Optic nerve sheath fenestration: Current status in France and comparison of 6 different surgical approaches.

PURPOSE: Optic nerve sheath fenestration (ONSF) is a surgical procedure commonly performed in the Anglo-Saxon countries for the treatment of medically refractory idiopathic intracranial hypertension (IIH). We chose to compare 6 different trans-orbital surgical approaches to ONSF. We also desired to determine the number of optic nerve decompression procedures performed in France in 2019 and 2020. METHODS: Four fresh frozen orbits were dissected at the University of Nice anatomy laboratory. We performed the following surgical approaches: (i) eyelid crease, (ii) lid-split, (iii) medial transconjunctival with medial rectus disinsertion, (iv) medial transconjunctival without rectus disinsertion, (v) lateral transconjunctival and (vi) lateral orbitotomy. For each surgical approach, we measured the distance between the incision and the optic nerve dura mater. We also extracted data from the French National PMSI (Programme de Médicalisation des Systèmes d' Information) database from January 2019 through December 2020 to determine the annual number of optic nerve decompression procedures. RESULTS: The lid crease and medial transconjunctival approaches provided the shortest distance to the optic nerve (average 21mm and 24mm, respectively) and the lowest levels of difficulty compared to the other surgical routes. A total of 23 and 45 optic nerve decompressions were performed in France in 2019 and 2020, respectively. Among them, only 2 and 7 procedures, respectively, were performed through a trans-orbital approach. CONCLUSION: Upper lid crease incision and medial transconjunctival approaches are the most direct and easiest surgical routes when performing an ONSF. We found that ONSF was rarely performed in France. We strongly recommend close cooperation between ophthalmologists, neurologists, neurosurgeons and interventional radiologists.

Functional outcome 1 year after aneurysmal subarachnoid hemorrhage due to ruptured intracranial aneurysm in elderly patients.

BACKGROUND: Population aging raises questions about extending treatment indications in elderly patients with aneurysmal subarachnoid hemorrhage (aSAH). We therefore assessed functional status 1 year after treatment. METHODS: This study involved 310 patients, aged over 70 years, with ruptured brain aneurysm, enrolled between 2008 and 2014 in a prospective multicentre trial (FASHE study: NCT00692744) but considered unsuitable for randomisation and therefore analysed in the observational arms of the study: endovascular occlusion (EV), microsurgical exclusion (MS) and conservative treatment. The aims were to assess independence, cognition, autonomy and quality of life (QOL) at 1 year post-treatment, using questionnaires (MMSE, ADLI, IADL, EORTC-QLQ-C30) filled in by independent nurses after discharge. RESULTS: The 310 patients received the following treatments: 208 underwent EV (67.1%), 54 MS (17.4%) and 48 were conservatively managed (15.5%). At 1 year, independence rates for patients admitted with good clinical status (WFNS I-III) were, according to the aneurysm exclusion procedure (EV, MS or conservative), 58.9%, 50% and 12.1% respectively. MMSE score was pathological in 26 of the 112 EV patients (23.2%), 10 of the 25 MS patients (40%) and 4 of the 9 patients treated conservatively (44%), without any statistically significant difference [Pearson's Chi2 test, F ratio=4.29; P=0.11]. Regarding QoL, overall score was similar between the EV and MS cohorts, but significantly lower with conservative treatment. CONCLUSION: Elderly patients in good clinical condition with aSAH should be treated regardless of associated comorbidities. Curative treatment (EV or MS) reduced mortality without increasing dependence, in comparison with conservative treatment.

A randomized controlled study assessing outcome, cognition, autonomy and quality of life in over 70-year-old patients after aneurysmal subarachnoid hemorrhage.

BACKGROUND: Current aging of the population with good physiological status and the increasing incidence of subarachnoid hemorrhage (SAH) in elderly patients has enhanced the benefit of treatment in terms of independence and long-term quality of life (QoL). METHODS: From November 1, 2008 to October 30, 2012, 351 patients aged 70 years or older with aneurysmal SAH underwent adapted treatment: endovascular coiling (EV) for 228 (65%) patients, microsurgical clipping (MS) for 75 (29.3%) or conservative treatment for 48 (13.7%). Forty-one of these were randomized to EV (n=20) or to MS (n=21). The objectives were to determine the proportion of patients with modified Rankin Scale score≤2 (independence) at 1 year, and, secondarily, to compare cognitive function on the Mini-Mental State Examination (MMSE), autonomy on the Activities of Daily Living Index (ADLI) and Instrumental Activities of Daily Living scale (IADL), and QoL, in the prospective and randomized arms, at 1 year. RESULTS: At 1 year, with 1 loss to follow-up in the EV arm, 11 patients (55%) were independent after EV occlusion and 8 (38.1%) after MS exclusion, without significant difference (P=0.29). Mortality was higher after MS during the first 2 postoperative months, and thereafter the difference between MS and EV ceased to be significant. Cognitive function and autonomy scores were similar in both arms. CONCLUSION: In elderly patients treated for aneurysmal SAH, approximately 50% were independent at 1 year, with conserved cognition and autonomy. EV and MS are valid procedures in this population, with similar results at 1 year in terms of independence, cognition, autonomy, and QoL.

Modification of cerebral vascular anatomy induced by Leo stent placement depending on the site of stenting: A series of 102 cases.

BACKGROUND AND PURPOSE: Recent studies demonstrated the capacity of stents to modify cerebral vascular anatomy. This study evaluates arterial anatomy deformation after Leo stent placement according to the stenting site and the impact on the immediate postoperative and six-month degree of aneurysmal occlusion. MATERIALS AND METHODS: A total of 102 stents were placed against the neck of aneurysms situated in the anterior cerebral circulation. Aneurysms were classified into two groups: The first was called the distal group (n = 62) and comprised aneurysms situated in the middle cerebral and anterior communicating arteries and the second was called the proximal group (n = 40) and comprised aneurysms in other sites. The stented arterial segment was classified as deformed or non-deformed by blinded review and superimposition of anonymised films before and after stenting. The degree of occlusion was determined immediately postoperatively and at six months. RESULTS: Significantly, anatomical deformity was observed in the distal group compared to the proximal group (85% vs 28%). No significant difference was observed between the two groups in terms of postoperative degree of occlusion. At six months, a significant difference was observed between the two groups: three recurrences in the distal group vs 10 recurrences in the proximal group. Two (3%) recurrences were observed in the deformed group vs 11 (31%) recurrences in the non-deformed group. CONCLUSIONS: Arterial deformity induced by stenting is even more marked for distal aneurysms. The recurrence rate is smaller when the stent placement results in an arterial anatomical change. The percentage of recurrence is lower when anatomy was amended by stent implantation.

Epidemiology, genetic, natural history and clinical presentation of giant cerebral aneurysms.

Giant cerebral aneurysms represent 5% of intracranial aneurysms, and become symptomatic between 40 and 70 years with a female predominance. In the paediatric population, the giant aneurysm rate is higher than in the adult population. Classified as saccular, fusiform and serpentine, the natural history of giant cerebral aneurysms is characterized by thrombosis, growth and rupture. The pathogenesis of these giant aneurysms is influenced by a number of risk factors, including genetic variables. Genome-wide association studies have identified some chromosomes highlighting candidate genes. Although these giant aneurysms can occur at the same locations as their smaller counterparts, a predilection for the cavernous location has been observed. Giant aneurysms present with symptoms caused by a mass effect depending on their location or by rupture; ischemic manifestations rarely reveal the aneurysm. If the initial clinical descriptions have been back up by imagery, the clinical context with a pertinent analysis of the risk factors remain the cornerstone for the management decisions of these lesions. Five year cumulative rupture rates for patients with giant aneurysm were 40% for those located on the anterior part of circle of Willis and 50% for those on the posterior part. The poor outcome of untreated patients justifies the therapeutic risks.

Percutaneous cementoplasty for the treatment of extraspinal painful bone lesion, a prospective study.

PURPOSE: The current gold standard treatment of localized painful bone lesion is radiotherapy but this technique has limitations. Our study aims to demonstrate that cementoplasty is an efficient alternative for these palliatives indications when lesions involve extraspinal bones. We prospectively followed 20 patients who received a percutaneous cementoplasty on painful lytic bone lesions between May 2008 and May 2010. MATERIALS: Seventeen patients also had difficulty walking in relation to the pain experienced. The clinical indication for treatment was severe pain (≥4 on the numeric scale) due to bone lesion on CT or MRI. All procedures (except one) were performed under local anesthesia. RESULTS: Feasibility was 100% without immediate complications. The patients experienced a significant and rapid decrease of their pain (4.1 points, P<000.1) and this effect was sustained over the long term (7.75 months of follow-up on average). Sixty-four percent of patients treated on the lower limbs and pelvis improved mobility. CONCLUSION: In our experience, percutaneous cementoplasty may be a safe and effective palliative treatment for localized painful lytic lesion. Combining CT and fluoroscopic guidance seems to be the safer option because of extravertebral localization. Smart fill of the bone and careful selection of patient determine the effectiveness of the procedure. Diffuse painful lesions and long bone diaphysis should not be good indications.

Endovascular treatment of renal aneurysms: a series of 18 cases.

PURPOSE: To retrospectively analyze the results and complications of the endovascular treatment of 18 renal aneurysms. METHODS: From 2002 to 2011, 15 patients (aged 31-76), with 18 renal aneurysms, were admitted in our institution for treatment by embolization. Except one, all were wide-necked aneurysms. One aneurysm was treated by occluding the parent artery considering its distal location; a small-necked aneurysm was treated by simple coiling, and the remaining 16 were embolized utilizing adjunctive techniques to protect the parent artery. We analyzed the rates of technical success, complication and clinical consequence, post-operative occlusion and recurrence. RESULTS: There was a 100% technical success rate. 15 aneurysms showed a total occlusion on the post-treatment angiogram. 2 aneurysms demonstrated neck remnants, and one had an intrasaccular residual in-flow. Two minor post-operative complications were encountered but resolved over time. No delayed clinical complications were observed and the long-term angiographic follow-up demonstrated stability of the occlusion of the target renal aneurysm with no major recurrence. CONCLUSION: Complications of the embolization of renal aneurysms are rare. Endovascular treatment should therefore be considered at first for the treatment of renal aneurysms.

Interferometer-based structured-illumination microscopy utilizing complementary phase relationship through constructive and destructive image detection by two cameras.

In an interferometer-based fluorescence microscope, a beam splitter is often used to combine two emission wavefronts interferometrically. There are two perpendicular paths along which the interference fringes can propagate and normally only one is used for imaging. However, the other path also contains useful information. Here we introduced a second camera to our interferometer-based three-dimensional structured-illumination microscope (I(5)S) to capture the fringes along the normally unused path, which are out of phase by π relative to the fringes along the other path. Based on this complementary phase relationship and the well-defined phase interrelationships among the I(5)S data components, we can deduce and then computationally eliminate the path length errors within the interferometer loop using the simultaneously recorded fringes along the two imaging paths. This self-correction capability can greatly relax the requirement for eliminating the path length differences before and maintaining that status during each imaging session, which are practically challenging tasks. Experimental data is shown to support the theory.

Endovascular treatment of recurrent coiled aneurysms: assessment of complications and rebleeding during a decade in a single center.

Recurrence is the main drawback of aneurysmal coiling. Additional coiling must sometimes be considered in patients with reopened aneurysms and expose the patient to the risk of a new procedure. Our purpose was to assess the procedural complications of additional endovascular treatments in patients with previously coiled but recurrent aneurysms treated by two neurointerventionalists during a decade in a single center. Between 1999 and 2009, 637 intracranial aneurysms were coiled and had a clinical and angiographic follow-up at our institution. Following the first embolization, 44 aneurysms were retreated with coils and 11 were retreated a second time. Retreatment was decided when a recurrence showed at angiographic follow-up. Early retreatments, performed in the first month after an incomplete or failed initial coiling, were excluded. We retrospectively analysed the procedural complications, rebleeding, clinical and angiographic outcomes of the retreatments. No death or bleeding occurred in these 55 additional procedures. We had three periprocedural thromboembolic complications and the procedural permanent morbidity was 1.8%. Clinical and angiographic follow-ups ranged from six months to nine years (mean: 37 months, median: 36 months). Thirty-seven of the 44 retreated aneurysms (84%) showed a stable occlusion at follow-up. Seven showed a recurrence but were not retreated due to the stability of the packing. No rebleeding was observed during the follow-up period. Our results show that endovascular treatment of recurrent aneurysms is associated with a low procedural risk.

Endovascular angioplasty before resection of a sphenoidal meningioma with vascular encasement.

We describe a case of sphenoid wing meningioma presenting with cerebral infarction due to extended vascular encasement in which endovascular angioplasty was performed before surgery to avoid perioperative ischemia. A severe stenosis involved the intracranial internal carotid artery and the proximal segments of the middle and anterior cerebral arteries. Endovascular dilatation was followed by complete surgical resection. Preoperative mild aphasia and hemiparesia resolved completely after surgery. Endovascular angioplasty of arterial trunks and their branches can be proposed before the resection of skull base meningiomas encasing these arteries to decrease the risk of perioperative brain ischemia related to their surgical manipulation or vasospasm.

Automated data collection for electron microscopic tomography.

A fundamental challenge in electron microscopic tomography (EMT) has been to develop automated data collection strategies that are both efficient and robust. UCSF Tomography was developed to provide an inclusive solution from target finding, sequential EMT data collection, to real-time reconstruction for both single and dual axes. The predictive data collection method that is the cornerstone of UCSF Tomography assumes that the sample follows a simple geometric rotation. As a result, the image movement in the x, y, and z directions due to stage tilt can be dynamically predicted with the required accuracy (15nm in x-y position and 100nm in focus) rather than being measured with additional images. Lacking immediate feedback during cryo-EMT data collection can offset the efficiency and robustness reaped from the predictive data collection and this motivated the development of an integrated real-time reconstruction scheme. Moderate resolution reconstructions were achieved by performing weighted back-projection on a small cluster in parallel with the data collection. To facilitate dual-axis EMT data collection, a hierarchical scheme for target finding and relocation after specimen rotation was developed and integrated with the predictive data collection and real-time reconstruction, allowing full automation from target finding to data collection and to reconstruction of 3D volumes with little user intervention. For nonprofit use the software can be freely downloaded from http://www.msg.ucsf.edu/tomography.

[Serious pulmonary embolism and thromboaspiration]. / Embolie pulmonaire grave et thrombo-aspiration.

Pulmonary embolism is a common disease with a mortality rate of approximately 3%. Polytraumatised patients are particularly susceptible to thromboembolism because of prolonged immobilisation and inflammatory syndrome, thrombembolic risk also increases significantly during the peripartum period. Rapid diagnosis and intervention are essential for survival. Conventional treatment consists of systemic intravascular thrombolysis, but this procedure is often contraindicated in intensive care patients because of the high risk of haemorrhage. We report two cases of successful treatment using radiological endovascular thrombectomy.

High-resolution wide-field microscopy with adaptive optics for spherical aberration correction and motionless focusing.

Live imaging in cell biology requires three-dimensional data acquisition with the best resolution and signal-to-noise ratio possible. Depth aberrations are a major source of image degradation in three-dimensional microscopy, causing a significant loss of resolution and intensity deep into the sample. These aberrations occur because of the mismatch between the sample refractive index and the immersion medium index. We have built a wide-field fluorescence microscope that incorporates a large-throw deformable mirror to simultaneously focus and correct for depth aberration in three-dimensional imaging. Imaging fluorescent beads in water and glycerol with an oil immersion lens we demonstrate a corrected point spread function and a 2-fold improvement in signal intensity. We apply this new microscope to imaging biological samples, and show sharper images and improved deconvolution.

Restenosis after balloon angioplasty for cerebral vasospasm.

Transluminal balloon dilatation for symptomatic vasospasm after subarachnoid hemorrhage is effective, and clinical studies have shown that it achieves long-lasting dilatation of spastic cerebral arteries. Delayed arterial renarrowing has not been reported. Here we report the case of a 58-year-old woman who presented asymptomatic and permanent restenosis after angioplasty for cerebral vasospasm.

Giant intracerebral telangiectasia in a case of blue rubber-bleb nevus syndrome.

Blue rubber-bleb nevus syndrome is a rare condition that consists of multiple venous malformations involving several organ systems, mainly the skin and gastrointestinal tract. Involvement of the central nervous system is particularly rare. We describe a patient with a huge intracerebral telengiectasia revealed by a progressive neurological deficit.

Dissection of the posteroinferior cerebellar artery: clinical characteristics and long-term follow-up in five cases.

BACKGROUND AND PURPOSE: Spontaneous isolated posteroinferior cerebellar artery (PICA) dissection is very rare. The aim of the study was to investigate the clinical manifestations, the neuroradiological aspects and the treatment of 5 cases collected in 5 years. METHODS AND RESULTS: From 1999 to 2003, five patients (40-71 years old) were hospitalized for PICA dissection. Two patients presented symptoms after cervical manipulation. No predisposing factor or traumatic cause was described in the other cases. The diagnosis was carried out by cerebral angiography in all the cases: in 4, angiography showed focal stenosis with saccular or fusiform dilatation of the artery at the site of the dissection; in 1 a double lumen aspect was described. One patient presented ischemic manifestations; he was treated with heparin. The others presented subarachnoid hemorrhage (SAH) and were treated by embolization (endovascular sacrifice of the PICA). No ischemic complication and no rebleeding were observed after sacrifice of the PICA. Three patients presented acute hydrocephalus and were treated with surgical derivation. The angiographic and clinical follow-up lasted more than 3 years. We assessed the long-term results with the Glasgow Outcome Score and the modified Rankin Score. A good recovery was achieved for 4 patients (modified Rankin Score 0); one patient who presented SAH and who was in bad clinical state on admission had a Glasgow Outcome Score of 3 and a modified Rankin Score of 4 three years later. CONCLUSION: Clinical course and prognosis are variable in PICA dissections. The treatment depends on the existence of a hemorrhagic event. In the group of patients presenting SAH, endovascular treatment was safe and effective. The long-term clinical results depend mainly on the clinical status on admission.

Stretched platinum coil during cerebral aneurysm embolization after direct carotid puncture: two case reports.

We describe two cases of coil unraveling that occurred during cerebral aneurysm embolization after direct carotid puncture. The unraveled coil was stretched and buried in the subcutaneous part of the neck. No immediate or long-term complication was observed.

Multiple cerebral aneurysms caused by cardiac myxoma. A case report and present state of knowledge.

SUMMARY: A case of multiple cerebral aneurysms caused by left atrial myxoma is reported.We present the details of this case and discuss the hypothetical pathogenesis, radiological aspects and treatment of these neoplastic aneurysms.