Hemorrhage Volume Drives Early Brain Injury and Outcome in Poor-Grade Aneurysmal SAH.

BACKGROUND AND PURPOSE: Early brain injury is a major determinant of clinical outcome in poor-grade (World Federation of Neurosurgical Societies [WFNS] IV-V) aneurysmal SAH and is radiologically defined by global cerebral edema. Little is known, though, about the effect of global intracranial hemorrhage volume on early brain injury development and clinical outcome. MATERIALS AND METHODS: Data from the multicentric prospective Poor-Grade Aneurysmal Subarachnoid Hemorrhage (POGASH) Registry of consecutive patients with poor-grade aneurysmal SAH admitted from January 1, 2015, to August 31, 2022, was retrospectively evaluated. Poor grade was defined according to the worst-pretreatment WFNS grade. Global intracranial hemorrhage volume as well as the volumes of intracerebral hemorrhage, intraventricular hemorrhage, and SAH were calculated by means of analytic software in a semiautomated setting. Outcomes included severe global cerebral edema (defined by Subarachnoid Hemorrhage Early Brain Edema Score grades 3-4), in-hospital mortality (mRS 6), and functional independence (mRS 0-2) at follow-up. RESULTS: Among 400 patients (median global intracranial hemorrhage volume of 91 mL; interquartile range, 59-128), severe global cerebral edema was detected in 218/400 (54.5%) patients. One hundred twenty-three (30.8%) patients died during the acute phase of hospitalization. One hundred fifty-five (38.8%) patients achieved mRS 0-2 at a median of 13 (interquartile range, 3-26) months of follow-up. Multivariable analyses showed global intracranial hemorrhage volume as independently associated with severe global cerebral edema (adjusted OR, 1.009; 95% CI, 1.004-1.014; P < .001), mortality (adjusted OR, 1.006; 95% CI, 1.001-1.01; P = .018) and worse clinical outcome (adjusted OR, 0.992; 95% CI, 0.98-0.996; P < .010). The effect of global intracranial hemorrhage volume on clinical-radiologic outcomes changed significantly according to different age groups (younger than 50, 50-70, older than 70 year of age). Volumes of intracerebral hemorrhage, intraventricular hemorrhage, and SAH affected the 3 predefined outcomes differently. Intracerebral hemorrhage volume independently predicted global cerebral edema and long-term outcome, intraventricular hemorrhage volume predicted mortality and long-term outcome, and SAH volume predicted long-term clinical outcome. CONCLUSIONS: Global intracranial hemorrhage volume plays a pivotal role in global cerebral edema development and emerged as an independent predictor of both mortality and long-term clinical outcome. Aging emerged as a reducing predictor in the relationship between global intracranial hemorrhage volume and global cerebral edema.

Factors affecting 30-day mortality in poor-grade aneurysmal subarachnoid hemorrhage: a 10-year single-center experience.

Background: The management of patients with poor-grade aneurysmal subarachnoid hemorrhage (aSAH) is burdened by an unfavorable prognosis even with aggressive treatment. The aim of the present study is to investigate the risk factors affecting 30-day mortality in poor-grade aSAH patients. Methods: We performed a retrospective analysis of a prospectively collected database of poor-grade aSAH patients (World Federation of Neurosurgical Societies, WFNS, grades IV and V) treated at our institution from December 2010 to December 2020. For all variables, percentages of frequency distributions were analyzed. Contingency tables (Chi-squared test) were used to assess the association between categorical variables and outcomes in the univariable analysis. Multivariable analysis was performed by using the multiple logistic regression method to estimate the odds ratio (OR) for 30-day mortality. Results: A total of 149 patients were included of which 32% had WFNS grade 4 and 68% had WFNS grade 5. The overall 1-month mortality rate was 21%. On univariable analysis, five variables were found to be associated with the likelihood of death, including intraventricular hemorrhage (IVH ≥ 50 mL, p = 0.005), the total amount of intraventricular and intraparenchymal hemorrhage (IVH + ICH ≥ 90 mL, p = 0.019), the IVH Ratio (IVH Ratio ≥ 40%, p = 0.003), posterior circulation aneurysms (p = 0.019), presence of spot sign on initial CT scan angiography (p = 0.015).Nonetheless, when the multivariable analysis was performed, only IVH Ratio (p = 0.005; OR 3.97), posterior circulation aneurysms (p = 0.008; OR 4.05) and spot sign (p = 0.022; OR 6.87) turned out to be independent predictors of 30-day mortality. Conclusion: The risk of mortality in poor-grade aSAH remains considerable despite maximal treatment. Notwithstanding the limitations of a retrospective study, our report highlights some neuroradiological features that in the emergency setting, combined with leading clinical and anamnestic parameters, may support the multidisciplinary team in the difficult decision-making process and communication with family members from the earliest stages of poor-grade aSAH. Further prospective studies are warranted.

Treatment of cerebral ventriculitis with a new self-irrigating catheter system: narrative review and case series.

Cerebral ventriculitis is a life-threatening condition that requires prompt and effective pharmacological intervention. The continuous irrigation of the cerebral ventricles with fluid and its drainage is a system to remove toxic substances and infectious residues in the ventricles; this system is called IRRAflow®. We used this kind of ventricular irrigation/drainage system to treat two patients with post-surgical cerebral ventriculitis and a patient with bacterial meningitis complicated with ventriculitis. In this case series, we discuss the management of these three cases of cerebral ventriculitis: we monitored cytochemical parameters and cultures of the cerebrospinal fluid of patients during their ICU stay and we observed a marked improvement after irrigation and drainage with IRRAflow® system. Irrigation/drainage catheter stay, mode settings, and antibiotic therapies were different among these three patients, and neurological outcomes were variable, according to their underlying pathologies. IRRAflow® system can be applied also in other types of brain injury, such as intraventricular hemorrhage, intracranial abscess, subdural hematomas, and intracerebral hemorrhage, with the aim to remove the hematic residues and enhance the functional recovery of the patients. IRRAflow® seems a promising and useful tool to treat infectious and hemorrhagic diseases in neuro-intensive care unit.

Clinical Impact and Predictors of Aneurysmal Rebleeding in Poor-Grade Subarachnoid Hemorrhage: Results From the National POGASH Registry.

BACKGROUND: Scarce data are available regarding rebleeding predictors in poor-grade aneurysmal subarachnoid hemorrhage (aSAH). OBJECTIVES: To investigate predictors and clinical impact of rebleeding in a national multicentric poor-grade aSAH. METHODS: Retrospective analysis of prospectively collected data from the multicentric Poor Grade Aneurysmal Subarachnoid Hemorrhage Study Group (POGASH) registry of consecutive patients treated from January 1, 2015, to June 30th, 2021. Grading was defined as pretreatment World Federation of Neurological Surgeons grading scale IV-V. Ultra-early vasospasm (UEV) was defined as luminal narrowing of intracranial arteries not due to intrinsic disease. Rebleeding was defined as clinical deterioration with evidence of increased hemorrhage on subsequent computed tomography scans, fresh blood from the external ventricular drain, or deterioration before neuroradiological evaluation. Outcome was assessed by the modified Rankin Scale. RESULTS: Among 443 consecutive World Federation of Neurological Surgeons grades IV-V patients with aSAH treated within a median of 5 (IQR 4-9) hours since onset, rebleeding occurred in 78 (17.6%). UEV (adjusted odds ratio [OR] 6.8, 95% CI 3.2-14.4; P < .001) and presence of dissecting aneurysm (adjusted OR 3.5, 95% CI 1.3-9.3; P = .011) independently predicted rebleeding while history of hypertension (adjusted OR 0.4, 95% CI 0.2-0.8; P = .011) independently reduced its chances. 143 (32.3) patients died during hospitalization. Rebleeding emerged, among others, as an independent predictor of intrahospital mortality (adjusted OR 2.2, 95% CI 1.2-4.1; P = .009). CONCLUSION: UEV and presence of dissecting aneurysms are the strongest predictors of aneurysmal rebleeding. Their presence should be carefully evaluated in the acute management of poor-grade aSAH.

Anatomical variations of the cavernous Internal Carotid Artery: Validation of an MRI-based classification.

OBJECTIVE: Variations of the cavernous Internal Carotid Artery (ICA) angulation (C4-bend) have been classified into 4 anatomical subtypes with particular surgical relevance, as a very angulated ICA comes in closest contact with the pituitary gland leading to higher risk of iatrogenic vascular injury. This study aimed to validate this classification using current routine imaging techniques. METHODS: The different cavernous ICA bending angles were measured on 109 MRI TOF sequences, within a retrospective database of patients with no sellar lesions. Each ICA was classified into one of 4 anatomical subtypes as already defined in a previous study [1]. Interrater agreement was assessed by a Kappa Correlation Coefficient. RESULTS: Kappa Correlation Coefficient was of 0.90 [0.82-0.95], validating the strong level of agreement between all observers when using the present classification. CONCLUSION: Classification of the cavernous ICA in 4 subtypes appears statistically valid on routinely used pre-operative MRI, providing an efficient tool to estimate the vascular iatrogenic risk prior to endoscopic endonasal transsphenoidal surgery.

The angio-architectural features of brain arteriovenous malformations: is it possible to predict the probability of rupture?

BACKGROUND: Hemorrhage is the most devastating complication of brain arteriovenous malformations (bAVMs), and to date, there is still concern about the needing for treatment in case of unruptured and asymptomatic bAVM. In fact, the morbidity and mortality of treatments may exceed that of the AVM's natural history. None of the classifications and scores for bAVM allows to predict the risk of bleeding. In this study, we aimed to identify the angio-architectural characteristics of brain AVMs associated with bleeding. METHODS: We retrospectively evaluated all consecutive patients diagnosed with cerebral AVMs, between January 2010 and December 2019 from our prospective bAVM database. Univariate and multivariate logistic regression analysis were used to evaluate relationships between angio-architectural features of ruptured and unruptured bAVMs. RESULTS: Of the 143 retrieved bAVMs, 65 were unruptured and 78 were ruptured. The univariate logistic regression analysis demonstrated statistically significant differences into angio-architectural features of unruptured and ruptured bAVMs. The multivariate logistic regression analysis fitted well (p =.113) with a good discrimination capacity (ROC = 0.83) of three independent angio-architectural features mainly related to bleeding in bAVMs: a smaller diameter of the nidus (p < .001), the absence of venous drainage alterations (p = .047), of the presence of prenidal aneurysms (p = .005). CONCLUSIONS: In our study, several features resulted related to an increased probability of rupture for bAVMs, among which the more relevant were a small diameter of the nidus, the absence of venous drainage alterations, and the presence of prenidal aneurysms.

Learning curve and influencing factors of performing microsurgical anastomosis: a laboratory prospective study.

Despite being a critical component of any cerebrovascular procedure, acquiring skills in microsurgical anastomosis is challenging for trainees. In this context, simulation models, especially laboratory training, enable trainees to master microsurgical techniques before performing real surgeries. The objective of this study was to identify the factors influencing the learning curve of microsurgical training. A prospective observational study was conducted during a 7-month diploma in microsurgical techniques carried out in the anatomy laboratory of the school of surgery. Training focused on end-to-end (ETE) and end-to-side (ETS) anastomoses performed on the abdominal aorta, vena cava, internal carotid and jugular vein, femoral artery and vein, caudal artery, etc. of Wistar strain rats under supervision of 2 expert anatomical trainers. Objective and subjective data were collected after each training session. The 44 microsurgical trainees enrolled in the course performed 1792 anastomoses (1577 ETE, 88%, vs. 215 ETS, 12%). The patency rate of 41% was independent from the trainees' surgical background and previous experience. The dissection and the temporary clamping time both significantly decreased over the months (p < 0.001). Technical mistakes were independently associated with thrombosis of the anastomoses, as assessed by the technical mistakes score (p < 0.01). The training duration (in weeks) at time of each anastomosis was the only significant predictor of permeability (p < 0.001). Training duration and technical mistakes constituted the two major factors driving the learning curve. Future studies should try and investigate other factors (such as access to wet laboratory, dedicated fellowships, mentoring during early years as junior consultant/attending) influencing the retention of surgical skills for our difficult and challenging discipline.

IV and V grade arteriovenous Malformations: A multicenter surgical experience. Use of multiple grading system to predict surgical risk.

OBJECTIVE: The aim of our study is to report a multicenter experience in the treatment of IV and V grade arteriovenous malformations (AVMs) and to apply commonly used grading scales for surgical risk assessment for these vascular high-grade lesions. METHODS: Between January 2015 and December 2019, a retrospective study was conducted to identify patients undergoing microsurgical intervention for cAVMs at two Italian centers specialized in the treatment of vascular pathologies. Data on patients with Spetzler-Martin IV and V and with a score equal or more than 7 according to Lawton-Young classification were collected. Ruptured AVMs at admission were subsequently classified according to the new proposed AVICH classification. RESULTS: A total of 20 patients with high grade (IV and V) cAVMs were enrolled in the study and the average follow-up was 36.45 months. The outcome based on mRS was favorable in 65 % of cases. The pre-operative mRS was a factor influencing clinical outcome, as well as the number of bleedings preceding the treatment, age, and nidus characteristics. S-M IV, L-Y 3 and S-M supp 7 scores were associated with good outcome. Based on the AVICH classification, for ruptured cAVMs, having a score of 9 ore less was correlated to a postoperative mRS fewer or equal than 2. CONCLUSIONS: Surgical management for high-grade AVMs should be considered in highly selected patients with repeated bleeding or disabling symptoms. Classification systems provide an aid in selecting patients for surgery, also in grade IV and V. It is essential to establish common registers for the management of these complex vascular malformations.

Efficacy of endoscopic management of primary central nervous system lymphoma: a multicentric study and literature review.

INTRODUCTION: To date, confined intra-ventricular localization of primary central nervous system lymphoma (PCNSL) has been usually managed with open surgical resection and/or stereotactic biopsy; nonetheless, the endoscopic approach to such localization can provide many advantages over standard microsurgery and/or stereotactic biopsy. Here we present our experience in managing such a rare pathology through the endoscopic approach. METHOD: In order to gather more information about such a rare pathology, a retrospective multicentric study on a prospectively built database has been performed during a 5 year period. Ten different European centers have been involved. RESULTS: A total of 60 patients, 25 women and 35 men, have been enrolled in the study. The mean age was 65.3 years. The mean lesion size was 40.3 mm. Among all selected patients, 40 (66.6%) had superficial lesions within the ventricle, whereas the remaining 20 (33.4%) had lesions involving/extending to deeper structures. All surgical procedures were uneventful and ETV was deemed necessary only in 20/60 cases. CONCLUSION: In our experience, endoscopic management of intraventricular PCNSL is an effective option. It should be considered after a careful examination of neurological and immunological status, alternative options for diagnostic sampling, location of the lesion, and presence or absence of hydrocephalus. Endoscopic management could be considered as a safe and minimally invasive option to obtain: (a) a biopsy sample of the lesion for further diagnostic workup, (b) CSF diversion through third ventriculostomy or VP shunt for the management of hydrocephalus, and (c) insertion of ventricular access devices for long term medical management and whenever necessary as a rescue option for ventricular tap.

A Laboratory Investigation on a Tailored Skin and Muscle Flap Variant for the Retrosigmoid Approach.

Introduction An anatomical study was conducted to test a modified C-shaped flap designed for patients undergoing a keyhole approach and/or minicraniotomy for retrosigmoid approach (KRSA). Materials and Methods Ten heads specimens were used. The surgical technique investigated was based on a 4-cm C-shaped skin incision with medial convexity (placed 8 cm laterally to the external occipital protuberance, with the lower edge terminating 1.5 to 2 cm above the mastoid tip), which followed by careful subperiosteal dissection and completed by reflecting and securing the skin flap layer anteriorly and the muscle flaps superiorly and inferiorly by stitches. Anatomical findings, including depth of surgical corridor till to the cerebellopontine cistern (CPC) as well as the sparing of neurovascular structures, were evaluated in every specimen. Results Twenty surgical approaches to CPC were conducted, resulting in a short working distance to the target (32 mm) without any need for a self-retaining retractor. In every specimen, the integrity of occipital muscles and cutaneous nerves was maintained, and a solid multilayer closure was always achieved. These data suggest that landmarks-based design of this C-shaped incision could be helpful in avoiding damages to the soft tissues encountered during KRSA. Conclusion This modified approach provides a wide surgical corridor to access the CPC while ensuring the minimal invasiveness of the standard S-shaped incision. Compared with the latter, it preserves better the integrity of the surrounding soft tissues and appears less likely to cause any iatrogenic injury to occipital muscles and cutaneous nerves.

Shadows and Lights: Perspectives of Training and Education in Neurosurgery for Undergraduate Students.

Introduction: Neurosurgical education should start during medical school to involve more students, favoring the recruitment of the most prepared and motivated ones and spreading this subject to the future medical generations. Despite multiple investigations, a dedicated educational plan does not exist. This study aims to assess the undergraduates' interests, needs, and perceptions of this subject. Materials and Methods: The survey was structured to collect demographic data of the participants, and to explore their interest in neurosurgery, their consideration of its importance in medical school, their opinions about the role of this subject in medical education, their needs in this training, and, the usefulness of this subject for their future career. Results: A total of 156 students participated in the survey. Interest in neurosurgery was shown by 76 (48.7%) participants, however, this subject was also perceived as intimidating by 86 (55.1%). Attending the first 2 years of medical school (p < 0.02), previous interest in neuroscience (p < 0.01), and in a surgical subject (p < 0.01) were the factors associated with a greater interest in this subject. Neurosurgery should be included in all students' education, according to 117 (75.0%) participants and practical operating room training should involve all students, according to 96 (61.5%). The most effective learning methods were considered internship (134, 85.9%), followed by participation in meetings or seminars (113, 72.4%). Online seminars were considered useful by 119 participants (76.3%). Neurosurgery was assessed as a potentially interesting career by 99 students (63.5%), who also considered that it can increase their preparation for other subjects (116, 74.4%). Conclusions: Neurosurgery was positively considered by medicals students, who, however, also perceived it as intimidating and hardly approachable. Demonstration that knowledge of neurosurgical concepts can improve their preparation also in general medical settings and, not only in the field of neuroscience, can be useful to promote their interest toward this subject. A combination of lectures and practical internships is considered an effective learning method, which can be fruitfully associated with new technologies.

Neurosurgery on the web: an analysis of the web-visibility of the European Neurosurgical Societies.

Nowadays, internet provides a great opportunity that allows the research community to constantly increase their scientific collaboration, together with information distribution. Aim of this study is to investigate the European National Neurosurgical Societies (ENNS) web-visibility that represents the necessary basis for diffusion of neurosurgical knowledge to both patients and neurosurgeons. We evaluated the web-visibility of each Neurosurgical Society affiliated to the European Associations of Neurosurgical Societies (EANS) using 3 different parameters: 1) the availability of the full list of all Neurosurgical Centers (NCs) of the country in each ENNS website; 2) the availability of a specific English-written section on the ENNS web-site; and 3) the availability of at least one section titled "news and events" and/or "educational" and/or "patient info" on the ENNS website. The web-visibility was categorized in significant (at least 2 out of 3 items fulfilled), not significant (1 out of 3 only) and insufficient (all not fulfilled). We also evaluated the web-visibility of single NCs, and the availability on the web of society's sections dealing with specific neurosurgical topics for each ENNS. Through the EANS Website we identified 38 ENNS. The rate of ENNS with significant web-visibility was 39%, while 24% of ENNS showed to have a not-significant web-visibility, while 37% had an insufficient visibility. The most unattended criterion was the availability of an English-written section of the website. Among ENNS with a significant web-visibility, this specific criterion was fulfilled in only 53% of cases. This percentage goes down to the 22% for ENNS with a non-significant web-visibility. The full list of NCs was available in 87% of cases for significant profiles and in zero cases for not-significant ones. Finally, the web-visibility rate of single NCs among different ENNS was 80%. Specific sections focusing on specific neurosurgical topics were available in 5 out of 38 ENNS websites (13%). This study highlighted the importance of increasing the ENNS web-visibility to spread the neurosurgical knowledge for patients, neurosurgeons and trainees. This could lead to an easier ENNS interaction, increasing the international collaboration between neurosurgical centers in the clinical, research and educational settings.

Odontoid Type II fractures in elderly: what are the real management goals and how to best achieve them? A multicenter European study on functional outcome.

Odontoid fractures constitute the most common cervical fractures in elderly. External immobilization is the treatment of choice for Type I and III; there is still no wide consensus about the best management of Type II fractures. Observational multicenter study was conducted on a prospectively built database on elderly patients (> 75 years) with Type II odontoid fracture managed conservatively during the last 10 years. All patients underwent CT scan on admission and at 3 months; if indicated, selected patient had CT scan at 6 and 12 months. All patients were clinically evaluated by Neck Disability Index (NDI), Charlson Comorbidity Index (CCI), and American Society of Anaesthesiologists classification (ASA) on admission; NDI was assessed also at 6 weeks, 3, 6, 12, and 24 months; furthermore, a quality of life (QoL) assessment with the SF-12 form was performed at 3 and 12 months. Among the 260 patients enrolled, 177 (68%) were women and 83 (32%) men, with a median age of 83 years. Patients were followed up for a minimum of 24 months: 247 (95%) showed an excellent functional outcome within 6 weeks, among them 117 (45%) showed a good bony healing, whereas 130 (50%) healed in pseudo-arthrosis. The residual 5% were still variably symptomatic at 12 weeks; however, only 5 out of 13 (2% of the total cohort) required delayed surgery. This study showed that a conservative approach to odontoid Type II fracture in elderly is an effective and valid option, resulting in an excellent functional outcome (regardless of bony fusion) in the majority of cases. Failure of conservative treatment can be safely addressed with surgical fixation at a later stage.

Primary Endoscopic Endonasal Management of Giant Pituitary Adenomas: Outcome and Pitfalls from a Large Prospective Multicenter Experience.

PURPOSE: To evaluate factors influencing clinical and radiological outcome of extended endoscopic endonasal transtuberculum/transplanum approach (EEA-TTP) for giant pituitary adenomas (GPAs). METHODS: We recruited prospectively all consecutive GPAs patients undergoing EEA-TTP between 2015 and 2019 in 5 neurosurgical centers. Preoperative clinical and radiologic features, visual and hormonal outcomes, extent of resection (EoR), complications and recurrence rates were recorded and analyzed. RESULTS: Of 1169 patients treated for pituitary adenoma, 96 (8.2%) had GPAs. Seventy-eight (81.2%) patients had visual impairment, 12 (12.5%) had headaches, 3 (3.1%) had drowsiness due to hydrocephalus, and 53 (55.2%) had anterior pituitary insufficiency. EoR was gross or near-total in 46 (47.9%) and subtotal in 50 (52.1%) patients. Incomplete resection was associated with lateral suprasellar, intraventricular and/or cavernous sinus extension and with firm/fibrous consistence. At the last follow-up, all but one patient (77, 98.7%) with visual deficits improved. Headache improved in 8 (88.9%) and anterior pituitary function recovered in 27 (50.9%) patients. Recurrence rate was 16.7%, with 32 months mean recurrence-free survival. CONCLUSIONS: EEA-TTP is a valid option for GPAs and seems to provide better outcomes, lower rate of complications and higher EoR compared to one- or multi-stage microscopic, non-extended endoscopic transsphenoidal, and transcranial resections.

Endoscopic Transorbital Approaches to Anterior and Middle Cranial Fossa: Exploring the Potentialities of a Modified Lateral Retrocanthal Approach.

BACKGROUND: Among the new perspectives to revolutionize skull base surgery, there are the transorbital neuroendoscopic (TONES) approaches to reach the anterior and middle cranial fossa (ACF and MCF). We conceived to explore the potentialities of a modified superiorly and medially extended lateral retrocanthal (LRC) approach. METHODS: Six head specimens were dissected. Applying the established conic model and the key surgical landmark of sphenofrontal suture, we tested the feasibility of a modified LRC to reach ACF and MCF; computed tomography (CT) scans were performed before and after dissection to obtain a morphometric analysis of the surgical corridors using a polygonal surfaces model. RESULTS: Through our anatomical study, we were able to identify and explore 3 different surgical corridors to reach the ACF and MCF: the superomedial, the superolateral, and the inferolateral. The superomedial corridor appeared most suitable to reach the medial part of the ACF and the optic-carotid region, whereas through the superolateral and inferolateral corridors it was possible to reach and explore the lateral part of ACF and MCF. The mean volumes of the 3 surgical corridors calculated on post-dissection CT scans were: 12.72 ± 1.99, 5.69 ± 0.34, and 6.24 ± 0.47 cm3, respectively. CONCLUSIONS: The development of TONES approaches has not replaced the traditional open or endoscopic approach; nonetheless, identification of surgical corridors and the possibility to combine them represent a major breakthrough. Clinical studies are necessary to demonstrate their validity and test the effectiveness, safety, and reproducibility of TONES approaches in managing lesions harboring in the ACF and MCF.

Endoscopic Endonasal Approach to the Ventral-Medial Portion of Posterior Paramedian Skull Base: A Morphometric Perspective of Surgical and Radiologic Anatomy.

OBJECTIVE: This study aims to provide morphometric analysis of endoscopic endonasal approach (EEA) to the ventral-medial portion of posterior paramedian skull base. Furthermore, it aims to investigate the surgical exposure obtained through EEA with and without eustachian tube (ET) removal, emphasizing the role of contralateral nostril (CN) access. METHODS: Five fresh adult head specimens were prepared for dissection. A predissection and a postdissection computed tomography study was performed. A surgically oriented classification into 4 regions was used: 1) tubercular region; 2) occipital condyle region; 3) parapharyngeal space (PPhS) region; and 4) jugular foramen (JF) region. The Student t-test was used to compare angulations and measures of EEA with access from the ipsilateral and CN, respectively, with and without ET removal. RESULTS: EEA to the ventral-medial portion of posterior paramedian skull base encompasses 2 medial trajectories (transtubercular and transcondylar) and 2 lateral pathways to the PPhS and JF. The CN access, without removal of the ET, allows a complete exposure of the petrous and intrajugular portion of the JF and superior PPhS without exposition of the parapharyngeal segment of internal carotid artery. The ipsilateral nostril approach with ET removal allows to obtain a wider exposure, reaching the medial sigmoid part of the JF. No significant differences exist in regard to transtubercular and transcondylar approaches. CONCLUSIONS: This study suggests that EEA to posterior paramedian skull base allows the realization of a corridor directed to the jugular tubercle, occipital condyle, medial PPhS, and ventral-medial JF. The CN approach with ET preservation can expose the petrous and intrajugular parts of the JF and PPhS. Case series are needed to demonstrate benefits and drawbacks of these approaches.

Endoscopic Transorbital Approaches to Anterior and Middle Cranial Fossa: A Laboratory Investigation on Surgical Anatomy and Potential Routes.

Background Transorbital neuroendoscopic (TONES) approaches promise to open up new horizons for skull base surgery, offering alternative routes to reach the anterior and middle cranial fossa (ACF and MCF, respectively). Objective The aim of this anatomical study is to acquire new surgical anatomy knowledge and exploit it for the refinement of TONES approaches, as an alternative to open surgery, to reduce the distance to the target, and the risk of neurovascular lesions in pathological conditions extending beyond the orbital cavity. Materials and Methods Six head specimens (12 orbits) were studied/dissected. The orbit was approached and divided in a four clockwise quadrants manner to simulate three transconjunctival routes: the precaruncular (PC), preseptal (PS), and lateral retrocanthal (LRC), and one transpalpebral route-the superior eyelid crease (SLC). The boundaries and the most important anatomical landmarks were identified and are herein duly detailed with particular attention to the neurovascular structures encountered in each of those routes. Results The dissections showed that the PC approach facilitates the treatment of optic nerve and frontal sinus pathologies, whereas LRC appears safer to reach ACF and MCF allowing for a free multiplanar working channel (up to 180 degrees) to the floor, roof, and lateral-to-medial walls. Conclusion The plane of tendon lateral canthal's insertion and the sphenofrontal suture (SFS) were identified as the key anatomical landmarks for TONES approaches. Further studies are warranted to establish a practical clinical algorithm based on the anatomical four clockwise quadrants herein implemented/proposed, and the key surgical landmarks identified.

Primary Endoscopic Management of Apoplexy in a Giant Pituitary Adenoma.

BACKGROUND: Sellar lesions with large suprasellar extension represent a neurosurgical challenge because of their nature and anatomic complexity. The goal of the extended transphenoidal-transtuberculum approach is enlarging the transsphenoidal route superiorly and laterally allowing for a surgical adequate exposure and offering a remarkable versatility in many sellar pathologies. CASE DESCRIPTION: We present the case of a 65-year-old man who suddenly developed blindness, right hemiparesis, and decreased alertness. The initial head computed tomography scan revealed a pituitary apoplexy of a giant adenoma associated with hydrocephalus resulting from obstruction of the foramen of Monro. The video shows a complete lesion removal through the sole endoscopic approach, with opening of the dural layer of sphenoidal plane and successful decompression of the third ventricle. Visual and functional improvement occurred in the immediate postoperative course. No lumbar drain has been used. CONCLUSIONS: This case demonstrates how the endoscopic approach can be attempted as a first and possibly stand-alone option for the surgical management of large sellar-suprasellar lesions. The endoscopic route is not associated with high rates of major complications and is safe when performed by experienced surgeons. In fact, it guarantees an enhanced control of the vascular feeders reaching the tumor from the anterior and middle fossa and results in a satisfactory manipulation of lesions invaginating into the floor of the third ventricle. A careful preoperative assessment of Knosp grade, tumor volume, hemorrhagic components, suprasellar extension, and sphenoid sinus invasion should always guide the management plan and suggest a staged or a combined (with transventricular or pterional approach) removal in particularly challenging cases.

Endovascular versus surgical treatment for improvement of oculomotor nerve palsy caused by unruptured posterior communicating artery aneurysms.

BACKGROUND: There is no consensus regarding the best treatment option for unruptured aneurysms of the posterior communicating artery (PCom) presenting with oculomotor nerve palsy (ONP). We aimed to assess predictors of ONP recovery in a multicenter series of consecutive patients. MATERIALS AND METHODS: A retrospective review of prospective databases in three tertiary neurosurgical centers was carried out, selecting patients with ONP caused by unruptured PCom aneurysms, treated by surgical clipping or embolization, between January 2006 and December 2013. Patient files and imaging studies were used to extract ophthalmological assessments, treatment outcomes, and follow-up data. Predictors of ONP recovery during follow-up were explored using univariate and multivariate analyses. RESULTS: We identified 55 patients with a median ONP duration before treatment of 11 days (IQR 4.5-18); the deficit was complete in 27 (49.1%) and incomplete in 28 (50.9%) cases. Median aneurysm size was 7 mm (IQR 5-9). Twenty-four (43.6%) patients underwent surgical clipping and 31 (56.4%) embolization as the primary treatment. Overall, ONP improved in 40 (72.7%) patients and persisted/recurred in 15 (27.3 %). Surgery, interval to complete treatment <4 weeks, aneurysm recurrence during follow-up, and retreatment during follow-up were significantly correlated with ONP outcome in the univariate analysis. In the multivariate analysis, independent predictors of ONP improvement were interval to complete treatment <4 weeks (OR 5.15, 95% CI 1.37 to 23.71, p=0.015) and aneurysm recurrence during follow-up (OR 0.1, 95% CI 0.02 to 0.47, p=0.003). CONCLUSION: There was no significant difference in ONP recovery between surgical clipping and embolization. The best predictor for ONP recovery was timely, complete, and durable aneurysm exclusion.