Spontaneous thrombosis in giant aneurysm of the anterior communicating artery complex in pediatric age: five-year follow-up.

Intracranial aneurysms are rare in the pediatric population, especially in infancy, representing less than 1% of all aneurysms. In this age group, they are more frequent at the carotid bifurcation and in the posterior circulation, with a greater number of giant aneurysms and spontaneous aneurysm thrombosis when compared with the adults. They are life-threatening, and, therefore, early investigation, characterization of the lesion, and treatment are essential. The appropriate management depends on the child's condition, aneurysm characteristics, and the experience of a multidisciplinary team. Noninvasive and radiation-free imagiological studies play an important role in the diagnosis and follow-up of these young patients. We present the case of a 3-month-old boy with an intracranial hemorrhage secondary to the rupture of a giant aneurysm of the anterior communicating artery complex, with spontaneous thrombosis, which is a rare situation due to its location. A conservative approach was assumed and noninvasive evolutive imagiological studies revealed a reduction in the thrombosed aneurysm size and no signs of recanalization. The child recovered to his baseline neurological condition and has had no rehemorrhage until 5 years of follow-up.

Training charter in epilepsy surgery added competence.

The present Training Charter in Epilepsy Surgery Added Competence constitutes the third stage of a program initiated by the European Society for Stereotactic and Functional Neurosurgery (ESSFN) and substantiated in close collaboration with the Union Européennedes Médecins Spécialists (UEMS) and the European Association of Neurosurgical Societies (EANS). This program aims to raise the standards of clinical practice by guiding education and quality control concepts. The particular sections of this Charter include: definitions and standards of added competence training, relations of the Epilepsy Unit with the Neurosurgical Department, duration of epilepsy surgery fellowship, institution and training program director requirements, operative totals for epilepsy surgery, educational program, individual requirements, and evaluation and qualification of the trainees. The specification of all these requirements is expected to improve harmonisation and quality of epilepsy surgery practice across Europe, and enhance the clinical activity and the scientific productivity of existing neurosurgical centres.

A report on neurosurgical workforce in the countries of the EU and associated states. Task Force "Workforce Planning", UEMS Section of Neurosurgery.

AIM: Aim of this report was to present recently collected data on neurosurgical workforce in the countries of the EU and associated states. METHODS: Data were obtained from 27 countries by means of a questionnaire developed by members of a working group of the UEMS Section of Neurosurgery (UEMS = Union Europénne des Médecins Spécialistes; European Union of Medical Specialists). Most data originate from 2005/2006. Results were discussed, amended, and approved by the countries' delegates of the UEMS Section of Neurosurgery. RESULTS: The number of Neurosurgeons (NS) per population varies considerably among these countries. The mean is one neurosurgeon per 99,152 population. The number of neurosurgical operations per population per year varies similarly with a mean of 1,642 operations per million population/year. Countries with fewer neurosurgeons per population tend to have less neurosurgical operations per population and vice versa. The average number of operations performed by one neurosurgeon per year (annual caseload) is between 56 and 300 with a mean of 154. A numerus clausus for neurosurgical training is reported in 13 countries, another 13 countries have no numerus clausus. The annual intake of new trainees is between 2.4 and 10.3% of the number of accredited neurosurgeons with a mean of approx. 5.2%. The average yearly loss rate due to retirement, sickness, other activities, etc. can only be estimated and lies in the range between 2.3 and 3.36% of the number of accredited NS. According to the figures provided by the countries, the total number of accredited NS in 2005/2006 was approx. 6,280 for a population of about 504.7 millions. These countries had an annual intake of approx. 332 new trainees.

Loss of topographic memory and prosopagnosia during migraine aura.

We report the case of a 28-year-old woman with a past history of acephalalgic migraine. She had a complex migraine aura with left-sided scintillating scotomas, hemianopia, left-sided paresthesias, a loss of topographic and procedural memory, and prosopagnosia. The rarity of right hemisphere cognitive dysfunction during the aura, its diagnostic difficulties, and differential diagnosis are discussed.

Innervation of the human middle meningeal artery: immunohistochemistry, ultrastructure, and role of endothelium for vasomotility.

The majority of nerve fibers in the middle meningeal artery and branching arterioles are sympathetic, storing norepinephrine and neuropeptide Y (NPY). A sparse supply of fibers contain acetylcholinesterase activity and immunoreactivity toward vasoactive intestinal peptide (VIP), peptidine histidine methionine (PHM), and calcitonin gene-related peptide (CGRP). Only few substance P and neuropeptide K immunoreactive fibers are noted. Electronmicroscopy shows axons and terminals at the adventitial medial border of the human middle meningeal artery, with a fairly large distance to the smooth muscle cells (>500 nM). Several axon profiles contain vesicles of different types, including putative sensory profiles. The perivascularly stored signal substances, norepinephrine and NPY induced vasoconstrictor. Relaxations were induced by acetylcholine and substance P, and these were significantly reduced in arteries without endothelium, while the responses to norepinephrine, NPY, VIP, PHM, and CGRP were not changed by endothelium removal. Blockade experiments showed that the vasomotor responses to norepinephrine were blocked by prazosin, to NPY by BIBP 3226, acetylcholine by atropin, substance P by RP 67580, and the human alpha-CGRP response by human alpha-CGRP(8-37).

Innervation pattern of malformative cortical vessels in Sturge-Weber disease: an histochemical, immunohistochemical, and ultrastructural study.

OBJECTIVE: This study was undertaken to elucidate the pattern of vascular innervation in areas of pial angiomatosis in Sturge-Weber disease (SWD) and eventually correlating it with the pathophysiology of the disease, namely its chronic ischemic changes. METHODS: We processed part of a surgical specimen resected from a 3-year-old female patient who underwent functional hemispherectomy for SWD and characterized the pattern of innervation of the malformative cortical vessels using histochemical, immunohistochemical, and ultrastructural techniques. RESULTS: Cortical vessels were observed to be supplied with numerous varicose nerve fibers containing immunoreactivity for neuropeptide tyrosine and the catecholamine-synthesizing enzyme, tyrosine, tyrosine hydroxylase. In contrast, no nerve fibers containing acetylcholinesterase activity and immunoreactivity for Substance P, a calcitonin gene-related peptide and vasoactive intestinal peptide, were detected. Ultrastructural studies revealed the presence of numerous axon varicosities at the adventitial-medial border. Neuropeptide tyrosine immunoreactivity was localized in large granular vesicles in nerve varicosities that also contained numerous small granular vesicles. CONCLUSION: These results demonstrate that nerve supplying cortical vessels in SWD are arranged in a distribution pattern similar to the one observed in human normal cortical veins and suggest that these abnormal vessels are innervated only with noradrenergic sympathetic nerve fibers. This represents a clear difference from the pattern of innervation observed in both normal cortical arteries and veins, and is the consequence of the anatomic and functional dysangiogenic process characteristic of the affected cortical areas in SWD.

Stereotactic angiographic localization as an adjunct to surgery of cerebral mycotic aneurysms: case report and review of the literature.

Less than 10% of all aneurysms affecting the arterial cerebral circulation are mycotic in nature. They occur in the setting of bacterial endocarditis and are the cause of considerable morbidity and mortality of affected patients. In selected cases surgery may play a curative role in the treatment plan. These aneurysms frequently arise in distal arterial branches, and their localization during surgery may at times prove laborious. We report the case of a mycotic aneurysm of a distal branch of the anterior cerebral artery surgically treated with the help of angiographic stereotactic localization. Stereotaxy should thus be regarded as a pertinent adjunct in selected cases of surgical treatment of distal mycotic cerebral aneurysms.

Nitroxidergic innervation of guinea pig cerebral arteries.

The presence and distribution of nitric oxide synthase (NOS)-immunoreactive nerve fibers associated with the guinea pig major cerebral arteries was studied by means of immunohistochemical, histochemical and ultrastructural techniques. Anterior arteries of the circle of Willis received a rich supply of perivascular nerve fibers containing NOS immunoreactivity while posteriorly localized arteries presented a moderate to sparse innervation. A double immunofluorescence staining technique revealed that NOS was localized in nerve fibers distinct from those displaying substance P or tyrosine hydroxylase. Combined immunofluorescence and histochemical staining of the same preparation indicated that NOS immunoreactivity was localized in putative cholinergic nerve fibers (identified by their acetylcholinesterase content) and that NADPH-diaphorase activity (a marker for NOS-containing neurons) was found in nerves which also possessed VIP immunoreactivity. The ultrastructural study revealed that NOS immunoreactivity was present in numerous nerve varicosities at the adventitial-medial border. These results suggest that NO and VIP co-exist in putative parasympathetic nerve fibers supplying the guinea pig cerebral arteries and may be release together in response to nervous stimulation.

The peptidergic innervation of human coronary and cerebral vessels.

It is now well established that in addition to nerves containing classical transmitters, the mammalian vascular system is also supplied by nerve fibre subpopulations containing several vasoactive peptides. The precise function of these peptides (neuropeptide Y, calcitonin gene-related peptide, vasoactive intestinal polypeptide, somatostatin and the tachykinins) is still unknown, however, their widespread occurrence in perivascular nerves indicates that they are likely candidates for a role in the neurogenic regulation of the vascular system. It has been suggested that they may exert a direct vasomotor action via their own receptors and/or modulate the release and action of other vascular transmitters. Recently, several studies have focused on the supply of nerve fibres storing neuropeptides in the coronary and cerebral vasculature of laboratory animals, however, little is known on the distribution of these putative transmitters in human coronary and cerebral vessels. In this paper, the immunocytochemical evidence that several neuropeptides are localized in subpopulations of afferent and efferent nerve fibres supplying the human coronary and cerebral vasculature is focused.

Demonstration of neuropeptide containing nerves and vasomotor responses to perivascular peptides in human cerebral arteries.

A rich supply of nerve fibers containing neuropeptide Y-like (NPY-LI) and tyrosine hydroxylase-like immunoreactivity was seen in human cerebral arteries, arterioles and veins. Only a sparse supply of vasoactive intestinal polypeptide (VIP-LI), substance P (SP-LI), and calcitonin gene-related peptide (CGRP-LI) was demonstrated in the walls of human cerebral vessels. In isolated ring segments of human cerebral arteries, NPY and noradrenaline caused vasoconstriction but did not potentiate each other. VIP, peptide histidine methionine, SP, neurokinin A, and CGRP relaxed arteries precontracted by prostaglandin F2 alpha. The degree of innervation and the vasomotor responses are discussed in relation to migraine pathophysiology.

Transcranial Doppler changes during staged surgical resection of cerebral arteriovenous malformations: a report of three cases.

The removal of large arteriovenous malformations (AVMs) in stages has been advocated to reduce the risk of perioperative hyperemic complications. In three patients who had a two-stage surgical removal of their large (> 6 cm) frontal AVMs, transcranial Doppler (TCD) was performed 1 day before and 1 day after each surgery. Arteries still feeding the AVM after the first procedure had an increase in mean velocity (MV) and a decrease in the pulsatility index (PI) in the period between the two surgeries. MV reactivity to carbon dioxide before each stage was higher in feeding arteries at the second surgery, suggesting that the total magnitude of the shunt through the AVM was lower in spite of flow recruitment. TCD can be used to monitor the hemodynamic changes after embolization or partial surgery and may be of help in better defining the optimal time for final resection.

The treatment of associated intracranial aneurysms and arteriovenous malformations.

Cerebral arterial aneurysm associated with arteriovenous malformation (AVM) has been described with a variable incidence, averaging 10% of AVM cases. The present series includes 39 patients with this association, derived from a total of 400 patients with AVM's evaluated and treated since 1970. The aneurysms are classified into four major groups, each carrying particular therapeutic implications. Optimum treatment of these lesions is based in part on a knowledge of the hemodynamic alterations associated with the AVM's. In most of these cases, the symptomatic lesion was treated first; occasionally, when feasible, both lesions were treated during the same operation. All patients had some form of treatment, either surgical or endovascular, directed to at least one of the two types of lesions. All symptomatic lesions were treated and all ruptured aneurysms were obliterated. There were no deaths in this series.