When anticoagulation management in atrial fibrillation becomes difficult: Focus on chronic kidney disease, coagulation disorders, and cancer.

Anticoagulation therapy (AT) is fundamental in atrial fibrillation (AF) treatment but poses challenges in implementation, especially in AF populations with elevated thromboembolic and bleeding risks. Current guidelines emphasize the need to estimate and balance thrombosis and bleeding risks for all potential candidates of antithrombotic therapy. However, administering oral AT raises concerns in specific populations, such as those with chronic kidney disease (CKD), coagulation disorders, and cancer due to lack of robust data. These groups, excluded from large direct oral anticoagulants trials, rely on observational studies, prompting physicians to adopt individualized management strategies based on case-specific evaluations. The scarcity of evidence and specific guidelines underline the need for a tailored approach, emphasizing regular reassessment of risk factors and anticoagulation drug doses. This narrative review aims to summarize evidence and recommendations for challenging AF clinical scenarios, particularly in the long-term management of AT for patients with CKD, coagulation disorders, and cancer.

Combined Transpetrosal Approach: 2-Dimensional Operative Video.

INDICATIONS CORRIDOR AND LIMITS OF EXPOSURE: This approach is suitable for petroclival lesions medial to V cranial nerve that extend in both middle and posterior fossa. It provides multiple surgical corridors with minimal brain retraction. ANATOMIC ESSENTIALS NEED FOR PREOPERATIVE PLANNING AND ASSESSMENT: Several critical neurovascular structures of the petrous bone are at risk during the approach. Meticulous reading of the preoperative images is fundamental. It is mandatory to perform a thin section computed tomography scan, an MRI, and, in case of petroclival meningiomas, a digital subtraction angiography. ESSENTIAL STEPS OF THE PROCEDURE: In the first illustrative case, we present our current "mini-combined petrosectomy" with minimal drilling of the labyrinth. Positioning, skin incision, and craniotomy are illustrated in the video. Once all the important neurovascular structures are identified, we perform the anterior and the posterior petrosectomy, with preservation of the endolymphatic sac. We continue with dura mater opening and tentorium cutting. After tumor removal, we can appreciate an unique view of ipsilateral and contralateral cranial nerves, as well as pituitary stalk and major arteries. PITFALLS/AVOIDANCE OF COMPLICATIONS: To avoid injuries to the main neurovascular structures, neuronavigation, neuromonitoring, and Doppler can be useful. VARIANTS AND INDICATIONS FOR THEIR USE: The second illustrative case shows an extension of the combined petrosectomy to the anterior fossa, this made possible to perform a transsylvian approach for this giant sphenopetroclival meningioma. The patients consented to the procedure and to the publication of his/her images. Appropriate consent was obtained for the publication of the cadaveric images.

Distal Posterior Cerebral Artery Ruptured Aneurysm: A Rare Case Report and Review of Literature.

Distal posterior cerebral artery aneurysms consist of a rare vascular entity whose treatment approach remains challenging. Few studies exist scarcely in the literature reporting cases of P4 ruptured aneurysms. In this study, we present the case of a 49-year-old female patient who was admitted to our Neurosurgery Department with the World Federation of Neurological Surgeons grade IV, Fischer grade IV subarachnoid hemorrhage due to a right distal posterior cerebral artery aneurysm. She successfully underwent surgery via a posterior occipital interhemispheric approach. The patient recovered well from surgery, and the following days, she was successfully extubated and had a significant neurological improvement. However, she died during her rehabilitation due to sepsis and severe acute respiratory distress syndrome.