Sex-dependent characteristics and outcomes after clipping of unruptured intracranial aneurysms: a multicenter propensity score-matched study.

OBJECTIVE: Disparities in the epidemiology and growth rates of aneurysms between the sexes are known. However, little is known about sex-dependent outcomes after microsurgical clipping of unruptured intracranial aneurysms (UIAs). The aim of this study was to examine sex differences in characteristics and outcomes after microsurgical clipping of UIAs and to perform a propensity score-matched analysis using an international multicenter cohort. METHODS: This retrospective cohort study involved the participation of 15 centers spanning four continents. It included adult patients who underwent clipping of UIAs between January 2016 and December 2020. Patients were stratified according to their sex and analyzed for differences in morbidities and aneurysm characteristics. Based on this stratification, female patients were matched to male patients in a 1:1 ratio with a caliper width of 0.1 using propensity score matching. Endpoints included postoperative complications, neurological performance, and aneurysm occlusion at discharge and 24 months after clip placement. RESULTS: A total of 2245 patients with a mean age of 57.3 (range 20-87) years were included. Of these patients, 1675 (74.6%) were female. Female patients were significantly older (mean 57.6 vs 56.4 years, p = 0.03) but had fewer comorbidities. Aneurysms of the internal carotid artery (7.1% vs 4.2%), posterior communicating artery (6.9% vs 1.9%), and ophthalmic artery (6.0% vs 2.8%) were more commonly treated surgically in females, while clipping of aneurysms of the anterior communicating artery was more frequent in males (17.0% vs 25.3%; all p < 0.001). After propensity score matching, female patients were found to have had significantly fewer pulmonary complications (1.4% vs 4.2%, p = 0.01). However, general morbidity (24.5% vs 25.2%, p = 0.72) and mortality (0.5% vs 1.1%, p = 0.34), as well as neurological performance (p = 0.58), were comparable at discharge in both sexes. Lastly, rates of aneurysm occlusion at the time of discharge (95.5% vs 94.9%, p = 0.71) and 24 months after surgery (93.8% vs 96.1%, p = 0.22) did not significantly differ between male and female patients. CONCLUSIONS: Despite overall differences between male and female patients in demographics, comorbidities, and treated aneurysm location, sex did not relevantly affect surgical performance or perioperative complication rates.

A novel method of neurophysiological brainstem mapping in neurosurgery.

BACKGROUND: Brainstem mapping with electrical stimulation allows functional identification of neural structures during resection of deep lesions. Single pulses or train of pulses are delivered to map cranial nerves and corticospinal tracts, respectively. NEW METHOD: We introduce a hybrid stimulation technique for mapping the brainstem. The stimulus consists of an electrical single pulse followed by a short train of 3-5 pulses at 500 Hz, at an interval of 60-75 ms. The responses to this stimulation pattern are recorded from appropriate cranial and limb muscles. RESULTS: Both the single pulse and the short train elicit electromyographic responses when motor fibers or motor nuclei of the cranial nerves are stimulated. Responses to the train but not to the preceding single pulse indicate activation of the descending motor tracts, in the mesencephalon and the pons. Conversely, in the medulla, limb responses to stimulation of the corticospinal tracts are elicited by a single pulse. Identification of the extra and intra-axial courses of the trigeminal motor and sensory fibers is possible by recording responses from the masseter and the tongue muscles. COMPARISON WITH EXISTING METHOD(S): To date, either a pulse or a train is delivered during brainstem mapping, switching from one to the other modality according to the expected target structure. This procedure can be time-consuming and may even lead to false negative responses to the stimulation, eventually leading to inaccurate neurosurgical procedures. CONCLUSIONS: The novel hybrid pulse-train technique enhances the advantage of brainstem mapping procedure, minimizing pitfalls and improving patient safety.

Microsurgical Clipping of Unruptured Anterior Circulation Aneurysms-A Global Multicenter Investigation of Perioperative Outcomes.

BACKGROUND AND OBJECTIVES: Microsurgical aneurysm repair by clipping continues to be highly important despite increasing endovascular treatment options, especially because of inferior occlusion rates. This study aimed to present current global microsurgical treatment practices and to identify risk factors for complications and neurological deterioration after clipping of unruptured anterior circulation aneurysms. METHODS: Fifteen centers from 4 continents participated in this retrospective cohort study. Consecutive patients who underwent elective microsurgical clipping of untreated unruptured intracranial aneurysm between January 2016 and December 2020 were included. Posterior circulation aneurysms were excluded. Outcome parameters were postsurgical complications and neurological deterioration (defined as decline on the modified Rankin Scale) at discharge and during follow-up. Multivariate regression analyses were performed adjusting for all described patient characteristics. RESULTS: Among a total of 2192 patients with anterior circulation aneurysm, complete occlusion of the treated aneurysm was achieved in 2089 (95.3%) patients at discharge. The occlusion rate remained stable (94.7%) during follow-up. Regression analysis identified hypertension (P < .02), aneurysm diameter (P < .001), neck diameter (P < .05), calcification (P < .01), and morphology (P = .002) as preexisting risk factors for postsurgical complications and neurological deterioration at discharge. Furthermore, intraoperative aneurysm rupture (odds ratio 2.863 [CI 1.606-5.104]; P < .01) and simultaneous clipping of more than 1 aneurysm (odds ratio 1.738 [CI 1.186-2.545]; P < .01) were shown to be associated with an increased risk of postsurgical complications. Yet, none of the surgical-related parameters had an impact on neurological deterioration. Analyzing volume-outcome relationship revealed comparable complication rates (P = .61) among all 15 participating centers. CONCLUSION: Our international, multicenter analysis presents current microsurgical treatment practices in patients with anterior circulation aneurysms and identifies preexisting and surgery-related risk factors for postoperative complications and neurological deterioration. These findings may assist in decision-making for the optimal therapeutic regimen of unruptured anterior circulation aneurysms.

Global Outcomes for Microsurgical Clipping of Unruptured Intracranial Aneurysms: A Benchmark Analysis of 2245 Cases.

BACKGROUND AND OBJECTIVES: Benchmarks represent the best possible outcome and help to improve outcomes for surgical procedures. However, global thresholds mirroring an optimal and reachable outcome for microsurgical clipping of unruptured intracranial aneurysms (UIA) are not available. This study aimed to define standardized outcome benchmarks in patients who underwent clipping of UIA. METHODS: A total of 2245 microsurgically treated UIA from 15 centers were analyzed. Patients were categorized into low- ("benchmark") and high-risk ("nonbenchmark") patients based on known factors affecting outcome. The benchmark was defined as the 75th percentile of all centers' median scores for a given outcome. Benchmark outcomes included intraoperative (eg, duration of surgery, blood transfusion), postoperative (eg, reoperation, neurological status), and aneurysm-related factors (eg, aneurysm occlusion). Benchmark cutoffs for aneurysms of the anterior communicating/anterior cerebral artery, middle cerebral artery, and posterior communicating artery were determined separately. RESULTS: Of the 2245 cases, 852 (37.9%) patients formed the benchmark cohort. Most operations were performed for middle cerebral artery aneurysms (53.6%), followed by anterior communicating and anterior cerebral artery aneurysms (25.2%). Based on the results of the benchmark cohort, the following benchmark cutoffs were established: favorable neurological outcome (modified Rankin scale ≤2) ≥95.9%, postoperative complication rate ≤20.7%, length of postoperative stay ≤7.7 days, asymptomatic stroke ≤3.6%, surgical site infection ≤2.7%, cerebral vasospasm ≤2.5%, new motor deficit ≤5.9%, aneurysm closure rate ≥97.1%, and at 1-year follow-up: aneurysm closure rate ≥98.0%. At 24 months, benchmark patients had a better score on the modified Rankin scale than nonbenchmark patients. CONCLUSION: This study presents internationally applicable benchmarks for clinically relevant outcomes after microsurgical clipping of UIA. These benchmark cutoffs can serve as reference values for other centers, patient registries, and for comparing the benefit of other interventions or novel surgical techniques.

Reducing the Gap in Neurosurgical Education in LMICs: A Report of a Non-Profit Educational Program.

INTRODUCTION: Central to neurosurgical care, neurosurgical education is particularly needed in low- and middle-income countries (LMICs), where opportunities for neurosurgical training are limited due to social and economic constraints and an inadequate workforce. The present paper aims (1) to evaluate the validity and usability of a cadaver-free hybrid system in the context of LMICs and (2) to report their learning needs and whether the courses meet those needs via a comprehensive survey. METHODS: From April to November 2021, a non-profit initiative consisting of a series of innovative cadaver-free courses based on virtual and practical training was organized. This project emerged from a collaboration between the Young Neurosurgeons Forum of the World Federation of Neurological Societies (WFNS), the NIHR Global Health Research Group on Neurotrauma, and UpSurgeOn, an Italian hi-tech company specialized in simulation technologies, creator of the UpSurgeOn Box, a hyper-realistic simulator of cranial approaches fused with augmented reality. Over that period, 11 cadaver-free courses were held in LMICs using remote hands-on Box simulators. RESULTS: One hundred sixty-eight participants completed an online survey after course completion of the course. The anatomical accuracy of simulators was overall rated high by the participant. The simulator provided a challenging but manageable learning curve, and 86% of participants found the Box to be very intuitive to use. When asked if the sequence of mental training (app), hybrid training (Augmented Reality), and manual training (the Box) was an effective method of training to fill the gap between theoretical knowledge and practice on a real patient/cadaver, 83% of participants agreed. Overall, the hands-on activities on the simulators have been satisfactory, as well as the integration between physical and digital simulation. CONCLUSIONS: This project demonstrated that a cadaver-free hybrid (virtual/hands-on) training system could potentially participate in accelerating the learning curve of neurosurgical residents, especially in the setting of limited training possibilities such as LMICs, which were only worsened during the COVID-19 pandemic.

Integrated spine trauma team protocol: Combined neurosurgical and orthopedic experience for the management of traumatic spinal injuries.

Objectives: During the last decades, spine surgery has grown exponentially. In spite of that, it remains a surgical specialty without a well-defined own certification. It is usually carried out, separately, by neurosurgeons and orthopedic surgeons, even if there is an overlapping of competence and skills. Materials and Methods: In our hospital, from January 2019, a systematic protocol called integrated spine trauma team protocol (ISTTP) was implemented to improve the management of traumatic spinal injuries in a multidisciplinary way. It is characterized by a specific algorithm from diagnosis to postoperative care. According to the new protocol, orthopedic spinal surgeons and neurosurgeons work together as an integrated spine trauma team. The authors analyzed, retrospectively, the results obtained by comparing patients treated before and after the application of the ISTTP. Results: The new protocol allowed a statistically significant reduction in waiting time before surgery and complication rate. Moreover, early discharge of patients was recorded. To the best of our knowledge, this is the first study that described a specific algorithm for a standardized multidisciplinary management of the spinal trauma with combined orthopedic and neurosurgeon expertise. Conclusion: Our preliminary results suggest that the application of our ISTTP leads to better results for treating traumatic spinal injury (TSI).

Compartmental Cerebrospinal Fluid Events Occurring after Subarachnoid Hemorrhage: An "Heparin Oriented" Systematic Review.

Subarachnoid hemorrhage (SAH) represents a severe acute event with high morbidity and mortality due to the development of early brain injury (EBI), secondary delayed cerebral ischemia (DCI), and shunt-related hydrocephalus. Secondary events (SSE) such as neuroinflammation, vasospasm, excitotoxicity, blood-brain barrier disruption, oxidative cascade, and neuronal apoptosis are related to DCI. Despite improvement in management strategies and therapeutic protocols, surviving patients frequently present neurological deficits with neurocognitive impairment. The aim of this paper is to offer to clinicians a practical review of the actually documented pathophysiological events following subarachnoid hemorrhage. To reach our goal we performed a literature review analyzing reported studies regarding the mediators involved in the pathophysiological events following SAH occurring in the cerebrospinal fluid (CSF) (hemoglobin degradation products, platelets, complement, cytokines, chemokines, leucocytes, endothelin-1, NO-synthase, osteopontin, matricellular proteins, blood-brain barrier disruption, microglia polarization). The cascade of pathophysiological events secondary to SAH is very complex and involves several interconnected, but also distinct pathways. The identification of single therapeutical targets or specific pharmacological agents may be a limited strategy able to block only selective pathophysiological paths, but not the global evolution of SAH-related events. We report furthermore on the role of heparin in SAH management and discuss the rationale for use of intrathecal heparin as a pleiotropic therapeutical agent. The combination of the anticoagulant effect and the ability to interfere with SSE theoretically make heparin a very interesting molecule for SAH management.

Reoperation in Chiari-1 Malformations.

(1) Background: The issue of unsuccessful surgery for Chiari-1 malformation (CM-1), as well as its potential causes and possible solutions, remains poorly documented and studied. (2) Methods: From a retrospective review of a personal series of 98 patients undergoing treatment for CM-1 during the past 10 years, we created two study groups. Group 1: 8 patients (8.1%) requiring additional surgeries owing to postoperative complications (7 cerebrospinal fluid leakage, 1 extradural hematoma); 7 patients (7.1%) undergoing reoperations for failed decompression during the follow-up. Group 2: During the same period, we also managed 19 patients who had previously been operated on elsewhere: 8 patients who required adequate CM-1 treatment following extradural section of the filum terminale; 11 patients requiring reoperations for failed decompression. Failed decompression was managed by adequate osteodural decompression, which was associated with tonsillectomy (6 cases), subarachnoid exploration (8 cases), graft substitution (6 cases), and occipito-cervical fixation/revision (1 case). (3) Results: There was no mortality or surgical morbidity in Group 1. However, one patient's condition worsened due to untreatable syrinx. In Group 2, there were two cases of mortality, and surgical morbidity was represented by functional limitation and pain in the patient who needed revision of the occipitocervical fixation. Twenty patients improved (58.8%), 6 remained unchanged (32.3%), 1 worsened (2.9%) and 2 died (5.9%). (4) Conclusions: The rate of complications remains high in CM-1 treatment. Unfortunately, a certain rate of treatment failure is unavoidable, but it appears that a significant number of re-operations could have been avoided using proper indications and careful technique.

Adaptive Staged-Dose Gamma Knife Radiosurgery for the Treatment of Large Brain Metastases: Report of 40 Consecutive Cases and Analysis of Literature.

Background: Brain metastases are the most common brain tumors, being one of the most frequent neurological complications of systemic cancer and an important cause of morbidity and mortality. Stereotactic radiosurgery is efficacious and safe in the treatment of brain metastases, with good local control rates and low adverse effects rate. Large brain metastases present some issues in balancing local control and treatment-related toxicity. Objective: Demonstrating adaptive staged-dose Gamma Knife radiosurgery (ASD-GKRS) being a safe and effective treatment for large brain metastases. Materials and Methods: We retrospectively analyzed our series of patients treated with two-stage Gamma Knife radiosurgery for large brain metastases in [BLINDED], between February 2018 and May 2020. Results: Forty patients with large brain metastases underwent adaptive staged-dose Gamma Knife radiosurgery, with median prescription dose of 12 Gy and a median interval between stages of 30 days. At three-month follow-up, the survival rate was 75.0% with a local control rate of 100%. At six-month follow-up, the survival rate was 75.0% with a local control rate of 96.7%. The mean volume reduction was 21.81 cm3 (16.76-26.86; 95% CI). The difference between baseline volume and six-month follow-up volume was statistically significant. Conclusions: Adaptive staged-dose Gamma Knife radiosurgery is a safe, non-invasive and effective treatment for brain metastases, with a low rate of side effects. Large prospective trials are needed to strengthen data obtained about the effectiveness and safety of this technique in managing large brain metastases.

Towards a common language in neurosurgical outcome evaluation: the NEON (NEurosurgical Outcome Network) proposal.

BACKGROUND: The aim of this study was to achieve a consensus on the minimum set of outcome measures and predictors to be used in the neurosurgical practice and on the timing of outcome assessment. METHODS: A consensus building approach was employed. All neurosurgical departments in Lombardy (Italy) were invited to participate by the Carlo Besta Neurologic Institute IRCCS Foundation. Three workshops were organized during which a multidisciplinary group called Neurosurgical Outcome Network (NEON) was created and the methodology to select outcome measures, predictors, and timing of outcome assessment was established. Eight working groups were created for the different neurosurgical diseases (neuro-oncological, skull base, vascular, traumatic, spinal, peripheral nervous system, malformation, functional) and 8 workshops were organized to identify the outcome measures and predictors specific for each of the neurosurgical diseases based on the experts' clinical practice and the existing literature. RESULTS: A total of 20 neurosurgical departments participated in this study. Specific outcome measures, predictors and the timing of outcome assessment were identified for each of the 8 neurosurgical diseases. Moreover, a list of variables common to all pathologies were identified by the NEON group as further data to be collected. CONCLUSIONS: A consensus on the minimum set of outcome measures and predictors and the timing of outcome assessments for 8 neurosurgical diseases was achieved by a group of neurosurgeons of the Lombardy region, called NEON. These sets could be used in future studies for a more homogeneous data collection and as a starting point to reach further agreement also at national and international level.

Defining activities in neurovascular microsurgery training: entrustable professional activities for vascular neurosurgery.

BACKGROUND: Entrustable professional activities (EPAs) represent an assessment framework with an increased focus on competency-based assessment. Originally developed and adopted for undergraduate medical education, concerns over resident ability to practice effectively after graduation have led to its implementation in residency training but yet not in vascular neurosurgery. Subjective assessment of resident or fellow performance can be problematic, and thus, we aim to define core EPAs for neurosurgical vascular training. METHODS: We used a nominal group technique in a multistep interaction between a team of experienced neurovascular specialists and a medical educator to identify relevant EPAs. Panel members provided feedback on the EPAs until they reached consent. RESULTS: The process produced seven core procedural EPAs for vascular residency and fellowship training, non-complex aneurysm surgery, complex aneurysm surgery, bypass surgery, arteriovenous malformation resection, spinal dural fistula surgery, perioperative management, and clinical decision-making. CONCLUSION: These seven EPAs for vascular neurosurgical training may support and guide the neurosurgical society in the development and implementation of EPAs as an evaluation tool and incorporate entrustment decisions in their training programs.

Flow diverter devices in the treatment of complex middle cerebral artery aneurysms when surgical and endovascular treatments are challenging.

OBJECTIVE: In this study, the authors retrospectively evaluated the effectiveness and the safety of non-surgical middle cerebral artery (MCA) aneurysms treated via the implantation of a flow diverter device (FDD). METHODS: Clinical, procedural and follow-up data were analyzed in order to evaluate the safety and effectiveness of the treatment with the FDD in complex MCA aneurysms. Safety was assessed recording (intra-procedural, peri-procedural and delayed) complications in order to determine the morbidity and mortality rates. Functional outcome was evaluated with modified Rankin Scale (mRS) prior and after the endovascular procedure. To assess the efficacy, midterm and long-term clinical, angiographic and cross-sectional imaging follow-ups were recorded. RESULTS: 47 patients (21 males; 26 females) with MCA aneurysms were treated with FDD. 7 were ruptured. 21 aneurysms were saccular, 19 dissecting, 3 fusiform, 2 blood blister-like and 2 were pseudo-aneurysms. 14 aneurysms were small, 23 large and 10 giant, with a mean size of 15.3 mm. 8 aneurysms were recurrent (Raymond-Roy class III): 2 patients had an aneurysmal sac recanalization after being treated with simple coiling and 6 after being treated with microsurgical clipping. In 4 cases (8.5%), more than one FDD was telescopically positioned in order to treat the aneurysm, for a total of 54 FDDs used. The overall mortality rate was 2.1% (1/47) and the overall morbidity rate was 8.6% (4/47). Midterm neuroimaging follow-ups showed the complete occlusion of the aneurysm in 63% cases, which became 91% at the end of the follow-up. CONCLUSIONS: FDD is a safe and effective tool that can be used in the treatment of complex MCA aneurysms, where conventional neurosurgical treatments can be challenging or ineffective.

Stereotactic Radiosurgery with Gamma Knife in Recurrent Rathke's Cleft Cyst: Case Report and Literature Analysis.

Background: Rathke's cleft cyst is a benign expansive lesion of the sella turcica. If related to clinical disorders, the patient needs surgical treatment. Objective: To demonstrate the efficacy of radiosurgery in the treatment of relapse of Rathke's cleft cyst as an alternative to surgery. Methods and Material: The stereotactic radiosurgical treatment was performed at the Gamma Knife Center of the Niguarda Hospital in a patient with Rathke's cleft cyst subjected to two subsequent neurosurgical resections with early regrowth of the cyst. The cyst underwent radiosurgery with a prescription dose of 12 Gy at 50% (minimum dose 9.8, mean 17.3 and maximum 24.4). Results: Three years after stereotactic radiosurgical treatment the patient is asymptomatic and does not present disorders of the hypothalamic-pituitary axis or further visual alterations. The control MRI shows a reduction of the cyst's volume. Conclusions: Stereotactic radiosurgery resulted in a reduction of the cyst's volume and avoided further recourse to surgery.

Posterior fossa syndrome in a population of children and young adults with medulloblastoma: a retrospective, multicenter Italian study on incidence and pathophysiology in a histologically homogeneous and consecutive series of 136 patients.

INTRODUCTION: Posterior fossa syndrome (PFS) is a set of debilitating complications that can occur after surgery for posterior fossa tumors. This study aimed to assess the preoperative radiological and surgical risk factors for the onset of PFS in a histologically homogeneous population of children with medulloblastoma and compare it to a similar population of young adults. METHODS: Included patients underwent posterior fossa surgery for medulloblastoma at 11 Italian neurosurgical wards (2003-2019) and were referred to Fondazione IRCCS Istituto Nazionale dei Tumori in Milan (INT) for postoperative treatments. We collected patients' pre- and post-operative clinical, surgical and radiological data from the INT charts. To compare the distribution of variables, we used the Mann-Whitney and Fisher tests for continuous and categorical variables, respectively. RESULTS: 136 patients (109 children and 27 young adults) were included in the study. Among children, 29 (27%) developed PFS, and all of them had tumors at midline site with invasion of the fourth ventricle. Radiological evidence of involvement of the right superior (39% versus 12%; p = 0.011) or middle cerebellar peduncles (52% versus 18%; p = 0.002) seemed more common in children who developed PFS. Young adults showed an expected lower incidence of PFS (4 out of 27; 15%), that may be due to anatomical, physiological and oncological elements. CONCLUSIONS: This study confirmed some factors known to be associated with PFS onset and shed light on other debated issues. Our findings enhance an already hypothesized role of cerebellar language lateralization. The analysis of a population of young adults may shed more light on the often-neglected existence of PFS in non-pediatric patients.

Early management of patients with aneurysmal subarachnoid hemorrhage in a hospital with neurosurgical/neuroendovascular facilities: a consensus and clinical recommendations of the Italian Society of Anesthesia and Intensive Care (SIAARTI)-Part 1.

BACKGROUND: Issues remain on the optimal management of subarachnoid hemorrhage (SAH) patients once they are admitted to the referring center, before and after the aneurysm treatment. To address these issues, we created a consensus of experts endorsed by the Italian Society of Anesthesia and Intensive Care (SIAARTI). In this manuscript, we aim to provide a list of experts' recommendations regarding the early management of SAH patients from hospital admission, in a center with neurosurgical/neuro-endovascular facilities, until securing of the bleeding aneurysm. METHODS: A multidisciplinary consensus panel composed of 24 physicians selected for their established clinical and scientific expertise in the acute management of SAH patients with different background (anesthesia/intensive care, neurosurgery, and interventional neuroradiology) was created. A modified Delphi approach was adopted. RESULTS: Among 19 statements discussed. The consensus was reached on 18 strong recommendations. In one case, consensus could not be agreed upon and no recommendation was provided. CONCLUSIONS: This consensus provides practical recommendations for the management of SAH patients in hospitals with neurosurgical/neuroendovascular facilities until aneurysm securing. It is intended to support clinician's decision-making and not to mandate a standard of practice.

Early management of patients with aneurysmal subarachnoid hemorrhage in a hospital with neurosurgical/neuroendovascular facilities: a consensus and clinical recommendations of the Italian Society of Anesthesia and Intensive Care (SIAARTI)-part 2.

BACKGROUND: Questions remain on the optimal management of subarachnoid hemorrhage (SAH) patients once they are admitted to the referring center, before and after the aneurysm treatment. To address these issues, we created a consensus of experts endorsed by the Italian Society of Anesthesia and Intensive Care (SIAARTI) to provide clinical guidance regarding this topic. Specifically, in this manuscript (part 2), we aim to provide a list of experts' recommendations regarding the management of SAH patients in a center with neurosurgical/neuroendovascular facilities after aneurysm treatment. METHODS: A multidisciplinary consensus panel composed by 24 physicians selected for their established clinical and scientific expertise in the acute management of SAH patients with different specializations (anesthesia/intensive care, neurosurgery, and interventional neuroradiology) was created. A modified Delphi approach was adopted. RESULTS: A total of 33 statements were discussed, voted, and approved. Consensus was reached on 30 recommendations (28 strong and 2 weak). In 3 cases, where consensus could not be agreed upon, no recommendation was provided. CONCLUSIONS: This consensus provides practical recommendations (and not mandatory standard of practice) to support clinician's decision-making in the management of SAH patients in centers with neurosurgical/neuroendovascular facilities after aneurysm securing.

A minimally invasive approach for giant middle cerebral artery thrombosed aneurysms treatment.

BACKGROUND: Management of complex thrombosed aneurysms of the middle cerebral artery (MCA) is challenging. Lesions not amenable to endovascular techniques or direct clipping might require a bypass procedure with subsequent aneurysm occlusion. Various bypass techniques followed by surgical or endovascular closure of the aneurysm are available, but an unpredictable extension of the thrombus to the parent vessel and/or to perforator vessels can occur. We presented a multidisciplinary technique with the aim to reduce invasiveness and complications. METHODS: We present two patients, harboring a thrombosed giant MCA bifurcation aneurysm, who were treated with a minimally invasive three-steps multimodality procedure. In both cases, through a limited exposure of the sylvian fissure, a side-to-side anastomosis between the two M2 branches was performed, followed in the immediate postop by an endovascular occlusion of the frontal M2 branch, with the aim of transforming a bifurcation aneurysm in a sidewall aneurysm, that was then treated a few days later by flow diverter deployment. RESULTS: Both patients had excellent outcomes and were discharged after 7 days without neurological deficits. CONCLUSIONS: Treatment of complex thrombosed MCA aneurysms is challenging. Side-to-side M2 anastomosis with the aim of transforming a bifurcation aneurysm in a sidewall aneurysm, suitable to be treated few days later by flow diverter deployment, offers a minimally invasive multimodal approach with the possibility of reducing serious complications.

A New Insight in Nonaneurysmal Subarachnoid Hemorrhage: The Potential Role of the Internal Jugular Veins.

BACKGROUND: Causes of the nonaneurysmal subarachnoid hemorrhage (na-SAH) are still debated. Many studies confirmed the possible involvement of the intracranial venous system, in particular variants of the basal vein of Rosenthal. STUDY OBJECT: The aim of this study is to investigate the role of extracranial venous system, in particular the jugular drainage, in the na-SAH pathophysiology. MATERIALS AND METHODS: This is a multicenter retrospective study including patients suffering from na-SAH who were radiologically screened to exclude vascular malformations. The course of the internal jugular veins was evaluated to reveal any stenosis (caliber reduction >80%). Particular attention was paid at the passage between the styloid process and the arch of C1 to detect possible compression. As a control group, we enrolled patients who underwent CT angiograms and/or cerebral DSAs in the past 2 years. RESULTS: We included 194 patients. The na-SAH group consisted of 94 patients, whereas the control group consisted of 100 patients. Fifty patients of the control group underwent a CT angiography for an ischemic cerebrovascular disease or trauma and 50 patients for an SAH due to a ruptured aneurysm. A significant jugular stenosis was found in 49 (52.1%) patients in the na-SAH group and in 18 (18%) patients in the control group. At univariate and multivariate analysis, the difference was statistically significant (p < 0.0001). CONCLUSIONS: This is the first study investigating the correlation between jugular stenosis and the occurrence of na-SAH. The impaired venous outflow due to reduced venous caliber could result in an engorgement of the upstream intracranial veins with transient hypertensive phases facilitating ruptures. Further larger prospective studies are necessary to confirm these data.

Surgical treatment of brainstem cavernous malformations: an international Delphi consensus.

OBJECTIVE: Indication for surgery in brainstem cavernous malformations (BSCMs) is based on many case series, few comparative studies, and no randomized controlled trials. The objective of this study was to seek consensus about surgical management aspects of BSCM. METHODS: A total of 29 experts were invited to participate in a multistep Delphi consensus process on the surgical treatment of BSCM. RESULTS: Twenty-two (76%) of 29 experts participated in the consensus. Qualitative analysis (content analysis) of an initial open-ended question survey resulted in 99 statements regarding surgical treatment of BSCM. By using a multistep survey with 100% participation in each round, consensus was reached on 52 (53%) of 99 statements. These were grouped into 4 categories: 1) definitions and reporting standards (7/14, 50%); 2) general and patient-related aspects (11/16, 69%); 3) anatomical-, timing of surgery-, and BSCM-related aspects (22/37, 59%); and 4) clinical situation-based decision-making (12/32, 38%). Among other things, a consensus was reached for surgical timing, handling of associated developmental venous anomalies, handling of postoperative BSCM remnants, assessment of specific anatomical BSCM localizations, and treatment decisions in typical clinical BSCM scenarios. CONCLUSIONS: A summary of typical clinical scenarios and a catalog of various BSCM- and patient-related aspects that influence the surgical treatment decision have been defined, rated, and interpreted.

Management of Slit Ventricle Syndrome: A Single-Center Case Series of 32 Surgically Treated Patients.

OBJECTIVE: Slit ventricle syndrome (SVS) is an iatrogenic disease occurring in patients with ventriculoperitoneal shunt. This article reports the management modalities and results in a case series from a single center. METHODS: We reviewed a series 48 hospitalized patients with severe SVS whom we managed in a 10-year period. Thirty-seven patients harboring programmable valves (P-valves) first underwent attempts at valve reprogramming. This treatment produced no effect in 21 patients, who therefore required surgical treatment. Surgery was also required by 11 patients without P-valve. Accordingly, 32 patients had to be operatively treated by shunt externalization followed by valve replacement or endoscopic third ventriculostomy basing on intracranial pressure and ventricular size. The new valve was either ProGav Mietke (Aesculap) or Medos Codman (Integra), each equipped with its own antisiphon system. In selected cases, a programmable antisiphon system (ProSa Mietke) was used. RESULTS: Surgical mortality was 3% and major morbidity accounted for 6%. Complete resolution was obtained in 55% of cases, improvement in 32%, and no effect or worsening in 13%. Only 1 patient became shunt free after endoscopic third ventriculostomy. Medos and ProGrav provided comparable outcomes, whereas ProSa was determinant in selected cases. Pediatric age, uncomplicated shunt courses, and short SVS histories were significantly favorable indicators. CONCLUSIONS: SVS management remains problematic. However, this study individuated factors that may improve the outcome, such as wider use of P-valves to treat hydrocephalus, timely diagnosis of overdrainage, and earlier and more aggressive indications to manage SVS.