Thrombectomy Outcomes of Intracranial Atherosclerosis-Related Occlusions.

Background and Purpose- Intracranial atherosclerosis (ICAS) is an important cause of large vessel occlusion and poses unique challenges for emergent endovascular thrombectomy. The risk factor profile and therapeutic outcomes of patients with ICAS-related occlusions (ICAS-O) are unclear. We performed a systematic review and meta-analysis of studies reporting the clinical features and thrombectomy outcomes of large vessel occlusion stroke secondary to underlying ICAS (ICAS-O) versus those of other causes (non-ICAS-O). Methods- A literature search on thrombectomy for ICAS-O was performed. Random-effect meta-analysis was used to analyze the prevalence of stroke risk factors and outcomes of thrombectomy between ICAS-O and non-ICAS-O groups. Results- A total of 1967 patients (496 ICAS-O and 1471 non-ICAS-O) were included. The ICAS-O group had significantly higher prevalence of hypertension (odds ratio [OR] 1.46; 95% CI, 1.10-1.93), diabetes mellitus (OR, 1.68; 95% CI, 1.29-2.20), dyslipidemia (OR, 1.94; 95% CI, 1.04-3.62), smoking history (OR, 2.11; 95% CI, 1.40-3.17) but less atrial fibrillation (OR, 0.20; 95% CI, 0.13-0.31) than the non-ICAS-O group. About thrombectomy outcomes, ICAS-O had higher intraprocedural reocclusion rate (OR, 23.7; 95% CI, 6.96-80.7), need for rescue balloon angioplasty (OR, 9.49; 95% CI, 4.11-21.9), rescue intracranial stenting (OR, 14.9; 95% CI, 7.64-29.2), and longer puncture-to-reperfusion time (80.8 versus 55.5 minutes, mean difference 21.3; 95% CI, 11.3-31.3). There was no statistical difference in the rate of final recanalization (modified Thrombolysis in Cerebral Infarction score of 2b/3; OR, 0.67; 95% CI, 0.36-1.27), symptomatic intracerebral hemorrhage (OR, 0.79; 95% CI, 0.50-1.24), good functional outcome (modified Rankin Scale score of 0-2; OR, 1.16; 95% CI, 0.85-1.58), and mortality (OR, 0.94; 95% CI, 0.64-1.39) between ICAS-O and non-ICAS-O. Conclusions- Patients with ICAS-O display a unique risk factor profile and technical challenges for endovascular reperfusion therapy. Intraprocedural reocclusion occurs in one-third of patients with ICAS-O. Intraarterial glycoprotein IIb/IIIa inhibitors infusion, balloon angioplasty, and intracranial stenting may be viable rescue treatment to achieve revascularization, resulting in comparable outcomes to non-ICAS-O.

IDH1 mutation-associated long non-coding RNA expression profile changes in glioma.

Isocitrate dehydrogenase 1 (IDH1) mutation is an important prognostic marker in glioma. However, its downstream effect remains incompletely understood. Long non-coding RNAs (lncRNAs) are emerging as important regulators of tumorigenesis in a number of human malignancies, including glioma. Here, we investigated whether and how lncRNA expression profiles would differ between gliomas with or without IDH1 mutation. By using our previously reported lncRNA mining approach, we performed lncRNA profiling in three public glioma microarray datasets. The differential lncRNA expression analysis was then conducted between mutant-type and wild-type IDH1 glioma samples. Comparison analysis identified 14 and 9 lncRNA probe sets that showed significantly altered expressions in astrocytic and oligodendroglial tumors, respectively (fold change ≥ 1.5, false discovery rate ≤ 0.1). Moreover, the differential expressions of these lncRNAs could be confirmed in the independent testing sets. Functional exploration of the lncRNAs by analyzing the lncRNA-protein interactions revealed that these IDH1 mutation-associated lncRNAs were involved in multiple tumor-associated cellular processes, including metabolism, cell growth and apoptosis. Our data suggest the potential roles of lncRNA in gliomagenesis, and may help to understand the pathogenesis of gliomas associated with IDH1 mutation.

Effects of progesterone vs. dexamethasone on brain oedema and inflammatory responses following experimental brain resection.

BACKGROUND: Dexamethasone (DEXA) is commonly used to reduce brain swelling during neurosurgical procedures. DEXA, however, has many side-effects that can increase the risks of post-operative complications. In contrast, progesterone (PRO) has fewer side-effects and has been found to be neuroprotective on traumatic brain injury (TBI). Whether PRO may be used as an alternative to DEXA during routine procedures has not been fully explored. OBJECT: To compare the effects of DEXA and PRO on surgical brain injury (SBI). METHODS: Seventy-five adult male Sprague Dawley rats were randomized into five groups: (1) SBI + drug vehicle (peanut oil, 1 ml kg(-1)); (2) SBI + DEXA (1 mg kg(-1)); (3) SBI + low-dose PRO (10 mg kg(-1)); (4) SBI + high-dose PRO (20 mg kg(-1)); and (5) sham SBI + drug vehicle. Magnetic resonance imaging study and assessments of brain water content (BWC), blood-brain barrier (BBB) permeability, cellular inflammatory responses and matrix metalloproteinase 9 (MMP-9) expression were conducted. RESULTS: This model consistently resulted in increased BWC and BBB disruption. PRO reduced astrocyte and microglia responses and attenuated brain oedema with preservation of BBB. A significant down-regulation of MMP-9 expression occurred in the PRO 20 group. CONCLUSIONS: PRO is as effective as DEXA in reducing brain oedema and inflammation following SBI; 10 mg kg(-1) of PRO was demonstrated to be more effective in relieving acute cellular inflammatory responses.

A long non-coding RNA signature in glioblastoma multiforme predicts survival.

Long non-coding RNAs (lncRNAs) represent the leading edge of cancer research, and have been implicated in cancer biogenesis and prognosis. We aimed to identify lncRNA signatures that have prognostic values in glioblastoma multiforme (GBM). Using a lncRNA-mining approach, we performed lncRNA expression profiling in 213 GBM tumors from The Cancer Genome Atlas (TCGA), randomly divided into a training (n=107) and a testing set (n=106). We analyzed the associations between lncRNA signatures and clinical outcome in the training set, and validated the findings in the testing set. We also validated the identified lncRNA signature in another two independent GBM data sets from Gene Expression Omnibus (GEO), which contained specimens from 68 and 101 patients, respectively. We identified a set of six lncRNAs that were significantly associated with the overall survival in the training set (P≤0.01). Based on this six-lncRNA signature, the training-set patients could be classified into high-risk and low-risk subgroups with significantly different survival (HR=2.13, 95% CI=1.38-3.29; P=0.001). The prognostic value of this six-lncRNA signature was confirmed in the testing set and the two independent data sets. Further analysis revealed that the prognostic value of this signature was independent of age and O-6-methylguanine-DNA methyltransferase (MGMT) promoter methylation status. The identification of the prognostic lncRNAs indicates the potential roles of lncRNAs in GBM pathogenesis. This six-lncRNA signature may have clinical implications in the subclassification of GBM.

Long non-coding RNA expression profiles predict clinical phenotypes in glioma.

Glioma is the commonest form of primary brain tumor in adults with varying malignancy grades and histological subtypes. Long non-coding RNAs (lncRNAs) are a novel class of non-protein-coding transcripts that have been shown to play important roles in cancer development. To discover novel tumor-related lncRNAs and determine their associations with glioma subtypes, we first applied a lncRNA classification pipeline to identify 1970 lncRNAs that were represented on Affymetrix HG-U133 Plus 2.0 array. We then analyzed the lncRNA expression patterns in a set of previously published glioma gene expression profiles of 268 clinical specimens, and identified sets of lncRNAs that were unique to different histological subtypes (astrocytic versus oligodendroglial tumors) and malignancy grades. These lncRNAs signatures were then subject to validation in another non-overlapping, independent data set that contained 157 glioma samples. This is the first reported study that correlates lncRNA expression profiles with malignancy grade and histological differentiation in human gliomas. Our findings indicate the potential roles of lncRNAs in the biogenesis, development and differentiation of gliomas, and provide an important platform for future studies.

Intracranial aneurysms: midterm outcome of pipeline embolization device--a prospective study in 143 patients with 178 aneurysms.

PURPOSE: To evaluate the midterm clinical and angiographic outcomes after pipeline embolization device (PED) placement for treatment of intracranial aneurysms. MATERIALS AND METHODS: This prospective nonrandomized multicenter study was approved by the review boards of all involved centers; informed consent was obtained. Patients (143 patients, 178 aneurysms) with unruptured saccular or fusiform aneurysms or recurrent aneurysms after previous treatment were included and observed angiographically for up to 18 months and clinically for up to 3 years. Study endpoints included complete aneurysm occlusion; neurologic complications within 30 days and up to 3 years; clinical outcome of cranial nerve palsy after PED placement; angiographic evidence of occlusion or stenosis of parent artery and that of occlusion of covered side branches at 6, 12, and 18 months; and clinical and computed tomographic evidence of perforator infarction. RESULTS: There were five (3.5%) cases of periprocedural death or major stroke (modified Rankin Scale [mRS] > 3) (95% confidence interval [CI]: 1.3%, 8.4%), including two posttreatment delayed ruptures, two intracerebral hemorrhages, and one thromboembolism. Five (3.5%) patients had minor neurologic complications within 30 days (mRS = 1) (95% CI: 1.3%, 8.4%), including transient ischemic attack (n = 2), small cerebral infarction (n = 2), and cranial nerve palsy (n = 1). Beyond 30 days, there was one fatal intracerebral hemorrhage and one transient ischemic attack. Ten of 13 patients (95% CI: 46%, 93.8%) completely recovered from symptoms of cranial nerve palsy within a median of 3.5 months. Angiographic results at 18 months revealed a complete aneurysm occlusion rate of 84% (49 of 58; 95% CI: 72.1%, 92.2%), with no cases of parent artery occlusion, parent artery stenosis (<50%) in three patients, and occlusion of a covered side branch in two cases (posterior communicating arteries). Perforator infarction did not occur. CONCLUSION: PED placement is a reasonably safe and effective treatment for intracranial aneurysms. The treatment is promising for aneurysms of unfavorable morphologic features, such as wide neck, large size, fusiform morphology, incorporation of side branches, and posttreatment recanalization, and should be considered a first choice for treating unruptured aneurysms and recurrent aneurysms after previous treatments. SUPPLEMENTAL MATERIAL: http://radiology.rsna.org/lookup/suppl/doi:10.1148/radiol.12120422/-/DC1.

Long-term outcome and prognostic factors after spontaneous cerebellar hemorrhage.

Cerebellar hemorrhage is the least common type of intracranial hemorrhage (ICH) encountered in clinical practice, and clinical data concerning the long-term outcomes are limited. This study aimed to investigate the long-term outcomes following spontaneous cerebellar hemorrhage in a cohort of Chinese patients. This single-center observational study was carried out between 1996 and 2010 and included 72 consecutive Chinese patients with a first spontaneous cerebellar hemorrhage. Of 440 patients with primary ICH, 72 (16.4%) had primary cerebellar hemorrhage. The mean age was 67.5 ± 12.3 years and patients were predominantly male (54%). The 30-day mortality was 16.7% with Glasgow coma scale ≤ 8 as the only predictor. At 6 months, 56.7% of patients who survived the first 30 days had a persistently poor functional status with modified Rankin scale score >2. After a mean follow-up of 4.7 years, 3.3% of patients had recurrent ICH, a recurrence rate of 7.3 per 1,000 patient-years. Ischemic stroke occurred in 12% of patients, an incidence of 25.5 per 1,000 patient-years. This study provided data on the long-term outcome of post-cerebellar hemorrhage in Chinese patients.

An endoscopic modification of the simultaneous 'above and below' approach to large pituitary adenomas.

Surgical resections of large-to-giant pituitary adenomas (PA) are technically challenging procedures. Tumors with a fibrous consistency or 'hour-glass' configurations are particularly difficult to remove completely and safely through the transsphenoidal route alone. Although the transcranial approach can facilitate the removal of a large suprasellar mass, it may be associated with significant bleeding within the intradural space. A simultaneous microscopic transcranial and transsphenoidal approach has been described as an alternative surgical strategy. We have further modified this 'above and below' approach by adopting endoscopic techniques for the transsphenoidal part of the procedure. This modified approach has the advantages of requiring only one operating microscope, and permitting freer maneuvers and easier orientation for both surgical teams. We present two patients successfully treated with this approach. Complete tumor removal was achieved and both patients achieved satisfactory functional recovery.

Surgical revascularization for moyamoya angiopathy: Clinical and radiological outcomes of direct and indirect bypasses in 86 affected hemispheres.

Moyamoya is a progressive cerebral angiopathy that entails a formidable natural history of repeated ischemic or haemorrhagic insults if not intervened. The potential advantages of direct/combined bypass can be harvested only if they are not outweighed by perioperative morbidity. Direct bypasses for the paediatric group have been less utilized because of small vessel calibres and an inherently more robust angioplasticity. This study was undertaken to examine the clinical and perfusion imaging outcomes of operated moyamoya disease or syndrome patients in Hong Kong's Southeast Asian population. Comparison was made between direct/combined and indirect bypass cohorts. Subgroup analysis of the paediatric cohort was conducted to determine outcomes of a direct-bypass-first strategy. From November 2000 to September 2020, 86 hemispheres underwent revascularization at a tertiary neurosurgical unit with a mean clinical follow-up time of 70.0 months. 70.9% of the procedures involved direct bypasses. Direct/combined revascularization demonstrated superiority in restoring adequate cerebrovascular reserve capacity (CVRC) (63.2% vs 27.3%, p = 0.015), and freedom from transient ischemic attacks in the first 5 years post-operation by Kaplan-Meier plot with log-rank test (p = 0.038). Follow-up imaging revealed 96.5% of the bypass grafts remained patent. Direct/combined procedures significantly predicted restoration of adequate CVRC on follow-up perfusions scans by binary logistic regression (OR 4.57, p = 0.009). Compared to the adult cohort, direct bypasses in children carried no excessive perioperative morbidity. These results support a liberal bypass-first paradigm in both adult and paediatric cohorts.

Predictive value of Bispectral Index (BIS) in emergency neurosurgical patients: Loss of BIS reactivity to propofol predicts poor functional outcomes.

AIM: In emergency neurosurgical patients, evaluation with Glasgow Coma Scale (GCS) alone immediately after stopping sedation post-operatively might not differentiate those with good recovery from those with poor outcomes at 3 months. This study aimed to evaluate the prognostic value of measuring the Bispectral Index (BIS) and the correlation to propofol dosage during the use of sedation in the early post-operative period. METHODS: This is a prospective study on consecutive post-operative neurosurgical patients admitted to the neurosurgical ICU on propofol sedation. The primary outcome was the correlation between early post-operative BIS and the Propofol dosage with the modified Rankin scale (mRS) at 3 months. Secondary outcomes included the post-operative propofol requirement in patients with good functional outcomes (mRS 0-3) versus poor functional outcomes (mRS 4-6) at 3 months. RESULTS: In total, 728 BIS readings were collected from twenty-four patients for analysis. The BIS readings were significantly correlated to the propofol dosage in patients with good function outcomes at 3 months (p < 0.0001). BIS readings in patients with no associations to changes in propofol dosage during their ICU stay had poor outcomes (mRS 4-6) at 3 months (r = -0.0407). For patients with good functional outcomes at 3 months, a significantly higher propofol dosage was used for deep sedation (BIS 40 - 60) during the post-operative period (p < 0.001). CONCLUSION: For emergency neurosurgical patients whose BIS readings had lost correlation to the propofol dosage upon recovery, their functional outcomes at 3 months were poor. For those with good functional outcomes at 3 months, a significantly higher propofol dosage was required for deep sedation during their ICU stay. Patients with preserved correlation of BIS readings to changes in propofol dosages during the early post-operative period were associated with good functional outcomes at 3 months.

Combined simultaneous transcranial and transsphenoidal resection of large-to-giant pituitary adenomas.

BACKGROUND: While large-to-giant pituitary adenomas (PAs) may be safely removed by experienced surgeons through a single route, the procedure is technically challenging. We present the outcome of a simultaneous combined transcranial and transsphenoidal approach and discuss its applications. METHODS: A retrospective review was conducted on 12 consecutive patients. Surgical complications, visual and endocrinological functions, and tumour control were reviewed. RESULTS: There were four men and eight women, with a mean age of 47.6 years. All but one patient had non-functioning PAs. The mean tumour height was 4.1 cm (range: 2.3-5.5). The predominant presenting symptoms were visual field loss in eight patients, headache in three patients and mental confusion in one patient. There was no operative mortality. Post-operative cerebrospinal fluid leakage occurred in one patient. Five of the eight patients who presented with visual field loss achieved full recovery, and three had partial improvement. Two patients developed permanent diabetes insipidus after surgery. Panhypopituitarism occurred in one patient. Gross total removal (GTR) was achieved in five, and subtotal removal (STR) in seven patients. Seven patients received post-operative external irradiation. All patients who had GTR remained tumour-free and all those with STR had stable diseases after a mean follow-up period of 53.1 months (range: 14.1-92.1). CONCLUSION: The simultaneous 'above and below' approach is a safe and effective surgical strategy for large-to-giant PAs, particularly when expertise in endoscopic transsphenoidal surgery is unavailable. Its use, however, should be limited to a carefully selected group of patients, and tailored to individual user's expertise and experience.

Surgical repair of a large intrathoracic meningocele associated with neurofibromatosis type 1 after failed cystoperitoneal shunts: illustrative case.

BACKGROUND: Surgical treatment of intrathoracic meningoceles, commonly associated with neurofibromatosis type 1 (NF1), aims to reduce sac size for symptomatic relief. The procedures can be divided into cerebrospinal fluid diversion and definitive repair. The authors describe the management of an intrathoracic meningocele in a 56-year-old female with preexisting NF1. OBSERVATIONS: The patient presented with progressive dyspnea. Magnetic resonance imaging revealed a left hemithoracic meningocele arising from the thecal sac at C7-T2. Two attempts at diversion by cystoperitoneal shunts resulted in recurrence. For definitive repair, T2-3 costotransversectomy was performed, and intradural closure of the meningocele opening was performed utilizing spinal dura and autologous fascia lata graft. Trapezius muscle regional flap was turned for reinforcement. Persistent leak warranted reoperation 7 days later. A transthoracic approach was undertaken using video-assisted thoracoscopic resection of the sac at aortic arch level, with reinforcement by latissimus dorsi flap and synthetic materials. Mechanical pleurodesis was performed. Intradural repair of the meningocele opening was revised. LESSONS: Inherent dural abnormality makes repair difficult for meningoceles associated with NF1. A combined intradural and thoracoscopic approach with regional muscle flap and synthetic material reinforcement is a unique method for definitive treatment. Some essential points of perioperative management are highlighted.

Thalamo-perforating artery aneurysm in Moyamoya disease - case report.

A 31-year-old man with Moyamoya disease had received a right encephalo-duro-arterial synangiosis and later developed a rupture of the left thalamo-perforating artery aneurysm. Surgical strategies were discussed. Perfusion studies revealed increased haemodynamic stress on the left hemisphere which was likely the cause of the aneurysm.

Near-complete regression 19 years after Gamma Knife radiosurgery of vestibular schwannoma with massive pseudoprogression: case report.

Gamma Knife radiosurgery (GKRS) is a frequent treatment choice for patients with small- to moderate-sized vestibular schwannoma (VS). However, pseudoprogression after GKRS is commonly observed, with a reported incidence ranging from 7% to 77%. The wide range of the reported incidence of pseudoprogression reflects the fact that there is no consensus on how it should be diagnosed. The authors present the case of a 66-year-old woman who had a 2.5-cm right-sided VS treated with GKRS in 1997. The first posttreatment MRI obtained 5 months later showed that the tumor volume had increased to 9.7 cm3. The tumor volume increased further and reached its peak 24 months after treatment at 20.9 cm3, which was a 161% increase from pretreatment volume. Thereafter, the tumor shrank gradually and mass effect on the brainstem reduced over time. By 229 months after treatment, the tumor volume was 1.0 cm3, equaling 12.5% of pretreatment tumor volume, or 4.8% of peak tumor volume after treatment. This case demonstrates that if a patient remains asymptomatic despite a dramatic increase in tumor volume after GKRS, observation remains an option, because even a very sizable tumor can shrink with near-complete resolution. Patients undergoing GKRS for VS should be counseled regarding the possibility of pseudoprogression, and followed carefully over time while avoiding premature decisions for surgical removal after treatment.

Endovascular Intervention for Early Postoperative Stenosis of Extracranial-Intracranial Bypass Graft: Case Report and Review of the Literature.

BACKGROUND: Bypass graft stenosis following extracranial-intracranial bypass surgery carries significant risks for morbidity and mortality. In case of graft failure, treatment options include surgical revision and endovascular intervention. Whereas endovascular intervention following coronary artery bypass is well established, the role of endovascular therapy in cerebral bypass conduits is rarely reported. We present a case of extracranial-intracranial bypass graft stenosis in the early postoperative period that was successfully treated by endovascular angioplasty and stenting. CASE DESCRIPTION: A middle-aged patient presented with a malignant skull base tumor with internal carotid artery invasion. Extracranial-intracranial bypass surgery was performed for flow preservation before tumor removal. Autologous radial artery was used as the bypass graft conduit. Symptomatic graft stenosis was encountered in the immediate postoperative period. Treatments in the form of intra-arterial vasodilator infusion and balloon angioplasty led to only minor flow improvement. The narrowing was eventually salvaged by endovascular stenting. Good clinical and radiologic outcomes were achieved at 6-month follow-up. CONCLUSIONS: Endovascular intervention is a feasible treatment option in management of graft stenosis after cerebral revascularization surgery. Our case adds evidence to the safety and role of endovascular intervention in early cerebral bypass conduit failure. In addition, endovascular stenting can be considered as a salvage option for cases that are refractory to angioplasty.

Vertebral-carotid bypass for common carotid artery occlusion.

One of the treatment options for long segment common carotid artery (CCA) occlusion is bypass surgery with different combinations of donors and receipts. Using vertebral artery (VA) as the donor for CCA occlusion was uncommonly reported. The reported cases were using jump graft to connect V3 segment of VA to either CCA or ICA. We describe our patient using V2 segment as the donor for VA-CCA bypass as treatment for CCA occlusion. Our patient was a 51 years old gentleman with Marfan syndrome and had multiple operations that included total arch replacement. He presented with sudden onset of spontaneous right frontal subarachnoid haemorrhage and repeated episodes of TIA with left upper limb numbness. CTA showed occluded right CCA and anastomosis between branches from subclavian artery and occipital artery. CT perfusion showed hypoperfusion of right hemisphere. To avoid damaging the anastomosis at subclavian artery and occipital artery, we decided for V2-RAG (radial artery graft)-CCA bypass. It was done by exposing the V2 segment at C4/5 level, performing end-to-side anastomoses at V2-RAG and RAG-CCA junctions where the RAG was underneath the internal jugular vein. Patient had no new deficits after surgery and no more TIAs. CTA performed one week after surgery showed patent RAG. In conclusion, using V2 for VA-CCA bypass is technically feasible and may have theoretical advantages over using V3. V2-CCA bypass is an option for CCA occlusion in very selected patients.

Successful Emergency Rescue Open Embolectomy for Failed Endovascular Thrombectomy in Acute Ischemic Stroke: 2-Dimensional Operative Video.

This operative video demonstrates an open surgical thrombectomy for a 61-yr-old woman with failed endovascular embolectomy in acute ischemic stroke. Good functional outcome can be achieved when this operation is timely performed within the therapeutic window. This patient has atrial fibrillation. She was admitted for sudden onset of left-sided hemiplegia and aphasia. National Institutes of Health Stroke Scale (NIHSS) was 20/42 before the operation. Computed tomography (CT) cerebral angiogram showed right internal cerebral artery (ICA) occlusion from the cervical portion. Urgent intra-arterial (IA) thrombectomy was started 2 h after symptom onset, but failed despite the use of a stentriver and a large-bore aspiration catheter together. Emergency rescue open thrombectomy was performed with right pterional craniotomy 6 h after symptom onset. Sylvian fissure was dissected to expose the supraclinoid ICA, ICA bifurcation, A1, and M1. A transverse arteriotomy was made at the ICA bifurcation and open surgical thrombectomy was performed. Reperfusion was established in 86 min after skin incision. Intraoperative indocyanine green video-angiography showed patent flow over ICA bifurcation to M1 and A1. She had a good recovery with the return of the left-sided power and was discharged home. At 2-mo postoperative assessment, she was able to walk unaided independently. The modified Barthel Index (BI) was 74/100. Her activity of daily living was independent. We must emphasize IA thrombectomy is the standard treatment, and the role of open surgery remains a potential rescue procedure. Good functional outcome can be achieved when emergency rescue open thrombectomy is performed within the therapeutic window.

Repair of Anterior Skull Base Defect by Dual-Layer/Split-Frontal Pericranial Flap.

INTRODUCTION: Normal skull base structures are destroyed either by the skull base pathology itself or during surgery that results in cerebrospinal fluid (CSF) leak. Skull base repair is usually performed transnasally by using a nasal septal flap. But when NSF is not available and failed repeated transnasal repair, a cranionasal repair with frontal pericranial flap (PF) can be attempted to achieve the highest successful chance. We performed a dual layer/split PF repair of a skull base defect using cranionasal approach and here we describe the technique. CASE DESCRIPTION: A 74-year-old man suffered from CSF leak and ventriculitis after multiple transnasal surgeries for pituitary macroadenoma despite multiple repairs with intranasal vascularized flaps. We performed repair by cranionasal approach and using frontal PF. The frontal PF was divided into left and right halves. The left half went intradural, through the chiasmatic window to reach the sella and cover the tubercular and sellar defect from above. The right half went through the nasion into the nose to cover the defect from below. So the defect was covered by two vascularized flap from a single frontal PF. The repair was successful with no CSF leak and infection successfully treated by antibiotics. CONCLUSION: We introduced the cranionasal dual layer/split PF technique to repair anterior skull base and successfully stopped the CSF leak in a patient after multiple EEA surgeries. This technique should only be considered in specific difficult situation where usual repair by EEA is impossible.

Long-Term Risk of In-Stent Restenosis and Stent Fracture for Extracranial Vertebral Artery Stenting.

PURPOSE: Stenting and angioplasty of the vertebral artery (VA) is used to treat symptomatic stenosis but the long-term outcomes and complications are unclear. This study evaluated the long-term clinical outcomes and procedure-related complications in patients who underwent extracranial VA stenting and angioplasty, in particular the risks of in-stent restenosis (ISR) and stent fracture. METHODS: This was a retrospective review of consecutive patients suffering from symptomatic extracranial VA stenosis who were treated with balloon-expandable bare metal stents. The clinical and angiographical outcomes were reviewed for procedural complications, recurrent stroke, ISR and stent fracture. RESULTS: In this study 22 patients (17 male, 5 female) with a mean age of 63.4 years (SD 9.1 years) were included. The median follow-up was 56 months (interquartile range IQR 51.8 months). There were no periprocedural complications. The cumulative ISR risk was 45% with 6 cases detected at 1 year and 3 cases detected at 3 years post operation. The cumulative stent fracture rate at 1 year, 3 years, 5 years and the entire follow-up period were 5%, 15%, 25%, and 30%, respectively. Posterior circulation stroke occurred in 1 patient (4.5%), and 3 patients died of non-cerebrovascular causes during follow-up. Of the patients 2 with ISR and stent fracture required additional treatment. CONCLUSION: The long-term ISR and stent fracture risks were high in extracranial VA stenosis treated with balloon-expandable bare metal stents. The risk of stent fracture increased over time during the follow-up period. Further studies should be conducted to clarify the long-term safety and efficacy of extracranial VA stenting.