Safety and Performance of a New Burr Hole Covering Device: Results of the Multicenter COVER Registry.

BACKGROUND: Burr hole covering in brain surgical procedures can avoid complications and unaesthetic results. The aim of this registry was to assess the safety and performance of a new polymeric burr hole covering device (Cranial COVER, NEOS Surgery). METHODS: A multicenter, prospective, clinical registry design was used for the study. All the patients who fulfilled the inclusion criteria were included in the study and followed up for 6 months. Baseline clinical parameters, surgical variables (technical success of the implantation, surgeon satisfaction), postoperative variables (aesthetic and functional results, neuroimaging artifacts), and adverse events were evaluated. RESULTS: Forty-three Cranial COVER devices were implanted in 30 patients. Most of them were implanted in frontal locations (53.5%). After implantation, 97.7% of the devices completely covered the burr hole, and 100% perfectly adapted to the skull surface. All surgeons ranked their satisfaction with the implantation procedure as very high or high. No artifacts were detected in any of the neuroimaging studies performed and no adverse events related with the device or its implantation were reported during the follow-up. There were significantly more scalp depressions associated with uncovered than with Cranial COVER-covered burr holes (p = 0.040). Patient satisfaction with covered burr holes located in the frontal and parietal areas was 9.0 ± 1.4 over 10. CONCLUSION: Cranial COVER is a safe and reliable burr hole covering system that offers excellent cosmetic results and high satisfaction rates for both surgeons and patients. Cranial COVER is highly adaptable to the skull surface, and it was predominantly used in frontal locations due to their cosmetic importance.

Endovascular assisted vertebrobasilar junction aneurysm clipping in a hybrid operation room. Case report.

Introduction: We present a case of a 60-year-old female that underwent surgery for clipping a right vertebrobasilar junction aneurysm (VBJA) in a hybrid operation room. Research question: Does the retrograde suction technique with a proximal balloon is safe and effective as an adjuvant technique in surgery of VBJA? Material and methods: After an extended retrosigmoid approach was performed, a 6F Neuron catheter with an intermediate multipurpose catheter were navigated to the right vertebral artery (VA) through a 6-French sheath, which caused a severe catheter-induced vasospasm in the right VA. The aneurysm was then deflated and clipped. After the withdrawal of the catheter the vasospasm was resolved. Results: The patient had a good recovery, with VI cranial nerve palsy and mild dysphagia due to mild right vocal cord palsy, both improving at 1-month follow-up and fully recovered at 6-month follow-up. Discussion and conclusion: The combination of endovascular procedures and microsurgery at the same hybrid operation room in that case resulted in a safe and effective technique. It is an interesting tool that could help neurosurgeons deal with certain selected cases of VBJA. Intraoperative angiography offers the possibility to reposition a misplaced clip in the same surgery. Good collaboration between interventional neuroradiologists and vascular neurosurgeons helps in achieving good results in such difficult cases.

High Myoinositol on Proton MR Spectroscopy Could Be a Potential Signature of Papillary Tumors of the Pineal Region-Case Report of Two Patients.

Papillary tumor of the pineal region (PTPR) is an uncommon entity in which a presurgical suspicion may be crucial for patient management. Maximal safe neurosurgical resection is of choice when PTPR is suspected, whereas non-surgical approaches can be considered in other tumors of the pineal region, such as pineocytoma or concrete subtypes of germ-cell tumors. In general terms, imaging features of tumors of the pineal region have been reported to be unspecific. Nevertheless, in this report, we describe two pathology-confirmed PTPRs in which presurgical proton MR spectroscopy demonstrated extremely high myoinositol, a pattern which drastically differs from that of other pineal tumors. We hypothesize that this high myoinositol may be related to PTPR's known ependymal component, and that it could be used as a specific non-invasive diagnostic signature.

Revascularization of the Anterior Inferior Cerebellar Artery Using Extracranial and Intracranial Donors: A Morphometric Cadaveric Study.

INTRODUCTION: Anterior inferior cerebellar artery (AICA) aneurysms are rare, accounting for 0.2%-1.3% of all intracranial aneurysms. The standard treatment is often endovascular embolization or neck clipping; however, sacrifice of the parent vessel is sometimes necessary. Addition of revascularization procedures is a subject of controversy. The occipital artery (OA) has been used as a donor for bypass, but recently there has been a trend toward intracranial-intracranial approaches. The posterior inferior cerebellar artery (PICA)-AICA side-to-side bypass may serve as a safe alternative. OBJECTIVE: To characterize the PICA-AICA side-to-side bypass and the OA-AICA end-to-side bypass and review the literature relevant to AICA revascularization. METHODS: We performed a far-lateral approach on 12 cadaveric specimens and analyzed the regional anatomy. On this basis, we performed either an OA-AICA or a PICA-AICA bypass and took morphometric measurements relevant to the technique. RESULTS: PICA-AICA bypass was successful in 6/12 specimens. The length of the flocculopeduncular segment was 42.6 ± 15.8 mm in the specimens in which the bypass was feasible and 26.2 ± 7.2 mm in those in which the bypass was not feasible (P = 0.04). Mean distance between AICA and PICA was 5.3 ± 4 mm in the specimens in which side-to-side bypass was feasible and 11.6 ± 4.2 mm in the specimens in which it was not (P = 0.02). OA-AICA end-to-side bypass was feasible in all the specimens (75% in the flocculopeduncular segment; 25% in the cortical segment). CONCLUSIONS: This is the first cadaveric study analyzing the PICA-AICA side-to-side bypass for AICA revascularization. Our analyses provide evidence for the feasibility of this bypass and document the anatomic variations that may indicate its use.

Clipping of High-Risk Dural Arteriovenous Fistula of the Posterior Fossa: 3-Dimensional Operative Video.

Dural arteriovenous fistulas (DAVFs) represent 10%-15% of all intracranial arteriovenous malformations.1 DAVFs located in the posterior cranial fossa are rare and often present with intracranial hemorrhage and myelopathy.2 Arterial supply could be provided by the meningeal branches of the vertebral artery and external and internal carotid arteries.3 A 68-year-old man presented with progressive lower-extremity weakness (Video 1). Magnetic resonance imaging revealed a patchy longitudinal cord signal abnormality extending from the cervicomedullary junction to C7. A tentorial DAVF supplied by the right posterior meningeal artery with drainage via dorsal and ventral perimedullary veins was identified on angiography. According to the Cognard classification, the patient's DAVF was determined to be high risk as a type V lesion with spinal venous drainage and progressive myelopathy.4 The fistula was embolized with 50% ethanol resulting in near-complete occlusion. However, follow-up angiography revealed a persistent arteriovenous shunt and slightly worsening symptoms for the patient. He underwent a sitting supracerebellar approach with a torcular craniotomy for successful clip ligation of the dural arteriovenous fistula. The patient was discharged with improvements in lower-extremity strength and no residual arteriovenous shunting in postoperative imaging.