were included, classified according to Bosniak 2019 classification using MRI as the reference standard. Using the portal venous phase, virtual monochromatic images at 40, 50, and 77 keV; virtual unenhanced (VUE) images; and iodine map images were reconstructed. Changes in attenuation values between VUE and 40 keV, 50 keV, and 77 keV measurements were computed and respectively defined as ∆HU40keV, ∆HU50keV, and ∆HU77keV. The values of ∆HU40keV, ∆HU50keV, and ∆HU77keV thresholds providing the optimal diagnostic performance for the detection of internal enhancement were determined using Youden index. RESULTS: Population study included 25 solid renal masses (25/127, 20%) and 102 cystic renal masses (102/127, 80%). To differentiate solid to cystic masses, the specificity of the predefined 20 HU threshold reached 88% (95%CI: 82, 93) using ∆HU77keV and 21% (95%CI: 15, 28) using ∆HU40keV. The estimated optimal threshold of attenuation change was 19 HU on ∆HU77keV, 69 HU on ∆HU50eV, and 111 HU on ∆HU40eV. The rsDECT classification was highly similar to that of MRI for solid renal masses (23/25, 92%) and for Bosniak 1 masses (62/66, 94%). However, 2 hyperattenuating Bosniak 2 renal masses (2/26, 8%) were classified as solid renal masses on rsDECT. CONCLUSION: DECT is a promising tool for Bosniak classification particularly to differentiate solid from Bosniak I-II cyst. However, known enhancement thresholds must be adapted especially to the energy level of virtual monochromatic reconstructions. CLINICAL STATEMENT: DECT is a promising tool for Bosniak classification; however, known enhancement thresholds must be adapted according to the types of reconstructions used and especially to the energy level of virtual monochromatic reconstructions. KEY POINTS: • To differentiate solid to cystic renal masses, predefined 20 HU threshold had a poor specificity using 40 keV virtual monochromatic images. • Most of Bosniak 1 masses according to MRI were also classified as Bosniak 1 on rapid kV-switching dual-energy CT (rsDECT). • Bosniak 2 hyperattenuating renal cysts mimicked solid lesion on rsDECT.

Incidence and clinical impact of bile ducts changes after multibipolar radiofrequency ablation for hepatocellular carcinoma.

OBJECTIVES: This study aimed to evaluate the incidence and clinical implications of bile duct changes following multibipolar radiofrequency ablation (mbpRFA) for hepatocellular carcinoma (HCC). MATERIALS AND METHODS: Radiological, clinical, and biological data from consecutive cirrhotic patients who underwent first-line mbpRFA between 2007 and 2014 for uninodular HCC ≤ 5 cm were retrospectively collected. Follow-up imaging was reviewed to identify bile duct changes and factors associated with biliary changes were assessed using multivariable analysis. Baseline and 6-month liver function tests were compared in patients with and without bile duct changes. Complications, cirrhosis decompensation, and survival rates were compared in both groups. RESULTS: A total of 231 patients (mean age 68 years [39-85], 187 men) underwent 266 mbpRFA sessions for uninodular HCC (mean size 26 mm). Of these, 76 (33%) developed bile duct changes (upstream bile duct dilatations and/or bilomas) with a mean onset time of 3 months. Identified risk factors for these changes were the infiltrative aspect of the tumor (p = 0.035) and its location in segment VIII (p < 0.01). The average increase in bilirubin at 6 months was higher in the group with biliary changes (+2.9 vs. +0.4 µg/mL; p = 0.03). There were no significant differences in terms of complications, cirrhosis decompensation at 1 year (p = 0.95), local and distant tumor progression (p = 0.91 and 0.14 respectively), and overall survival (p = 0.4) between the two groups. CONCLUSION: Bile duct changes are common after mbpRFA for HCC, especially in tumors with an infiltrative aspect or those located in segment VIII. These changes do not appear to negatively impact the course of cirrhosis at 1 year or overall survival. CLINICAL RELEVANCE STATEMENT: Bile duct changes following mbpRFA for HCC are relatively common. Nevertheless, they do not raise clinical concerns in terms of complications, deterioration in liver function, or survival rates. Consequently, specific monitoring or interventions for these bile duct changes are not warranted. KEY POINTS: • Bile duct changes are frequently observed after multibipolar radiofrequency ablation for hepatocellular carcinoma, occurring in 33% of cases in our study. • Patients with bile duct changes exhibited a higher increase in bilirubin levels at 6 months but no more cirrhosis decompensation or liver abscesses. • Biliary changes following multibipolar radiofrequency ablation for hepatocellular carcinoma are not alarming and do not necessitate any specific monitoring or intervention.

Supraorbital Keyhole Versus Pterional Approach: A Morphometric Anatomical Study.

OBJECTIVE: Although the supraorbital (SO) keyhole approach has a wide range of indications, its routine usefulness with the advance of current technology has not been fully evaluated. In an attempt to address this issue, a cadaveric morphometric analysis to the supra- and parasellar regions was performed, comparing the standard Pterional craniotomy (PT) with the SO keyhole. METHODS: ETOH-fixed and silicone-injected human cadaveric heads were used. SO (n = 8) and PT craniotomies (n = 8) were performed. Pre- and post-dissection CT, along with pre-dissection MRI scans were also completed for neuro-navigation purposes, aimed to verify predetermined anatomical landmarks selected for morphometric analysis. RESULTS: Notwithstanding the smaller craniotomy, the SO approach allowed optimal anatomical exposure when compared to the PT approach. With 30° of head rotation, the SO keyhole showed a wider surgical field of the suprasellar region. CONCLUSIONS: Using detailed preoperative image-guided surgical planning, the SO keyhole approach offered an appropriate alternative route to the supra- and parasellar regions, compared to the PT craniotomy.

Technical Feasibility of Electromagnetic US/CT Fusion Imaging and Virtual Navigation in the Guidance of Spine Biopsies.

PURPOSE: To test the technical feasibility of electromagnetic computed tomography (CT) + ultrasound fusion (US)-guided bone biopsy of spinal lesions. MATERIALS AND METHODS: This retrospective study included 14 patients referred for biopsy of spinal bone lesions without cortical disruption or intervertebral disc infection. Lesions were located in the sacrum (n = 4), lumbar vertebral body (n = 7) or intervertebral disc (n = 3). Fusion technology matched a pre-procedure CT scan with real-time ultrasound. The first six procedures were performed under both standard CT and CT + US fusion guidance (group 1). In the last eight procedures, the needle was positioned under fusion imaging guidance alone, and CT was only used at the end of needle placement to confirm correct positioning (group 2). Additionally, we retrieved 8 patients (controls) with location-matched lesions as group 2, which were biopsied in the past with the standard CT-guided technique. The procedure duration and number of CT passes were recorded. RESULTS: Mean procedure duration and median CT pass number were significantly higher in group 1 vs. group 2 (45 ±â€Š5 vs. 26 ±â€Š3 minutes, p = 0.002 and 7; 5.25-8.75 vs. 3; 3-3.25, p = 0.001). In controls, the mean procedure duration was 47 ±â€Š4 minutes (p = 0.001 vs. group 2; p = 0.696 vs. group 1) and the number of CT passes was 6.5 (5-8) (p = 0.001 vs. group 2; p = 0.427 vs. group 1). No complications occurred and all specimens were adequate overall. In one case in group 2, the needle position was modified according to CT assessment before specimen withdrawal. CONCLUSION: Electromagnetic CT+US fusion-guided bone biopsy of spinal lesions is feasible and safe. Compared to conventional CT guidance, it may reduce procedural time and the number of CT passes.

Endovascular management of the deep venous thrombosis: A new challenging role for the endovascular specialist in 2020.

Over the last years, the endovascular approach to the management of the acute and chronic deep vein thrombosis (DVT) has gained more and more attention from the scientific community. DVT is the third most common cardiovascular disease after coronary heart disease and stroke, with classic treatment based on anticoagulation. Recent evidences have highlighted the risk of postthrombotic syndrome as high as 30%-50% in proximal ilio-femoral lesions, with irreversible clinical symptoms and impact on the quality of life of the population. Since 2000s, the new concept of thrombus removal in the acute phase has been supported by the introduction of different techniques based on the endovascular ablation of the clot by in-situ fibrinolysis and, more recently, fragmentation and aspiration. In the chronic phase, recanalization of the thrombosed segment is recommended by stent placement to remove the obstruction and eventually reduce the congestion. Immediate technical success of these procedures is widely satisfying, whereas the long-term clinical benefits are still debated. This paper presents an overview of the modern management of the DVT by endovascular approach with regard to the clinical contexts, interventional strategies and clinical outcomes. Endovascular specialist needs to be aware of this incoming challenge, as local expertise is demanded for the modern management of these patients in multidisciplinary theaters.

The ipsilateral interhemispheric transprecuneal approach: microsurgical anatomy, indications, and neurosurgical applications.

Surgical treatment of intraventricular lesions is challenging because of their deep location, vascularization, and their complex relationships with white matter fibers. The authors undertook this study to describe the microsurgical anatomy of the white matter fibers covering the lateral wall of the atrium and temporal horn and to demonstrate how the ipsilateral interhemispheric transprecuneal approach can be safely used to remove lesions of this region sparing the anatomo-functional integrity of the fibers themselves. A detailed description of the approach including operative measurements is also given. The Klingler' technique with progressive identification of white matter fibers covering the lateral wall of the atrium and temporal horn was performed on ten formalin-fixed human hemispheres. Then, ten fresh, non-formalin-fixed non-silicon-injected adult cadaveric heads were analyzed for the simulation of the ipsilateral interhemispheric transprecuneal approach. Three illustrative cases are presented. The simulation of the interhemispheric transprecuneal approach on ten fresh non-formalin-fixed specimens showed that a 10 to 20 mm corticotomy perpendicular to the parieto-occipital sulcus at the junction with the cingulum allows a wide corridor for the exposure of the entire atrial cavity and the posterior third of the temporal horn. The ipsilateral interhemispheric transprecuneus approach represents a safe and effective option for tumors involving the atrium and the posterior third of the temporal horn.

The Decision-Making Process in Traumatic Lesions of the Craniovertebral Junction: An Evidence-Based Approach? Part II.

This paper is Part II of a two-part report. Part I of the report covered atlanto-occipital dislocation or dissociation, and isolated condylar fractures. This part of the report covers isolated and combination fractures of the atlas and axis.

DEB-TACE: a standard review.

Drug-eluting bead transarterial chemoembolization (DEB-TACE) is a relative new endovascular treatment based on the use of microspheres to release chemotherapeutic agents within a target lesion with controlled pharmacokinetics. This aspect justifies the immediate success of DEB-TACE, that nowadays represents one of the most used treatments for unresectable hepatocellular carcinoma. However, there is no consensus about the choice of the best embolotherapy technique. In this review, we describe the available microspheres and report the results of the main comparative studies, to clarify the role of DEB-TACE in the hepatocellular carcinoma management. We underline that there is no evidence about the superiority of DEB-TACE over conventional TACE in terms of efficacy, but there may be some benefits with respect to safety especially with the improvement of new technologies.

Clinical impact of computed tomography in the emergency department in nontraumatic chest and abdominal conditions.

AIM: To evaluate the clinical impact of CT scan in modifying the clinical management in patients referred to the emergency department. METHODS: We prospectively evaluated 300 patients (177 males, 63 ± 18 years old) admitted in the emergency department (ED) of a single institution, who underwent a CT examination for thoracic and/or abdominal complains. Demographic and clinical data were collected. Hypothesized outcome prior to CT scan and final management (i.e., discharge, short observation in the ED, hospitalization, and department of admission) were compared. RESULTS: After CT examination, a major variation in diagnosis occurred in 37% of cases and clinical management changed in 43%, occurring in 51% of patients who underwent abdominal CT, in 40% of chest CT, and in 29% of chest/abdominal CT (P = 0.015). Department of hospitalization changed in 26% of cases (P < 0.001). Clinical impact of CT scan was significantly associated (P = 0.001) with the color code at admission. In particular, the more severe was the clinical condition, the lower was the variation of management after CT examination. CONCLUSIONS: This work confirms the crucial role of CT examination in the management of nontraumatic patients admitted to the ED, both in terms of better clarifying the diagnosis and in influencing the clinical management.

Technical success, technique efficacy and complications of minimally-invasive imaging-guided percutaneous ablation procedures of breast cancer: A systematic review and meta-analysis.

OBJECTIVES: To systematically review studies concerning imaging-guided minimally-invasive breast cancer treatments. METHODS: An online database search was performed for English-language articles evaluating percutaneous breast cancer ablation. Pooled data and 95% confidence intervals (CIs) were calculated. Technical success, technique efficacy, minor and major complications were analysed, including ablation technique subgroup analysis and effect of tumour size on outcome. RESULTS: Forty-five studies were analysed, including 1,156 patients and 1,168 lesions. Radiofrequency (n=577; 50%), microwaves (n=78; 7%), laser (n=227; 19%), cryoablation (n=156; 13%) and high-intensity focused ultrasound (HIFU, n=129; 11%) were used. Pooled technical success was 96% (95%CI 94-97%) [laser=98% (95-99%); HIFU=96% (90-98%); radiofrequency=96% (93-97%); cryoablation=95% (90-98%); microwave=93% (81-98%)]. Pooled technique efficacy was 75% (67-81%) [radiofrequency=82% (74-88); cryoablation=75% (51-90); laser=59% (35-79); HIFU=49% (26-74)]. Major complications pooled rate was 6% (4-8). Minor complications pooled rate was 8% (5-13%). Differences between techniques were not significant for technical success (p=0.449), major complications (p=0.181) or minor complications (p=0.762), but significant for technique efficacy (p=0.009). Tumour size did not impact on variables (p>0.142). CONCLUSIONS: Imaging-guided percutaneous ablation techniques of breast cancer have a high rate of technical success, while technique efficacy remains suboptimal. Complication rates are relatively low. KEY POINTS: • Imaging-guided ablation techniques for breast cancer are 96% technically successful. • Overall technique efficacy rate is 75% but largely inhomogeneous among studies. • Overall major and minor complication rates are low (6-8%).

Non-healing post-surgical fistulae: treatment with image-guided percutaneous injection of cyanoacrylic glue.

OBJECTIVES: To present the results of our experience with cyanoacrylic glue percutaneous injection to treat post-surgical non-healing enteric fistulae after failure of standard treatments. METHODS: Eighteen patients (14 males; age range 33-84, mean 69 years) were treated for a non-healing post-surgical enteric fistula after failure of standard treatments. Under computed tomography and/or fluoroscopic guidance, a mixture of cyanoacrylic glue (Glubran 2, GEM, Viareggio, Italy) and ethiodized oil was injected at the site of the fistula. Fistula was considered healed when no material was drained by the percutaneous drainage and a subsequent computed tomography confirmed the disappearance of any fluid collection. RESULTS: In all cases, it was possible to reach the site of the fistula using a percutaneous access. A median of 1 injection (range 1-5) was performed. Fistula healing was achieved in 16/18 (89 %) patients. One patient died for other reasons before fistula healing. Median time for fistula healing was 0 days (mean 8, range 0-58 days). No complications occurred. Reoperation was needed in one patient. CONCLUSIONS: Percutaneous injection of cyanoacrylic glue is feasible, safe, and effective to treat non-healing post-surgical enteric fistulae. It may represent a further option to avoid surgical reoperation in frail patients.

Quality-of-life impairment after endoluminal locoregional resection and laparoscopic total mesorectal excision.

BACKGROUND: For selected patients with rectal cancer, endoluminal locoregional resection (ELRR) by transanal endoscopic microsurgery (TEM) may be an alternative treatment option to laparoscopic total mesorectal excision (LTME). Few data are available on quality of life (QoL) after LTME and TEM. This study aimed to compare short- and medium-term QoL for T1 rectal cancer patients undergoing LTME or ELRR by TEM. METHODS: This study investigated 35 patients with T1N0 rectal cancer who underwent TEM (n = 17) or LTME (n = 18). Quality of life was evaluated by European Organization for Research and Treatment of Cancer (EORTC) QLQ-C30 and QLQ-C38 questionnaires preoperatively and then 1, 6, and 12 months after surgery. RESULTS: Observation 1 month after LTME showed worsening in all items of both questionnaires. After ELRR, the QLQ-CR38 showed worsening of gastrointestinal (p = 0.005) and defecation problems (p = 0.001), and the QLQ-C30 showed worsening of global health status (p = 0.014), physical functioning (p = 0.02) role functioning (p = 0.003), fatigue (p = 0.002), and pain (p = 0.001). The QLQ-CR38 6 months after LTME showed worsening of body image (p = 0.009), micturition (p = 0.035), and gastrointestinal problems (p = 0.011), and the QLQ-C30 showed worsening of physical functioning (p = 0.003), role functioning (p = 0.002), fatigue (p = 0.004), and nausea/vomiting (p = 0.030). After ELRR, neither the QLQ-CR38 nor the QLQ-C30 questionnaire showed any worsening but demonstrated improvement in global health status and physical functioning. The QLQ-CR38 12 months after LTME showed significant improvement in defecation problems (p = 0.004) and weight loss (p = 0.003), and the QLQ-C30 showed significant improvement in global health status (p = 0.001), nausea and vomiting (p = 0.003), and pain (p = 0.005). After ELRR, the QLQ-C30 showed improvement in emotional functioning (p = 0.012), whereas no significant difference was observed by the QLQ-C38. CONCLUSIONS: Functional sequelae are present up to 1 month only after ELRR by TEM and up to 6 months after LTME. At 12 months, neither procedure showed a significant difference in QoL compared with preoperative status.

Enhanced Recovery after Cranial Surgery in Elderly: A Review.

BACKGROUND: Enhanced recovery after surgery (ERAS) is a multidisciplinary approach aimed at reducing the length of hospital stay, improving patient outcomes, and reducing the overall cost of care. Although ERAS protocols have been widely adopted in various surgical fields, their application in cranial surgery remains relatively limited. METHODS: Considering that the aging of the population presents significant challenges to healthcare systems, and there is currently no ERAS protocol available for geriatric patients over the age of 65 requiring cranial surgery, this article proposes a new ERAS protocol for this population by analyzing successful ERAS protocols and optimal perioperative care for geriatric patients described in the literature. RESULTS: Our aim is to develop a feasible, safe, and effective protocol for geriatric patients undergoing elective craniotomy, which includes preoperative, intraoperative, and postoperative assessments and management, as well as outcome measures. CONCLUSIONS: This multidisciplinary and evidence-based ERAS protocol has the potential to reduce perioperative morbidity, improve functional recovery, and enhance postoperative outcomes after cranial surgery in elderly. Further research will be necessary to establish strict guidelines.

Preoperative Spinal Arterial Supply Mapping Using Non-Selective Cone Beam Computed Tomography before Complex Aortic Repair.

Pre-op spinal arterial mapping is crucial for complex aortic repair. This study explores the utility of non-selective cone beam computed tomography (CBCT) for pre-operative spinal arterial mapping to identify the Adamkiewicz artery (AKA) in patients undergoing open or endovascular repair of the descending thoracic or thoracoabdominal aorta at risk of spinal cord ischemia. Pre-operative non-selective dual-phase CBCT after intra-aortic contrast injection was performed in the aortic segment to be treated. The origin of detected AKA was assessed based on image fusion between CBCT and pre-interventional computed tomography angiography. Then, the CBCT findings were compared with the incidence of postoperative spinal cord ischemia (SCI). Among 21 included patients (median age: 68 years, 20 men), AKA was detected in 67% within the explored field of view, predominantly from T7 to L1 intercostal and lumbar arteries. SCI occurred in 14%, but none when AKA was not detected (p < 0.01). Non-selective CBCT for AKA mapping is deemed safe and feasible, with potential predictive value for post-surgical spinal cord ischemia risk. The study concludes that non-selective aortic CBCT is a safe and feasible method for spinal arterial mapping, providing promising insights into predicting post-surgical SCI risk.

Association between spontaneous intracranial epidural hematoma and craniofacial infections: A systematic literature review.

Background: Spontaneous and nontraumatic epidural hematoma (SEDH) is a rare entity. Etiology is various, including vascular malformations of the dura mater, hemorrhagic tumors, and coagulation defects. The association between SEDH and craniofacial infections is rather unusual. Methods: We performed a systematic review of the available literature using the PubMed, Cochrane Library, and Scopus research databases. Literature research was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. We exclusively included studies reporting demographic and clinical data, published until October 31, 2022. We also report one case from our experience. Results: A total of 18 scientific publications, corresponding to 19 patients, met the inclusion criteria for the qualitative and quantitative analysis. Patients were mostly adolescents, with a clear male predominance. SEDHs frequently occurred in the frontal area, usually near the site of the infection. Surgical evacuation was the treatment of choice with good postoperative outcomes. Endoscopy of the involved paranasal sinus should be achieved as soon as possible to remove the cause of the SEDH. Conclusion: SEDH may occur as a rare and life-threatening complication of craniofacial infections; therefore, prompt recognition and treatment are mandatory.

Petroclival Clinoidal Folds and Arachnoidal Membranes of the Anteromedial Incisural Space: Clinical Anatomy for Neuro Critical Care.

A systematic and narrative literature review was performed, focusing attention on the anatomy of the area located at the junction of the sphenoid and the basal portion of the temporal bone (petrous bone, petrous apex, upper petro-clival region) encircled by the free edge of the tentorium, the insertion of the tentorium itself to the petrous apex and the anterior and posterior clinoid processes that give rise to three distinct dural folds or ligaments: the anterior petroclinoid ligament, the posterior petroclinoid ligament and the interclinoid ligament. These dural folds constitute the posterior portion of the roof of the cavernous sinus denominated "the oculomotor triangle". The main purpose of this review study was to describe this anatomical region, particularly in the light of the relationships between the anterior margin of the free edge of the tentorium and the above-mentioned components of the sphenoid and petrous bone.

Single brain metastases from melanoma: remarks on a series of 84 patients.

The authors report on 84 patients with single melanoma brain metastasis surgically treated from 1997 to 2007. There were 46 males and 38 females; mean age was 41 years (range 24-58 years). All patients were surgically treated, and 52 of them received postoperative adjuvant therapy consisting of whole-brain radiation therapy (36), radiosurgery (9), or a combination of these two techniques (7). Brain recurrences were observed in 44 cases, of which 9 were local. Of the latter, seven were re-operated while the remaining two were treated by radiosurgery. At 1-year follow-up, the survival rate was 52% (32 patients) whereas only 12 patients (14%) were still alive after 2 years. None of the patients in which removal was subtotal survived for more than 6 months after surgical treatment. Three years after the onset of the brain metastasis, five patients (6%) were still alive. Survival was significantly influenced by treatment with regard to overall survival reported in other series. A review of literature, together with our own series, suggests that radical surgical treatment of the lesion possibly employing the internal no-touch technique has significantly increased survival in our patients (p < 0.05) and that the association of postoperative radiotherapy and re-operation in the event of recurrent metastatic lesions is advisable even though statistical significance was not reached (p > 0.05).

Microsurgical Anatomy of the Hypoglossal Nerve in the Lateral Approaches to the Craniovertebral Junction: A Study on Fresh Non-Formalin-Fixed Human Specimens.

The aim of this anatomical study is to describe the anatomy of the hypoglossal nerve (HN) from its origin to the extracranial portion as it appears by performing a combined posterolateral and anterolateral approach to the craniovertebral junction (CVJ). Twelve fresh, non-formalin-fixed adult cadaveric heads (24 sides) were analyzed for the simulation of the combined lateral approach to the CVJ. The HN is divided into three main parts: cisternal, intracanalicular, and extracranial The anatomical relationships between the HN and other nerves, muscles, arteries and veins were carefully recorded, and some measurements were made between the HN and related structures. Thus, various landmarks were determined for the easy identification of the HN. Understanding the detailed anatomy of the HN and its relationships with the surrounding structures is crucial to prevent some complications during CVJ surgery.

The Ipsilateral Interhemispheric Transprecuneal Approach to the Atrium: Technical Considerations and Clinical Outcome on a Series of 7 Patients.

Surgical removal of tumors of the atrium is challenging due to their deep location, vascularization, and to their complex three-dimensional relationships with the highly functional white matter fibers of the region. To assess the feasibility and the effectiveness of the ipsilateral interhemispheric transprecuneus approach (IITA) for tumors involving the atrium and the posterior third of the temporal horn, a retrospective chart review of all patients who had undergone a surgical treatment for intraventricular tumors between January 2008 and January 2017 was performed, and the step-by-step approach is described. Ten patients affected by lesions of the atrium of the lateral ventricle underwent surgical treatment, seven of which were approached through the IITA. The mean age was 42.8 years (range 6-63 years). The symptoms presented included severe, drug-resistant headache (90%), lateral homonymous hemianopsia (50%), seizures (30%), and speech disturbances (30%). Histological examinations revealed seven patients with meningioma (70%), one with a metastasis (10%), one with a choroid plexus papilloma (10%) and one with a cavernoma (10%). In all cases, a gross total removal was obtained. All patients had a significant improvement in their headache. Two patients experienced a worsening of the pre-operative visual disturbances, while two patients had a significant improvement. No patients without pre-operative visual disturbances described a post-operative worsening of visual symptoms. The IITA represents a feasible approach for tumors of the atrium. The three-quarter prone position facilitates the enlargement of the interhemispheric fissure by increasing the working angle and facilitating the exposure of the lateral wall of the atrium.

Management of Complex Cerebral Aneurysms.

BACKGROUND: Complex intracranial aneurysms (CIAs) are challenging pathologies to treat. Characteristics making an aneurysm complex include dimension, history of previous treatment, location, absence of collateral circulation, intraluminal thrombosis, and calcification of the wall. The goal of the therapeutic process is to exclude the malformation from the cerebral circulation and both endovascular and surgical treatments are valid procedures. METHODS: Between 1990 and 2020, 170 CIAs were treated at our institution (33 ruptured, 137 unruptured). They were 3 prepetrous segment of the internal carotid artery (ICA), 14 purely intracavernous sinus, 27 intracavernous with subarachnoid extension, 60 paraclinoid, 4 ICA bifurcation, 15 anterior communicating artery, 24 middle cerebral artery, and 23 in the posterior circulation. All the patients underwent neuroradiologic examinations and images were evaluated by the neurosurgical and interventional radiologist team. Endovascular treatment was considered as the treatment of choice. Alternative treatment was surgical clipping; revascularization procedures were performed when neither endovascular treatment nor direct clipping were possible. RESULTS: Of 170 patients, 45 underwent endovascular treatment, 77 surgical clipping, and 55 revascularization procedures. In the unruptured group, 12 patients died, 22 reported major complications, 3 had minor complications, and 101 had an uneventful postoperative course. In the ruptured group, 9 patients died, 10 had minor complications, 1 minor complication, and 13 had a complete recovery. CONCLUSIONS: Endovascular treatment should represent the treatment of choice for CIAs. Alternative treatments include direct surgical clipping and revascularization. Overall, the correct identification of the therapeutic process guarantees a good clinical outcome.