Microsurgical clipping versus newer endovascular techniques in treatment of unruptured anterior communicating artery-complex aneurysms: a meta-analysis and systematic review.

The aim of this study is to compare occlusion rate, complication rate, and clinical outcome of microsurgical clipping (MC) and advanced endovascular techniques (EVT) in unruptured anterior communicating artery-complex aneurysms (ACoCAs). We reviewed the scientific literature reporting occlusion rate, time of occlusion assessment, and clinical outcome of MC and EVT in patients with unruptured ACoCAs, from January 2009 to December 2019. We included in our analysis 25 studies and 872 patients with unruptured ACoCAs (434 treated with endovascular techniques and 438 with MC). Ninety-three (10.7%), 320 (36.7%), 21 (2.4%), and 438 (50.2%) were treated with flow diverter (FD), stent-assisted coiling (SAC), endosaccular devices (ES), and microsurgical clipping (MC) respectively. FD, SAC, ES, and MC subgroups presented minor complications in 11.8%, 3.8%, 14.3%, and 7.1% of cases (p=.016), and major complications in 3.2%, 4.4%, 0%, and 7.1% (p=.136) of patients. A total occlusion rate post-treatment has been achieved in 4.3%, 87.1%, 47.6%, and 98.2% of cases (p=.000), while at 12 months' follow-up in 50%, 66%, 83.3%, and 80% of patients (p=.001). FD, SAC, ES, and MC subgroups had a good clinical outcome at 12 months in 93.5%, 90.5%, 100%, and 67.8% of cases. MC is associated with higher post-treatment total occlusion rate, but higher complication and lower good clinical outcome rates. EVT are promising in treating unruptured anterior cerebral artery aneurysms with high margin of safety and good clinical outcome, despite the lower total occlusion rate.

Blister-like aneurysms of middle cerebral artery: a multicenter retrospective review of diagnosis and treatment in three patients.

Blood blister-like aneurysms (BBA) were described for the first time in the 1990s, as small hemispherical bulges arising from a very fragile arterial wall. Until 2008, it was thought that this type of aneurysm almost exclusively affected the internal carotid artery, in particular, its dorsal portion. Subsequently, it was discovered that a BBA may also be present on the anterior communicating artery and on the vessels of the posterior cranial fossa. However, we found no reports in English-language literature of BBA arising from the middle cerebral artery (MCA). In this article, we present three cases of MCA BBA and discuss the unique diagnostic and therapeutic aspects of this vascular lesion. In our retrospective, multicenter review of 1330 patients with non-traumatic subarachnoid hemorrhage admitted to our services from 2000 to 2013, we found three cases (all in men) of MCA BBA. The patients' outcome was assessed using the modified Rankin scale. All three patients underwent angio-computed tomography, which did not reveal any aneurysms. Digital subtraction angiography performed within 24-48 h after admission, in all cases, demonstrated a very small aneurysm (<2 mm), with a triangular shape and abroad base, at non-branching sites of MCA. All the aneurysms were treated: one by wrapping + clipping, one by wrapping + flow-diverter stent, and one with coils. At the time of surgery, the aneurysms appeared on the surface of the parent artery without any involvement of the branches. All presented as blister-like aneurysms that were thin-walled and lacked a surgical neck. At the time of discharge, the outcome was good in one patient and poor in the other two. Our cases demonstrate that BBA can also arise from the MCA, despite the lack of previous reports of this occurrence; a BBA should be suspected, particularly in cases of non-perimesencephalic subarachnoid hemorrhage in which the presence of a MCA aneurysm is suspected but not revealed by digital subtraction angiography or angio-computed tomography.

Does recurrent laryngeal nerve anatomy condition the choice of the side for approaching the anterior cervical spine?

AIM: The anterior cervical presternocleidomastoid approach is a safe and standardized procedure. Nevertheless, in all the largest series presented in literature, a certain risk of injury to the recurrent laryngeal nerves (RLNs) is reported and the choice of the side of the approach seems to influence such risk. Our aim was to study the surgical anatomy of the RLNs and to understand whether the side of the approach can be a risk factor for their surgical damage. METHODS: We performed an anatomical dissection of 6 fresh cadavers, studying the origin and the course of both the RLNs, to assess their vulnerability in the anterior presternocleidomastoid approach to the cervical spine. RESULTS: The origin of the right RLN was at C7 in 2 cases and at T1 in 4 cases. In all cases it arose where vagus nerve crossed the subclavian artery and it was directed superiorly and transversely to the esophagotracheal groove. CONCLUSIONS: The right and left RLNs have different origin and course. Although the discussion about the best side for the anterior cervical approach is debated, in our opinion, both anatomical and surgical considerations, concerning RLNs, lead to the evidences that the left side approach, when possible, should be preferred below the level of C4.

A comparison of acute vascular damage caused by ADAPT versus a stent retriever device after thrombectomy in acute ischemic stroke: a histological and ultrastructural study in an animal model.

BACKGROUND: It has been amply demonstrated that endovascular procedures can be successful treatment for stroke, both in terms of revascularization and clinical outcome. There is not, however, a published comparison of any histological or ultrastructural damage to the vessels that may be caused by a direct aspiration first pass technique (ADAPT) or stent retrievers (SR) used in these procedures. This study analyses and compares acute damage to the arterial wall caused by ADAPT or SR. MATERIAL AND METHODS: Damage to the walls of swine extracranial arteries was evaluated after ADAPT with the Penumbra system or thrombectomy with an SR (Solitaire 6×30). The procedures were performed after injecting thrombi into the selected arteries (arteries with diameters similar to those of the human internal carotid artery and first segment of the middle cerebral artery). After the procedures, the animal was euthanized and 12 arterial samples were obtained for analysis by optical and electronic microscopy. RESULTS: Tissue samples from the vessels treated with SR showed almost complete loss of endothelium, thickening of the internal elastic lamina, and degeneration of the elastic fibers of the bordering lamina media and adventitia. In contrast, tissue samples of the vessels treated with ADAPT had a clear integral internal elastic lamina and uninterrupted endothelial lining, although cell alignment was altered and there were surface lacerations due to manipulation of the samples. CONCLUSIONS: Both techniques caused acute damage to the vessel walls, however, thrombectomy with SR appeared to be more harmful to all layers of the arterial wall, particularly the endothelium.

Ghost lesions in patient with cerebral-isolated neurosarcoidosis. A case report.

We present a case of isolated cerebral neurosarcoidosis with remitting nodular lesions resembling intraventricular neoplasms. The patient, admitted at our Department for surgical treatment of a magnetic resonance imaging (MRI) demonstrated fourth ventricle lesion, presented acute intracranial hypertension. A second MRI performed before the scheduled operation showed the disappearance of the fourth ventricle lesion and a tetra-ventricular hydrocephalus. The patient has been treated with a third-ventriculostomy, followed, after 15 days, by ventriculoperitoneal shunt. High doses of steroids have been administered. Cerebrospinal fluid analysis has been conducted and a high concentration of ACE, specific marker of neurosarcoidosis, has been found. No biopsy was performed to avoid surgical complications. A systemic chemotherapy with azathioprine has been started, but the patient died six months later for worsening of the clinical conditions. The autopsy confirmed the diagnosis of neurosarcoidosis. This is the first MRI documented case of neurosarcoidosis with remitting lesions. Diagnosis of isolated neurosarcoidosis is difficult and it is based on clinical and radiological exclusion of other entities. CSF examination is useful for diagnosis, for the reported specificity and sensibility of ACE. Medical treatment is based on corticosteroids and chemotherapic agents. Neurosurgical intervention can be related to treat hydrocephalus due to ependymal and arachnoidal involvement or to remove large lesions. In our opinion biopsy should be limited only to ACE negative patients and to those who do not respond to chemotherapy.

A Systematic Review and Meta-Analysis of Treatment and Outcome of Blister-Like Aneurysms.

BACKGROUND AND PURPOSE: Blister-like aneurysms are uncommon but challenging lesions. Their small size and atypical location often make the diagnosis difficult. Microsurgery and endovascular procedures have been used for their treatment, but there is no consensus on the best treatment technique. We conducted a systematic review and meta-analysis of treatments and outcomes of these vascular lesions. MATERIALS AND METHODS: We reviewed English-language articles on "blood blister-like aneurysms" published between January 1997 and November 2014. All studies reporting patients with these aneurysms treated with surgery, endovascular procedures, or combined therapy with data on treatment modalities and clinical and/or angiographic outcomes were selected, including case reports and series. We performed a meta-analysis on the 2 largest treatment groups (surgery and endovascular management). RESULTS: Sixty studies with 334 patients met our inclusion criteria. Surgery was performed in 114 patients (34.2%), and endovascular treatment, in 199 patients (59.5%). A combined treatment was used in 19 patients (5.7%). A favorable outcome (mRS 0-2) was reported in 67.4% and 78.9% of patients treated with surgery and with endovascular therapy, respectively (P = .034). CONCLUSIONS: Blister-like aneurysms are challenging vascular lesions. The choice of treatment method must be based on the initial clinical presentation and an analysis of the radiologic features of the lesion to select the best technique. Endovascular treatment seems to have lower morbidity and mortality and provides a better outcome compared with surgical approaches. Further prospective studies must be performed to confirm such interesting results.

Chemical meningitis: unusual presentation of a cerebellar astrocytoma: case report and review of the literature.

Chemical meningitis resulting from the spillage of the contents of a cystic tumor rarely constitutes the sole manifestation of a cranial or spinal tumor. The case of a man who initially had signs and symptoms of meningitis that on computed tomographic scan was shown to be a space-occupying cerebellar lesion is reported. Thirty-five cases of cranial and spinal tumors in which the presenting symptom was chemical meningitis are also reviewed.

Mucoceles of the paranasal sinuses with intracranial and intraorbital extension: report of 28 cases.

Twenty-eight patients received surgical treatment for a paranasal sinus mucocele with intracranial and/or intraorbital extension. The lesions were classified by site and extension: anterior without intracranial extension (Type 1), 7 patients; anterior with intracranial extension (Type 2), 11 patients; posterior midline without intracranial extension (Type 3), 5 patients; and posterior with intracranial extension (Type 4), 5 patients. The surgical approaches were: transnaso-orbital, transfrontonaso-orbital, transsphenoidal, transmaxillosphenoidal, and subfrontal transbasal; the choice depended on the site and extension of the lesion, with the aim of securing maximum exposure to ensure total removal of the lesion with its capsule. A transcranial approach was reserved for mucoceles possessing an intracranial extension or causing distension of the bone structures with optic pathway neurological symptoms. With a coronal or transfacial skin incision along the lines of the forehead, nose, and orbital muscles of expression and careful reconstruction, the patients' natural cast of features was spared or restored in a single operation.

Cerebral hydatidosis in childhood: a retrospective survey with emphasis on long-term follow-up.

We report the long-term outcome of surgery for cerebral hydatid cyst in 12 children. In only one child, who had been operated on for cardiac hydatidosis a year earlier, was the brain cyst known to be secondary. Of the 12 children, 10 had a single cyst and 2 had multiple cysts. Five single cysts were removed intact by "hydatid birth," two cysts--one single and one multiple--were removed after puncture and aspiration of the cyst fluid, and the other five--four single and one multiple--were accidentally ruptured in the course of the operation. One patient died of infection of the residual space, 2 died of intracranial recurrence of the parasite (7 and 22 months later, respectively), and one, the child with secondary cerebral echinococcosis, died 6 years later of systemic echinococcosis. Eight patients who had a mean follow-up of 28 years are still living and enjoy very good health, both general and neurological. This long-term follow-up with such good results confirms the usually primary character of cerebral hydatid disease, at least in children. The combination of patent ductus arteriosus and ingestion of unboiled animals' milk might well explain how primary cerebral hydatid disease develops in children.

Surgical management of orbital cavernous angiomas: prognosis for visual function after removal.

The authors report the outcome of surgical treatment in a group of 25 patients with cavernous angioma of the orbital cavity. In the majority of cases, good esthetic results were appreciable within a few days of surgery. However, the onset or deterioration of preexisting visual deficits, in spite of the complete preservation of the optic nerve in a third of these patients, draws attention to the need for accurate surgical timing.

Long-term results of the surgical treatment of spinal dermoid and epidermoid tumors.

The clinical findings and the results of surgical treatment in 16 patients with spinal dermoid or epidermoid tumors are reported. In 9 patients the tumor capsule adhered so tightly to the nervous tissue that part of it was left in situ. In a follow-up study ranging from 5 to 30 years with a mean of 14.2 years only 1 patient had a recurrence of the tumor and 10 patients resumed a normal working life.

Epidermoid tumors of the 4th ventricle: report of seven cases.

Epidermoid tumors occur very rarely in the 4th ventricle. We discuss the history, clinical course, and the surgical results for seven patients. One patient had a remittal of symptoms, probably due to the emergence of the tumor from the 4th ventricle into the cisterna magna. Total removal of the capsule was possible only in the youngest patient. At present, four patients (mean follow-up, 6 years) enjoy good general and neurological health.

Supratentorial dermoid cysts.

Supratentorial dermoid cysts are rare lesions. In eight cases presented here, the lack of recurrence after subtotal removal of the capsule and the good long-term prognosis are emphasized. This finding is in agreement with the literature. The frequent relationship of these lesions with the cavernous sinus suggests a vascular genesis in the development of intracranial dermoid cysts.

Occipitocervical pseudomalignant osseous tumor of the soft tissue (Fasciitis ossificans). Case report.

The authors describe the case of a 12-year-old girl in whom a pseudomalignant osseous tumor of the soft tissue was diagnosed. The lesion was resected, and at 3-year postresection follow-up examination, neuroradiological studies demonstrated no recurrence of the tumor.

Cholesterol granuloma of the cerebello-pontine angle.

An unusual case of cholesterol granuloma of the temporal bone is described presenting as a cerebellopontine tumor. This lesion seemed to arise from an inflammatory process obstructing pneumatized cells. It consists of extradural granulation tissue and must be distinguished from intradural epidermoid cyst, which is, instead, a dysembryogenetic neoplasm. Simple drainage of the granuloma was accomplished by posterior fossa approach, but the lesion recurred after a year. The diagnosis and surgical management of cholesterol granuloma are discussed.

Supratentorial hemangioblastoma in a patient with breast cancer. A case report.

Patients with breast cancer may develop cerebral metastasis. Radio- and chemotherapy are advocated as an alternative to surgery in such patients. A woman operated on for breast cancer 2 years earlier developed a cerebral lesion. A definite preoperative diagnosis of the lesion was not possible on the basis of CT and MRI findings. The lesion proved to be a supratentorial hemangioblastoma. Neurosurgical treatment is recommended for patients with breast cancer who present a cerebral lesion, since a correct diagnosis may only be possible in the operating theater.

Neurinoma of the oculomotor nerve.

A rare case of neurinoma of cranial nerve III is described. Preoperative diagnosis of such tumors is difficult because they may be mistaken for brainstem tumors.

Transient cerebellar mutism after posterior cranial fossa surgery in an adult. Case report and review of the literature.

Transient mutism, without disorders of consciousness or cranial nerve deficits, arising after surgical operations on the posterior cranial fossa is a recently described entity. To date 22 cases have been reported, to which we add the present case (the first report of the syndrome in an adult). We review the salient features of the syndrome in the light of the published cases and speculate on the underlying physiopathology.

Trigeminal schwannoma with infratemporal extension. Case report.

The case of a 55-year-old woman with a rare trigeminal schwannoma extending into the infratemporal fossa is described. The presentation and treatment of this type of intra and extracranial tumor are discussed.

Radiation-induced schwannomas of the nervous system. Report of five cases and review of the literature.

Radiation therapy has important delayed effects on the central nervous system. Prominent among these effects is radiation necrosis of nervous tissue, but an oncogenic effect is also recognized. Both benign and malignant intracranial tumors can develop in irradiated fields, particularly in children. Most of these tumors are sarcomas, meningiomas or gliomas and only occasionally schwannomas. We report 5 cases of postirradiation acoustic nerve schwannoma observed in our Department.