Capillary Hemangioma of the Spinal Cord: Case Report and Systematic Review of Literature.

BACKGROUND: Capillary hemangiomas are rare vascular lesions that rarely affect the central nervous system. When they present within the spinal canal, they are typically confined intradurally, with intramedullary extension rare. We present a rare case of spinal intramedullary capillary hemangioma, with a systematic review of the literature. METHODS: Medical records and imaging data were retrospectively reviewed using the health record software EPIC (Verona, Wisconsin, USA) and the radiology management software system RIS/PACS (Radiology Information System/Picture Archiving and Communication System; QREADS). The report was written in accordance with the CARE (case reports) guidelines. We also performed a systematic review of the literature on all cases of intramedullary spinal capillary hemangiomas in accordance with PRISMA (preferred reporting items for systematic reviews and meta-analyses) guidelines. RESULTS: We report a case of a 54-year-old man who presented with progressive paraplegia and sensory deficits in the lower extremities. Spinal magnetic resonance imaging showed an intramedullary enhancing lesion centered at T11 with associated spinal cord compression. He underwent thoracic laminectomy and gross total resection of the lesion without complications and subsequent improvement on his neurological examination. Histological examination showed findings consistent with a capillary hemangioma. The literature review also documented 21 studies with a combined total of 38 cases of intramedullary spinal capillary hemangioma. CONCLUSIONS: Purely intramedullary capillary hemangiomas are unusual spinal lesions with only a few cases reported in the literature. These should be considered in the differential diagnosis of intramedullary tumors. Surgical management remains the first line of treatment for symptomatic patients.

A Novel Preoperative Score to Predict Long-Term Biochemical Remission in Patients with Growth-Hormone Secreting Pituitary Adenomas.

OBJECTIVE: Transsphenoidal surgery (TSS) is considered the treatment of choice in most patients with growth hormone (GH)-secreting pituitary adenomas. Several preoperative factors have been studied to predict postsurgical remission. Our objective was to design a score that could be used in the preoperative setting to identify patients that will achieve long-term biochemical remission after TSS. METHODS: A retrospective analysis of consecutive patients with GH-secreting pituitary adenomas that underwent TSS in our institution from 2000 to 2015 who fulfilled prespecified criteria were included. Logistic regression methods were used to evaluate independent preoperative variables predicting long-term remission. Beta coefficients were used to create a scoring system for clinical practice. RESULTS: Sixty-eight patients were included, with a mean follow-up time of 87 months. Twenty (29%) patients had tumors with a Knosp grade ≥ 3A. Gross-total resection was achieved in 43 (63%) patients. Thirty-three (48%) patients had long-term biochemical remission after TSS. In a multivariate analysis, the following variables were statistically significantly associated with long-term biochemical remission: age, adenoma size (diameter), Knosp grade, GH level, and insulin growth-factor 1index 1 at diagnosis. A score of <3 out of 8 total points was identified as a cutoff associated with long-term remission, with a sensitivity of 91.4% and specificity of 72.7% (AUC 0.867, OR 28.44, 95% CI 6.94-116.47, P = < 0.001). CONCLUSIONS: A novel, simple, easy-to-use scoring system was created to identify patients with the highest chances of long-term biochemical remission following TSS. This scale should be prospectively validated in a multicenter study before widespread adoption.

Middle meningeal artery embolization for chronic subdural hematoma: A single-center experience and predictive modeling of outcomes.

BACKGROUND: Remarkable interest is rising around middle meningeal artery embolization (MMAE) as an emerging alternative therapy for chronic subdural hematoma (cSDH). The study aims to highlight a large center experience and the variables associated with treatment failure and build experimental machine learning (ML) models for outcome prediction. MATERIAL AND METHODS: A 2-year experience in MMAE for managing patients with chronic subdural hematoma was analyzed. Descriptive statistical analysis was conducted using imaging and clinical features of the patients and cSDH, which were subsequently used to build predictive models for the procedure outcome. The modeling evaluation metrics were the area under the ROC curve and F1-score. RESULTS: A total of 100 cSDH of 76 patients who underwent MMAE were included with an average follow-up of 6 months. The intervention had a per procedure success rate of 92%. Thrombocytopenia had a highly significant association with treatment failure. Two patients suffered a complication related to the procedure. The best performing machine learning models in predicting MMAE failure achieved an ROC-AUC of 70%, and an F1-score of 67%, including all patients with or without surgical intervention prior to embolization, and an ROC-AUC of 82% and an F1-score of 69% when only patients who underwent upfront MMAE were included. CONCLUSION: MMAE is a safe and minimally invasive procedure with great potential in transforming the management of cSDH and reducing the risk of surgical complications in selected patients. An ML approach with larger sample size might help better predict outcomes and highlight important predictors following MMAE in patients with cSDH.

Anterior clinoid meningiomas: surgical results and proposed scoring system to predict visual outcomes.

OBJECTIVE: The authors report a single-surgeon experience with anterior clinoid meningiomas (ACMs) and propose a novel scoring system to predict visual outcomes based on preoperative risk factors. METHODS: A cohort study of all ACMs that were surgically treated by a single surgeon between 2003 and 2021 was performed. Visual function was assessed by an ophthalmologist pre- and postoperatively. Based on the combination of visual fields and visual acuity, 4 visual grades were described. Favorable visual outcomes were defined as mild visual deficit or intact vision postoperatively. Unfavorable visual outcomes were defined as a severe or moderate visual deficit. Predictors of unfavorable visual outcomes were identified using multivariable logistic regression analysis. A scoring system was then created using the resulting ß coefficient. A receiver operating characteristic curve analysis was performed to identify a cutoff point on the grading score for stratifying patients at risk for unfavorable visual outcomes. RESULTS: Fifty-two patients met all inclusion criteria. Twenty-five (48%) patients presented with intact vision, and 27 (51%) presented with some visual dysfunction. Postoperative favorable visual outcomes were achieved in 39 patients (75%). Among the 27 patients presenting with visual dysfunction, 14 (52%) experienced improvement after surgery. No new visual deficits were observed among the 25 patients with intact vision at baseline. Nine patients (17%) had a reversible complication. Multivariable analysis showed that severe preoperative visual deficit (OR 13.03, 95% CI 2.64-64.39; p = 0.002), radiographic evidence of optic nerve (ON) encasement (OR 4.20, 95% CI 1.06-16.61; p = 0.04), intraoperative evidence of ON invasion (OR 17.31, 95% CI 2.91-102.86; p = 0.002), an average ganglion cell layer thickness of ≤ 70 µm (OR 21.54, 95% CI 2.94-159.04; p = 0.003), and an average retinal nerve fiber layer thickness of ≤ 80 µm (OR 13.68, 95% CI 1.91-98.00; p = 0.009) were associated with unfavorable visual outcome. The predictive score included the following factors: abnormal optical coherence tomography (OCT) findings, radiographic evidence of ON encasement by the tumor, and severe preoperative visual deficit. A score ≥ 4 of 6 points was demonstrated to be the cutoff associated with unfavorable visual outcome, with a sensitivity of 80%, specificity of 88%, positive predictive value of 80%, negative predictive value of 88%, and area under the curve of 0.847 (95% CI 0.674-1.0; p = 0.003). CONCLUSIONS: The authors have designed a practical and novel scoring system to predict visual outcomes in patients with ACMs. This scoring system may guide preoperative discussions with patients and timely surgical intervention to yield optimal visual function outcomes. Although most patients have excellent neurosurgical outcomes, severe baseline visual deficits, ON encasement, and characteristic OCT abnormalities are associated with unfavorable visual function after ACM resection.

Predictive Value of K i -67 Index in Evaluating Sporadic Vestibular Schwannoma Recurrence: Systematic Review and Meta-analysis.

Introduction K i -67 is often used as a proliferation index to evaluate how aggressive a tumor is and its likelihood of recurrence. Vestibular schwannomas (VS) are a unique benign pathology that lends itself well to evaluation with K i -67 as a potential marker for disease recurrence or progression following surgical resection. Methods All English language studies of VSs and K i -67 indices were screened. Studies were considered eligible for inclusion if they reported series of VSs undergoing primary resection without prior irradiation, with outcomes including both recurrence/progression and K i -67 for individual patients. For published studies reporting pooled K i -67 index data without detailed by-patient values, we contacted the authors to request data sharing for the current meta-analysis. Studies reporting a relationship between K i -67 index and clinical outcomes in VS for which detailed patients' outcomes or K i -67 indices could not be obtained were incorporated into the descriptive analysis, but excluded from the formal (i.e., quantitative) meta-analysis. Results A systematic review identified 104 candidate citations of which 12 met inclusion criteria. Six of these studies had accessible patient-specific data. Individual patient data were collected from these studies for calculation of discrete study effect sizes, pooling via random-effects modeling with restricted maximum likelihood, and meta-analysis. The standardized mean difference in K i -67 indices between those with and without recurrence was calculated as 0.79% (95% confidence interval [CI]: 0.28-1.30; p = 0.0026). Conclusion K i -67 index may be higher in VSs that demonstrate recurrence/progression following surgical resection. This may represent a promising means of evaluating tumor recurrence and potential need for early adjuvant therapy for VSs.

Contemporary Surgical Management of Juvenile Nasopharyngeal Angiofibroma.

Objectives Juvenile nasopharyngeal angiofibromas (JNAs) are uncommon tumors with an evolving treatment paradigm. The objective of this study was to compare our prior experience reported in 2005 with our most contemporary series to compare practice improvements and the impact of expanded endonasal procedures. Design Retrospective review comparing a contemporary 22 patients with JNA who underwent surgical management between 2005 and 2019, compared with a historical cohort of 65 patients from the same center. Results The most common presenting symptom was epistaxis (68%). The median maximum tumor diameter was 4.4 cm. All patients underwent preoperative embolization. An endoscopic endonasal approach (EEA) was used in 18 patients (82%), compared with 9% in the series prior to 2005. Gross total resection was achieved in all patients. The median estimated blood loss was 175 and 350 mL for EEA and open (transfacial) cases, respectively. Only two patients (9%) required a blood transfusion compared with 52% on the previous series. The median follow-up was 19 months. The overall recurrence rate was 9% in this series and 24% in the previous series. No patient required radiation therapy in follow-up compared with 3% in our historical cohort. Conclusion There have been significant changes regarding the management of patients with JNA compared with the previous Mayo Clinic experience. The EEA has become the preferred route over the transfacial approaches to treat JNA in selected patients who do not have intracranial extension. Preoperative embolization has aided in reducing the postoperative transfusion rates.

Mycotic aneurysm.

Angioinvasive fungal infections of the cerebral vasculature often lead to significant morbidity and mortality. High clinical suspicion and early antifungal therapy could improve outcomes. We describe the fatal case of a patient with a rapidly enlarging cavernous carotid aneurysm due to angioinvasive fungus. This case highlights the challenges in diagnosis and management of this condition.

Prognostic Factors Independently Associated With Improved Progression-Free Survival After Surgical Resection in Patients With Spinal Cord Astrocytomas: An Institutional Case Series.

BACKGROUND: Spinal astrocytomas are rare tumors in which the extent of resection and adjuvant therapy remain controversial. A number of new molecular markers are used, but their utility in spinal cord tumors remains unclear. OBJECTIVE: To determine prognostic indicators of progression-free survival (PFS) in patients with spinal astrocytomas. METHODS: A retrospective chart review identified all patients managed at a single institution for spinal cord astrocytomas between 1999 and 2019. Data collected included baseline demographics, presenting signs and symptoms, tumor size, operative outcomes, and adjuvant treatment. Pathological data including histopathological grade, proliferative index, and molecular profile were collected. Duration of follow-up, presence of tumor progression, and status at last follow-up were documented. Univariate and multivariate analyses were performed to determine predictors of PFS. RESULTS: Seventy-five patients were included in our study with an average age of 42 ± 17 yr. The thoracic spine was the most commonly involved spinal segment (50 patients), and most patients had grade I or grade II tumors (50 patients). On univariate analysis, gross total resection (GTR), lower tumor grade, and low Ki-67 index were associated with lower tumor progression (P-values .01, .04, and .00013, respectively). On multivariate Cox regression analysis, GTR, adjuvant chemotherapy and radiation, and low Ki-67 index were independent predictors of PFS (P-values .009, .011, and .031, respectively). CONCLUSION: In spinal astrocytomas, GTR, adjuvant therapy, and low Ki-67 are independently associated with improved PFS. These data may help guide management of these tumors and provide important prognosticating information.

Predicting pituitary adenoma consistency with preoperative magnetic resonance elastography.

OBJECTIVE: Pituitary adenoma is one of the most common primary intracranial neoplasms. Most of these tumors are soft, but up to 17% may have a firmer consistency. Therefore, knowing the tumor consistency in the preoperative setting could be helpful. Multiple imaging methods have been proposed to predict tumor consistency, but the results are controversial. This study aimed to evaluate the efficacy of MR elastography (MRE) in predicting tumor consistency and its potential use in a series of patients with pituitary adenomas. METHODS: Thirty-eight patients with pituitary adenomas (≥ 2.5 cm) were prospectively evaluated with MRI and MRE before surgery. Absolute MRE stiffness values and relative MRE stiffness ratios, as well as the relative ratio of T1 signal, T2 signal, and diffusion-weighted imaging apparent diffusion coefficient (ADC) values were determined prospectively by calculating the ratio of those values in the tumor to adjacent left temporal white matter. Tumors were classified into three groups according to surgical consistency (soft, intermediate, and firm). Statistical analysis was used to identify the predictive value of the different radiological parameters in determining pituitary adenoma consistency. RESULTS: The authors included 32 (84.21%) nonfunctional and 6 (15.79%) functional adenomas. The mean maximum tumor diameter was 3.7 cm, and the mean preoperative tumor volume was 16.4 cm3. Cavernous sinus invasion was present in 20 patients (52.63%). A gross-total resection was possible in 9 (23.68%) patients. The entire cohort's mean absolute tumor stiffness value was 1.8 kPa (range 1.1-3.7 kPa), whereas the mean tumor stiffness ratio was 0.66 (range 0.37-1.6). Intraoperative tumor consistency was significantly correlated with absolute and relative tumor stiffness (p = 0.0087 and 0.007, respectively). Tumor consistency alone was not a significant factor for predicting gross-total resection. Patients with intermediate and firm tumors had more complications compared to patients with soft tumors (50.00% vs 12.50%, p = 0.02) and also had longer operative times (p = 0.0002). CONCLUSIONS: Whereas other MRI sequences have proven to be unreliable in determining tumor consistency, MRE has been shown to be a reliable tool for predicting adenoma consistency. Preoperative knowledge of tumor consistency could be potentially useful for surgical planning, counseling about potential surgical risks, and estimating the length of operative time.

Management of Mobile Thrombus With Distal Protection Devices During Carotid Artery Angioplasty: 2-Dimensional Operative Video.

Embolic protection devices (EPDs) have become a standard of care during internal carotid artery revascularization.1,2 This video is about a 57-yr-old-male who presented with a wake-up stroke with a left hemispheric syndrome. Head computed tomography angiography (CTA) revealed tandem occlusions of the proximal left internal carotid artery (ICA) and of the distal left middle cerebral artery (MCA) with an ASPECT (Alberta Stroke Program Early CT Score) score of 6. The patient underwent a cerebral angiogram and was treated with balloon angioplasty with a distal EPD and mechanical thrombectomy. The EPD became occluded with thrombus from the ICA and was retrieved through a 6-Fr Sofia (MicroVention) under continuous aspiration. Successful revascularization of the proximal ICA and distal MCA was achieved. No procedure-related complications occurred, and the patient's neurological exam improved. Tandem occlusions can occur in up to 15% of strokes. The optimal treatment can be controversial, but mechanical thrombectomy and ICA revascularization with a distal EPD appear to be safe and effective in selected patients.3 Consent was obtained for the procedure and for the video production.

A new method for quantification and 3D visualization of brain tumor adhesion using slip interface imaging in patients with meningiomas.

OBJECTIVES: To develop an objective quantitative method to characterize and visualize meningioma-brain adhesion using MR elastography (MRE)-based slip interface imaging (SII). METHODS: This retrospective study included 47 meningiomas (training dataset: n = 35; testing dataset: n = 12) with MRE/SII examinations. Normalized octahedral shear strain (NOSS) values were calculated from the acquired MRE displacement data. The change in NOSS at the tumor boundary (ΔNOSSbdy) was computed, from which a 3D ΔNOSSbdy map of the tumor surface was created and the probability distribution of ΔNOSSbdy over the entire tumor surface was calculated. Statistical features were calculated from the probability histogram. After eliminating highly correlated features, the capability of the remaining feature for tumor adhesion classification was assessed using a one-way ANOVA and ROC analysis. RESULTS: The magnitude and location of the tumor adhesion can be visualized by the reconstructed 3D ΔNOSSbdy surface map. The entropy of the ΔNOSSbdy histogram was significantly different between adherent tumors and partially/completely non-adherent tumors in both the training (AUC: 0.971) and testing datasets (AUC: 0.900). Based on the cutoff values obtained from the training set, the ΔNOSSbdy entropy in the testing dataset yielded an accuracy of 0.83 for distinguishing adherent versus partially/non-adherent tumors, and 0.67 for distinguishing non-adherent versus completely/partially adherent tumors. CONCLUSIONS: SII-derived ΔNOSSbdy values are useful for quantification and classification of meningioma-brain adhesion. The reconstructed 3D ΔNOSSbdy surface map presents the state and location of tumor adhesion in a "clinician-friendly" manner, and can identify meningiomas with a high risk of adhesion to adjacent brain parenchyma. KEY POINTS: • MR elastography (MRE)-based slip interface imaging shows promise as an objective tool to preoperatively discriminate meningiomas with a high risk of intraoperative adhesion. • Measurement of the change of shear strain at meningioma boundaries can provide quantitative metrics depicting the state of adhesion at the tumor-brain interface. • The surface map of tumor adhesion shows promise in assisting precise adhesion localization, using a comprehensible, "clinician-friendly" 3D visualization.

The Role of Angioplasty Alone in Intracranial Atherosclerosis: 2-Dimensional Operative Video.

Intracranial atherosclerosis disease (IAD) is the cause of stroke in up to 10% of cases. Symptomatic IAD results mainly from hypoperfusion, embolic phenomenon, and occlusion. Treatment consists of conservative management with aggressive medical treatment, surgery, and endovascular therapy.1,2 This video is about a 62-yr-old male who presented with left-sided hemiparesis and right gaze preference secondary to an acute ischemic stroke in the right middle cerebral artery (MCA) territory treated initially with  tissue plasminogen activator (tPA). Head computed tomography (CT) angiography (CTA) revealed occlusion of the extracranial and cavernous segments of the internal carotid artery (ICA). CT perfusion (CTP) showed hypoperfusion in the MCA territory and magnetic resonance imaging (MRI) revealed multifocal, wedge-shaped areas of restricted diffusion in the right hemisphere. During his hospitalization, he experienced worsening of his symptoms in the setting of hypoperfusion (hypotension). The patient underwent a cerebral angiogram with thrombectomy and submaximal angioplasty (SA). Successful revascularization of the right ICA was obtained. No procedure-related complications occurred, and the patient's neurological exam improved. SA can be as efficient and a safer option than conventional angioplasty or angioplasty and stenting for symptomatic IAD. The patient consented for the procedure and for the video production.

Combined Anterior Transmaxillary (Caldwell-Luc) With an Endoscopic Endonasal Transpterygoid Approach for Resection of a Large Juvenile Nasopharyngeal Angiofibroma: 2-Dimensional Operative Video.

Juvenile nasopharyngeal angiofibroma (JNA) is a highly vascular benign tumor that originates in the sphenopalatine foramen and often spreads to adjacent compartments.1 Microsurgical resection with preoperative embolization remains the treatment of choice.2 We present a case of a large JNA involving multiple compartments. The patient is a 20-yr-old male who presented with long-term right nasal congestion. The MRI demonstrated a large enhancing mass that extended from the right nasal cavity and nasopharynx into the right pterygopalatine fossa (PPF), infratemporal fossa (ITF), and parapharyngeal space. Preoperative angiogram for embolization showed a highly vascular tumor with blood supply mainly from the internal maxillary artery and about 10% from a persistent mandibular branch of the internal carotid artery. Based on the UPMC JNA staging system, this tumor was a stage IV.2 A combined anterior transmaxillary (Caldwell-Luc) with an endoscopic endonasal transpterygoid approach was performed. The addition of the anterior transmaxillary approach increases the surgical freedom for traditional bipolar devices and improves the view and trajectory to more lateral structures like the PPF and ITF.3 Gross total resection was achieved without complications. The patient was discharged home with a partial V2 numbness (right superior gum) that improved with time. The endoscopic endonasal approach is a safe and effective technique even for large JNA. A multidisciplinary team consisting of an interventional radiologist, a skull base neurosurgeon, and an otorhinolaryngologist with expertise in endoscopic surgery may play a role for optimal surgical results. The patient consented for the procedure and for the video production.

Teflon versus Ivalon in Microvascular Decompression for Trigeminal Neuralgia: A 2-Center 10-Year Comparison.

BACKGROUND: Trigeminal neuralgia features jolts of pain along the distribution of the trigeminal nerve. If patients fail conservative management, microvascular decompression (MVD) is typically the next step in treatment. MVD consists of implanting a separating material, often Teflon, between the nerve and compressive lesions. A review found similar success and complication rates between Teflon and Ivalon, another commonly used material. The aim of this study was to analyze outcomes and complications associated with Teflon and Ivalon in MVD. METHODS: We conducted a 2-center retrospective cohort study of trigeminal neuralgia treated with MVD between 2005 and 2019. Patients with no postoperative follow-up were excluded. Postoperative pain was graded using the Barrow Neurological Institute (BNI) pain intensity score. Relapse was defined as a BNI score of 4-5 during follow-up after initial pain improvement or an initial BNI score of 1-3. RESULTS: The study included 221 MVD procedures in 219 patients. Ivalon was implanted in 121 procedures, and Teflon was implanted in 100 procedures. Multivariate analysis found that implant type had no effect on final BNI score (P = 0.305). Relapse rates were similar at 5- and 10-year follow-up (5-year: Ivalon 10.7%, Teflon 18.0%, P = 0.112; 10-year: Ivalon 11.6%, Teflon 19.0%, P = 0.123). There was no difference in postoperative immediate facial numbness (P = 0.125). Postoperative hearing difficulty was higher in the Ivalon cohort (8.4% vs. 1.0%; P = 0.016). CONCLUSIONS: We found no significant difference in final BNI score or risk of relapse between Ivalon and Teflon. Complications were similar, although Ivalon was more associated with temporary postoperative hearing loss.

Pituitary adenomas in the setting of multiple endocrine neoplasia type 1: a single-institution experience.

OBJECTIVE: Multiple endocrine neoplasia type 1 (MEN1) is a rare, autosomal-dominant tumor disorder characterized by the development of pituitary tumors and other endocrine neoplasms. Diagnosis is made clinically based on the development of 2 or more canonical lesions (parathyroid gland, anterior pituitary, and enteropancreatic tumors) or in family members of a patient with a clinical diagnosis of MEN1 and the occurrence of one of the MEN1-associated tumors. The goal of this study was to characterize pituitary tumors arising in the setting of MEN1 at a single institution. The probability of tumor progression and the likelihood of surgical intervention in patients with asymptomatic nonfunctional pituitary adenomas were also analyzed. METHODS: A retrospective review of a prospectively maintained institutional database was performed for patients with MEN1 diagnosed from 1970 to 2017. Data included patient demographics, tumor characteristics, treatment strategies, and outcomes. RESULTS: A review of the database identified 268 patients diagnosed with MEN1, of whom 158 (59%) were female. Among the 268 patients, 139 (51.8%) had pituitary adenomas. There was a higher prevalence in women than in men (65% vs 35%, p < 0.005). Functional adenomas (57%) were more common. Prolactin-secreting adenomas were the most common functional tumors. Macroadenomas were seen in 27% of patients and were more likely to be symptomatic and locally aggressive (p < 0.001). Forty-nine patients (35%) underwent transsphenoidal resection at some point during their disease course. In 52 patients who were initially observed with MEN1 asymptomatic nonfunctional adenomas, only 5 (10%) progressed to need surgery. In MEN1 patients, an initial parathyroid lesion is most likely followed in order by pituitary, pancreatic, adrenal, and, finally, rare carcinoid tumors. CONCLUSIONS: Asymptomatic nonfunctional pituitary adenomas in patients with MEN1 may be followed safely with MRI. In this series, parathyroid tumors developed at the lowest median age of all cardinal tumors, and development of additional cardinal MEN1 lesions followed a predictable pattern. This pattern of disease progression could have significant implications for disease surveillance in clinical practice and may help to target clinical resources to the lesions most likely to develop next. This may aid with early detection and treatment and warrants further study.

Transylvian Clip Occlusion of an Enlarging High-Flow Tentorial Arteriovenous Fistula: 2-Dimensional Operative Video.

Endovascular therapy is the primary treatment for the majority of tentorial dural arteriovenous fistulas (dAVF). Surgical occlusion is an effective alternative when embolization is not possible. This video demonstrates microsugical occlusion of a right-sided tentorial dAVF in a symptomatic 45-yr-old male. The dAVF was fed directly by meningohypophyseal trunk. Venous drainage was retrograde through the sphenoparietal sinus, superficial sylvian vein, vein of Labee, and transverse sinus. The patient underwent a right-sided pterional craniotomy; the sylvian fissure was widely opened. Subarachoid dissection was performed until a large arterialized draining vein was identified exiting dura subtemporally. Intraoperative indocyanine green angiography confirmed the fistulous site and the draining vein was occluded and divided. The patient remained neurologically intact after surgery. Immediate angiography demonstrates complete occlusion of the dAVF. This video demonstrates the surgical access obtained through a transylvian approach for this tentorial dAVF. Occlusion of the draining vein, with or without resection of the fistula, is enough to permanently treat these lesions.

Microsurgical resection of an enlarging lateral pontomedullary cavernous malformation.

The extended retrosigmoid approach provides an excellent corridor to the lateral aspect of the pontomedullary junction (PMJ).1,2 This video demonstrates a microsurgical resection of a progressive enlarging cavernous malformation (CM) of the PMJ. The patient is a 33-year-old woman with progressive symptoms, including right facial droop, left hemianesthesia, diplopia, and nystagmus. The patient underwent a right extended retrosigmoid approach with intraoperative neuronavigation and neuromonitoring. Lower cranial nerve dissection allowed access to the lateral PMJ. A longitudinal corticotomy was performed above the glossopharyngeal. The CM was removed in a piecemeal fashion. Postoperative MRI confirmed gross-total resection and the patient remained neurologically stable. The video can be found here: https://youtu.be/K_TtiTo1RsQ.

Supracerebellar Infratentorial and Occipital Transtentorial Approaches to the Pulvinar: Ipsilateral Versus Contralateral Corridors.

BACKGROUND: Due to the critical neurovascular structures that surround the pulvinar, deciding the best surgical approach can be challenging, with multiple options available. OBJECTIVE: To analyze and compare the ipsilateral vs the contralateral version of the 2 main approaches to the cisternal pulvinar surface: paramedian supracerebellar infratentorial (PSCI) and interhemispheric occipital transtentorial (IOT). METHODS: The PSCI and IOT approaches were performed on 7 formalin-fixed adult cadaveric heads to evaluate qualitatively and quantitatively the microsurgical exposure of relevant anatomic structures. We quantitatively measured the corridor distance to our target with each approach. RESULTS: The ipsilateral PSCI approach provided an easier access and a better exposure of the anteromedial portion of the cisternal pulvinar surface. The contralateral approach provided a wider and more accessible exposure of the posterolateral portion of the cisternal pulvinar surface. When protrusion of the posterior parahippocampal gyrus above the free edge of the tentorium was present, the contralateral PSCI approach provided an unobstructed view to both areas. The IOT approach provided a better view of the anteromedial portion of the cisternal pulvinar surface, especially with a contralateral approach. CONCLUSION: Multiple approaches to the pulvinar have been described, modified, and improved. Based on this anatomic study we believe that although the corridor distance with a contralateral approach is longer, the surgical view and access can be better. We recommend the use of a PSCI contralateral approach especially when a significant protrusion of the posterior parahippocampal gyrus is present.

The medial wall of the cavernous sinus. Part 2: Selective medial wall resection in 50 pituitary adenoma patients.

OBJECTIVE: Pituitary adenomas often invade the medial wall of the cavernous sinus (CS), but this structure is generally not surgically removed because of the risk of vascular and cranial nerve injury. The purpose of this study was to report the surgical outcomes in a large series of cases of invasive pituitary adenoma in which the medial wall of the CS was selectively removed following an anatomically based, stepwise surgical technique. METHODS: The authors' institutional database was reviewed to identify cases of pituitary adenoma with isolated invasion of the medial wall, based on an intraoperative evaluation, in which patients underwent an endoscopic endonasal approach with selective resection of the medial wall of the CS. Cases with CS invasion beyond the medial wall were excluded. Patient complications, resection, and remission rates were assessed. RESULTS: Fifty patients were eligible for this study, 15 (30%) with nonfunctional adenomas and 35 (70%) with functional adenomas, including 16 growth hormone-, 10 prolactin-, and 9 adrenocorticotropic hormone (ACTH)-secreting tumors. The average tumor size was 2.3 cm for nonfunctional and 1.3 cm for functional adenomas. Radiographically, 11 cases (22%) were Knosp grade 1, 23 (46%) Knosp grade 2, and 16 (32%) Knosp grade 3. Complete tumor resection, based on intraoperative impression and postoperative MRI, was achieved in all cases. The mean follow-up was 30 months (range 4-64 months) for patients with functional adenomas and 16 months (range 4-30 months) for those with nonfunctional adenomas. At last follow-up, complete biochemical remission (using current criteria) without adjuvant treatment was seen in 34 cases (97%) of functional adenoma. No imaging recurrences were seen in patients who had nonfunctional adenomas. A total of 57 medial walls were removed in 50 patients. Medial wall invasion was histologically confirmed in 93% of nonfunctional adenomas and 83% of functional adenomas. There were no deaths or internal carotid artery injuries, and the average blood loss was 378 ml. Four patients (8%) developed a new, transient cranial nerve palsy, and 2 of these patients required reoperation for blood clot evacuation and fat graft removal. There were no permanent cranial nerve palsies. CONCLUSIONS: The medial wall of the CS can be removed safely and effectively, with minimal morbidity and excellent resection and remission rates. Further follow-up is needed to determine the long-term results of this anatomically based technique, which should only be performed by very experienced endonasal skull base teams.

[Recurrent pericardial effusion due to familiar Mediterranean fever]. / Pericarditis recidivante y fiebre mediterránea familiar.

Pericarditis is usually a complication of viral or bacterial infection. In addition, it can be associated to systemic diseases such as autoimmune disorders, rheumatic fever, cancer, tuberculosis and AIDS. It can also be related to familial Mediterranean fever, an autosomic recessive inflammatory disease, characterized by fever, abdominal pain, and pleuritis mainly seen in persons from the Mediterranean area. In this study, we described the evolution and treatment response to colchicine in three patients with pericarditis associated to familial Mediterranean fever. Two of the patients had a pericardiectomy showing in their biopsy nonspecified inflammatory changes. Later their diagnosis were confirmed by genetic markers, echocardiogram and EKG. They were treated with antiviral and antibiotics without any improvement; subsequently they had good results with colchicine.