Microsurgical Removal of an Anterior Clinoid Meningioma With Extensive Vascular Encasement: 2-Dimensional Operative Video.

Anterior clinoid meningiomas are challenging skull base lesions especially when they encase the internal carotid artery and its branches. According to the Al-Mefty classification, type I can originate in the subclinoid dura, type II on the superolateral aspect of the anterior clinoid process, and type III at the optic foramen, with type I being the most often associated with vascular encasement.1,2 We present the case of a 70-year-old patient who presented with visual disturbances revealing a large type I anterior clinoid meningioma encasing the internal carotid artery and its branches. The extended pterional approach with removal of the posterior part of the superior and lateral walls of the orbit3 was offered to the patient given the size of the tumor and the visual impairment. We present the main steps of the surgery: extended pterional approach with postero-lateral orbitotomy, extradural removal of the anterior clinoid process, and hyperosthosis. The meningioma is removed in a stepwise fashion starting in the less dangerous frontal sector of the tumor and ending in the supra cavernous and supra diaphragmatic sectors of the meningioma. The postoperative course was favorable, and at 3-month follow-up, the patient showed a significant visual improvement. Brain MRI showed a subtotal resection of the meningioma and no postoperative complications. We present the nuances and the surgical technique for anterior clinoid meningiomas with extensive vascular encasement. We discuss the factors predicting the preservation of the arachnoid planes reported in the literature.4 The patient consented to the procedure and to the publication of the images. Our Institutional Review Board ethics committee does not require an approval for this type of publication.

Surgical treatment of hemifacial spasms: how to predict failure and complications through a series of 200 patients.

Primary hemifacial spasm (pHFS) is a benign but disabling movement disorder caused by a neurovascular conflict involving the facial nerve. Surgical treatment by microvascular decompression (MVD) is the most effective therapeutic. Predictors of surgical failure and surgical complications are still lacking. The aim of this study is to identify such predictors through the retrospective analysis of a series of 200 consecutive patients. All patients who underwent MVD for pHFS from January 1991 to December 2017 were included. All patients had at least two years follow-up. In addition to the demographic data, the outcome and the complications were collected. The primary outcome analysis showed that 7.5% of patients had a recurrence. Multiple and AICA related neurovascular conflicts were statistically associated to a higher recurrence rate after MVD (respectively p < 0.001 and p = 0.02). Permanent facial palsy occurred in 2.5% of patients, hearing loss in 9.0% (2.0% of complete unilateral impairment) and dizziness in 2.5%. The risk of each of these peripheral neurological impairments was statistically increased by a long duration between the first pHFS symptom and the MVD (p < 0.001). In case of recurrence, a second MDV was offered. Long term follow-up showed that all patients had a complete resolution of the HFS. Post-operative complication rate was not significantly increased after a second MVD. Multiple and AICA related neurovascular conflicts are associated to a higher risk of surgical failure. When a pHFS recurrence occurs, a second surgical procedure is associated with excellent outcome without significant increase of post-operative complications and should therefore be recommended.

Endovascular treatment of brain arteriovenous malformations: clinical outcomes of patients included in the registry of a pragmatic randomized trial.

OBJECTIVE: The role of endovascular treatment in the management of patients with brain arteriovenous malformations (AVMs) remains uncertain. AVM embolization can be offered as stand-alone curative therapy or prior to surgery or stereotactic radiosurgery (SRS) (pre-embolization). The Treatment of Brain AVMs Study (TOBAS) is an all-inclusive pragmatic study that comprises two randomized trials and multiple registries. METHODS: Results from the TOBAS curative and pre-embolization registries are reported. The primary outcome for this report is death or dependency (modified Rankin Scale [mRS] score > 2) at last follow-up. Secondary outcomes include angiographic results, perioperative serious adverse events (SAEs), and permanent treatment-related complications leading to an mRS score > 2. RESULTS: From June 2014 to May 2021, 1010 patients were recruited in TOBAS. Embolization was chosen as the primary curative treatment for 116 patients and pre-embolization prior to surgery or SRS for 92 patients. Clinical and angiographic outcomes were available in 106 (91%) of 116 and 77 (84%) of 92 patients, respectively. In the curative embolization registry, 70% of AVMs were ruptured, and 62% were low-grade AVMs (Spetzler-Martin grade I or II), while the pre-embolization registry had 70% ruptured AVMs and 58% low-grade AVMs. The primary outcome of death or disability (mRS score > 2) occurred in 15 (14%, 95% CI 8%-22%) of the 106 patients in the curative embolization registry (4 [12%, 95% CI 5%-28%] of 32 unruptured AVMs and 11 [15%, 95% CI 8%-25%] of 74 ruptured AVMs) and 9 (12%, 95% CI 6%-21%) of the 77 patients in the pre-embolization registry (4 [17%, 95% CI 7%-37%] of 23 unruptured AVMs and 5 [9%, 95% CI 4%-20%] of 54 ruptured AVMs) at 2 years. Embolization alone was confirmed to occlude the AVM in 32 (30%, 95% CI 21%-40%) of the 106 curative attempts and in 9 (12%, 95% CI 6%-21%) of 77 patients in the pre-embolization registry. SAEs occurred in 28 of the 106 attempted curative patients (26%, 95% CI 18%-35%, including 21 new symptomatic hemorrhages [20%, 95% CI 13%-29%]). Five of the new hemorrhages were in previously unruptured AVMs (n = 32; 16%, 95% CI 5%-33%). Of the 77 pre-embolization patients, 18 had SAEs (23%, 95% CI 15%-34%), including 12 new symptomatic hemorrhages [16%, 95% CI 9%-26%]). Three of the hemorrhages were in previously unruptured AVMs (3/23; 13%, 95% CI 3%-34%). CONCLUSIONS: Embolization as a curative treatment for brain AVMs was often incomplete. Hemorrhagic complications were frequent, even when the specified intent was pre-embolization before surgery or SRS. Because the role of endovascular treatment remains uncertain, it should preferably, when possible, be offered in the context of a randomized trial.

Clipping Versus Coiling for Ruptured MCA Aneurysms Associated with Intracerebral Hematoma Requiring Surgical Evacuation.

BACKGROUND: Ruptured middle cerebral artery aneurysm (MCAa) can lead to intracerebral hematoma, and surgical evacuation can be performed in these cases. MCAa can be treated by clipping or before by endovascular therapy (EVT). Our objective was to compare the impact on the functional outcome of MCAa in patients with intracerebral hematoma requiring evacuation. METHODS: This is a multicenter, retrospective, cohort study with nine French neurosurgical units from January 1, 2013, to December 31, 2020. All participants were adult patients who required evacuation of an intracerebral hematoma. We looked for risk factors for poor outcomes by comparing the baseline characteristics and treatments performed by using the 6-month modified Rankin scale score. Poor outcomes were defined by an modified Rankin scale score of 3-6. RESULTS: A total of 162 patients were included. A total of 129 (79.6%) patients were treated by microsurgery, and 33 (20.4%) patients were treated by EVT. In multivariate analysis, factors associated with poor outcomes included hematoma volume, realization of a decompressive craniectomy, occurrence of procedure-related symptomatic cerebral ischemia, occurrence of delayed cerebral ischemia, and EVT. In the propensity score matching analysis (n = 33 per group), poor outcomes were observed in 30% of the patients in the clipping group versus 76% in the EVT group (P < 0.001). These differences may have been related to a longer delay between hospital admission and hematoma evacuation in the EVT group. CONCLUSIONS: In the specific subgroup of ruptured MCAa with intracerebral hematoma that requires surgical evacuation, clipping with concomitant hematoma evacuation could provide better functional outcomes than EVT followed by surgical evacuation.

Patient Selection in a Pragmatic Study on the Management of Patients with Brain Arteriovenous Malformations.

BACKGROUND: The Treatment of Brain Arteriovenous Malformations Study (TOBAS) is an all-inclusive pragmatic study comprising 2 randomized clinical trials (RCTs). Patients excluded from the RCTs are followed in parallel treatment and observation registries, allowing a comparison between RCT and registry patients. METHODS: The first randomized clinical trial (RCT-1) offers 1:1 randomized allocation of intervention versus conservative management for patients with arteriovenous malformation (AVM). The second randomized clinical trial (RCT-2) allocates 1:1 pre-embolization or no pre-embolization to surgery or radiosurgery patients judged treatable with or without embolization. Characteristics of RCT patients are reported and compared to registry patients. RESULTS: From June 2014 to May 2021, 1010 patients with AVM were recruited; 498 patients were observed and 373 were included in the treatment registries. Randomized allocation in RCT-1 was applied to 139 (26%) of the 512 patients (including 127 of 222 [57%] with unruptured AVMs) considered for curative treatment. RCT-1 AVM patients differed (in rupture status, Spetzler-Martin grade and baseline modified Rankin Score) from those in the observation or treatment registries (P < 0.001). Most patients had small (<3 cm; 71%) low-grade (Spetzler-Martin I-II; 64%) unruptured (91%) AVMs. The allocated management was conservative (n = 71) or curative (n = 68), using surgery (n = 39), embolization (n = 16), or stereotactic radiosurgery (n = 13). Pre-embolization was considered for 179/309 (58%) patients allocated/assigned to surgery or stereotactic radiosurgery; 87/179 (49%) were included in RCT-2. RCT-2 patient AVMs differed in size, eloquence and grade from patients of the pre-embolization registry (P < 0.01). Most had small (<3 cm in 82%) low-grade (83%) AVMs in non-eloquent brain (64%). CONCLUSIONS: Patients included in the RCTs differ significantly from registry patients. Meaningful results can be obtained if multiple centers actively participate in the TOBAS RCTs.

Ethical Management of COVID-19 Pandemic at a Neurological Hospital: The Ethicovid Report.

BACKGROUND: During the first wave of the coronavirus disease-2019 (COVID-19) pandemic, it was necessary to prepare for the possibility of triaging patients who could benefit from access to an intensive care unit (ICU). In our neuroscience institution, the challenge was to continue to manage usual neurological emergencies as well as the influx of COVID-19 patients. METHODS: We report the experience of an ethical consulting unit to support care clinical decisions during the first wave of the pandemic (March 16 to April 30, 2020). Three objective evaluation criteria were defined: 2 of these criteria, patient's factors and general disease severity (Simplified Acute Physiology Score II), were common to all patients, and the third was the specific severity of the disease (neurological for brain injury, respiratory for COVID-19). Given our scarce resources, we used a high probability of a 3-month modified Rankin Scale ≤3 as the criterion for further resuscitation and management. RESULTS: A total of 295 patients were admitted during the first pandemic wave; 111 with COVID-19 and 184 with neurological emergencies. The ethical unit's expertise was sought for 75 clinical situations in 56 patients (35 COVID-19 and 21 neurological). Decisions were as follows: 11% no limitation on care, 5% expectant care with reassessment (maximum therapy to assess possible progress pending decision), 67% partial limitation (no intensification of care or no transfer to ICU), and 17% limitation of curative care. At no time did a lack of availability of ICU beds require the ethical unit to advise against admission to the ICU. CONCLUSIONS: Our ethical consulting unit allowed for collegial ethical decision-making in line with international recommendations. This model could be easily transferred to other triage situations, provided it is adapted to the local context.

Surgical treatment of brain arteriovenous malformations: clinical outcomes of patients included in the registry of a pragmatic randomized trial.

OBJECTIVE: The Treatment of Brain Arteriovenous Malformations Study (TOBAS) is a pragmatic study that includes 2 randomized trials and registries of treated or conservatively managed patients. The authors report the results of the surgical registry. METHODS: TOBAS patients are managed according to an algorithm that combines clinical judgment and randomized allocation. For patients considered for curative treatment, clinicians selected from surgery, endovascular therapy, or radiation therapy as the primary curative method, and whether observation was a reasonable alternative. When surgery was selected and observation was deemed unreasonable, the patient was not included in the randomized controlled trial but placed in the surgical registry. The primary outcome of the trial was mRS score > 2 at 10 years (at last follow-up for the current report). Secondary outcomes include angiographic results, perioperative serious adverse events, and permanent treatment-related complications leading to mRS score > 2. RESULTS: From June 2014 to May 2021, 1010 patients were recruited at 30 TOBAS centers. Surgery was selected for 229/512 patients (44%) considered for curative treatment; 77 (34%) were included in the surgery versus observation randomized trial and 152 (66%) were placed in the surgical registry. Surgical registry patients had 124/152 (82%) ruptured and 28/152 (18%) unruptured arteriovenous malformations (AVMs), with the majority categorized as low-grade Spetzler-Martin grade I-II AVM (118/152 [78%]). Thirteen patients were excluded, leaving 139 patients for analysis. Embolization was performed prior to surgery in 78/139 (56%) patients. Surgical angiographic cure was obtained in 123/139 all-grade (89%, 95% CI 82%-93%) and 105/110 low-grade (95%, 95% CI 90%-98%) AVM patients. At the mean follow-up of 18.1 months, 16 patients (12%, 95% CI 7%-18%) had reached the primary safety outcome of mRS score > 2, including 11/16 who had a baseline mRS score ≥ 3 due to previous AVM rupture. Serious adverse events occurred in 29 patients (21%, 95% CI 15%-28%). Permanent treatment-related complications leading to mRS score > 2 occurred in 6/139 patients (4%, 95% CI 2%-9%), 5 (83%) of whom had complications due to preoperative embolization. CONCLUSIONS: The surgical treatment of brain AVMs in the TOBAS registry was curative in 88% of patients. The participation of more patients, surgeons, and centers in randomized trials is needed to definitively establish the role of surgery in the treatment of unruptured brain AVMs. Clinical trial registration no.: NCT02098252 (ClinicalTrials.gov).

Extended Endoscopic Endonasal Approach for a Giant Parasellar Epidermoid Cyst.

Epidermoid cysts are rare lesions which typically grow slowly. For this reason, these lesions are usually discovered when they are already very large. The parasellar location is no exception to this rule and may involve the cavernous sinus or the Meckel cave. We present a 34-year-old female patient without past medical history who was admitted in our tertiary referral center for episodes of diplopia in the right lateral gaze and right trigeminal dysesthesias. Brain magnetic resonance imaging (MRI) showed a large right parasellar mass with mixed intensity signal on the T1 and T2 sequences, without contrast enhancement and a typical hypersignal intensity on diffusion-weighted sequences evoking an epidermoid cyst. We discuss the radiologic criteria which differentiate the lesions originating in the cavernous sinus from those of the Meckel cave ( Figs. 1 and 2 ). Parasellar tumors may be approached through classical transcranial approaches such the epidural temporopolar or the subtemporal approach which involve a significant degree of brain retraction. The last decade witnessed the advent of extended endonasal approaches which offer an interesting alternative and avoid the manipulation of the brain. We used the endoscopic transpterygoid approach in our patient and we were able to achieve an excellent clinical and radiological result. We discuss the nuances of the technique and present the surgical steps of the procedure ( Figs. 3 and 4 ). The endoscopic endonasal approach represents an excellent therapeutic option for parasellar lesions. A thorough knowledge of the anatomy and experience with endoscopic techniques are obvious prerequisite. The link to the video can be found at: https://youtu.be/QonSvHrCwOU .

Microsurgical Clipping of Middle Cerebral Artery Aneurysms: Complications and Risk Factors for Complications.

OBJECTIVE: Middle cerebral artery aneurysms (MCAAs) have been considered good candidates for microsurgery. Our objective was to evaluate the risk of complications and the risk factors for complications with microsurgical treatment of MCAAs to better define the indications for microsurgery. METHODS: We conducted a retrospective cohort study from 3 tertiary neurosurgical units from January 2013 to May 2020. We evaluated the frequency of complications and searched for the risk factors for complications after microsurgery. Complications were defined as a composite criterion with the presence of one of the following: procedural-related death, symptomatic cerebral ischemia, impossible exclusion, incomplete exclusion, or rebleeding of the treated aneurysm and symptomatic surgical site hematoma. RESULTS: A total of 292 MCAAs were treated, with 29 complications (9.9%), including symptomatic cerebral ischemia (4.8%), aneurysm rebleeding (0.3%), surgical site hematoma (1.0%), impossible exclusion (0.3%), and incomplete exclusion (4.1%). Severe complications, defined as death or a modified Rankin scale score of ≥4 at 3 months, were infrequent, occurring in 7 of the 292 patients (2.4%). On multivariate analysis, the risk factors were a ruptured aneurysm, a larger maximum aneurysm size, a larger neck size, and arterial branches passing <1 mm from the aneurysm neck or dome. CONCLUSIONS: Microsurgical management of MCAAs can be performed with very low morbidity rates. In some cases, at least for factors that do not result in significant difficulty for endovascular therapy, such as the presence of an en passage artery or ruptured aneurysm, endovascular therapy can be considered to be as safe and effective as clipping.

Preservation of frontal white matter tracts in ventricular surgery: favoring an anterior interhemispheric transcallosal approach vs a transcortical transfrontal transventricular approach.

Secondary to the creation of a surgical corridor and retraction, white matter tracts degenerate, causing long-term scarring with potential neurological consequences. Third and lateral ventricle tumors require surgery that may lead to cognitive impairment. Our objective is to compare the long-term consequences of a transcortical transfrontal approach and an interhemispheric transcallosal approach on corpus callosum and frontal white matter tracts degeneration. Surgical patients with ventricular tumor accessible through both approaches were included and clinico-radiological data were retrospectively analyzed. The primary endpoint was the callosotomy length at 3-month post-operative T1 MRI, corrected by the extension of the tumor and the use of neuronavigation. Secondary outcomes included perioperative criteria such as bleeding, use of retractors and duration, FLAIR hypersignal on 3-month MRI, and re-do surgeries. To assess white matter tract interruption, 3-month FLAIR hypersignal was superposed to a tractography atlas. Seventy patients were included, 57 (81%) in the transfrontal group and 13 (19%) in the interhemispheric group. There was no difference in the mean callosotomy length on 3-month MRI (12.3 mm ± 5.60 transfrontal vs 11.7 mm ± 3.92 interhemispheric, p = 0.79) on univariate and multivariate analyses. The callosotomy length was inferior by - 3.13 mm for tumors located exclusively in the third ventricle (p = 0.016), independent of the approach. Retractors were used more often in transfrontal approaches (60% vs 33%, p < 0.001). The extent of frontal FLAIR hypersignal was higher after transfrontal approach (14.1 mm vs 0.525 mm, p < 0.001), correlated to the use of retractors (p < 0.05). After the interhemispheric approach, no tract other than corpus callosum was interrupted, whereas, after the transfrontal approach, frontal arcuate fibers and projections from the thalamus were interrupted in all patients, the cingulum in 19 (33%), the superior fronto-occipital fasciculus in 15 (26%), and the superior longitudinal fasciculus in 2 (3%). Transfrontal and interhemispheric approaches to the third and lateral ventricles both lead to the same long-term damage to the corpus callosum, but the transfrontal approach interrupts several white matter tracts essential to cognitive tasks such as attention and planning, even in the non-dominant hemisphere. These results encourage all neurosurgeons to be familiar with both approaches and favor the interhemispheric approach when both can give access to the tumor with a comparable risk. Neuropsychological studies are necessary to correlate these anatomical findings to cognitive outcomes.

Microsurgical Ligation of a Dural Arteriovenous Fistula of the Petrous Apex-A 2-Dimensional Operative Video.

Dural arteriovenous fistulas are rare acquired vascular lesions that represent 15% of the vascular malformations. While endovascular treatment has recently became the first line of treatment, microsurgical ligation may still be indicated in specific cases. We present the case of a 75-year-old patient who presented a progressive tetraparesis culminating in a spastic paraplegia and urinary retention. Cranial and spinal magnetic resonance imaging showed a T2 hypersignal in the cervical spinal cord and lower brainstem associated with flow voids in the subarachnoid space. Brain angiography demonstrated a dural arteriovenous fistula of the right petrous apex fed by the inferior lateral and meningohypophyseal trunks of the right cavernous internal carotid artery and draining in the lateral vein of the pons and the anterior medullary vein. Given the small size and tortuous feeders, endovascular treatment was considered too risky and microsurgical ligation was offered to the patient. The main issue of the microsurgical ligation of the dural arteriovenous fistula is the precise identification of the fistulous point, and therefore a detailed study of the specific vascular anatomy of the cerebellopontine angle is compulsory. Indocyanine green angiography plays a major role in confirming the location of the fistula and its correct occlusion. We discuss the technical nuances of the fistula ligation through a retrosigmoid approach and present Video 1 illustrating these principles. Given the retrospective nature of this report, informed consent was not required.

Middle Cerebral Artery Aneurysm Trial (MCAAT): A Randomized Care Trial Comparing Surgical and Endovascular Management of MCA Aneurysm Patients.

BACKGROUND: Whether the best management of middle cerebral artery (MCA) aneurysm patients is surgical or endovascular remains uncertain, with little evidence to guide decision-making. A randomized care trial offering MCA aneurysm patients a 50% chance of surgical and a 50% chance of endovascular management may optimize outcomes in the presence of uncertainty. METHODS: The Middle Cerebral Artery Aneurysm Trial (MCAAT) is an investigator-initiated, multicenter, parallel group, prospective, 1:1 randomized controlled clinical trial. All adult patients with MCA aneurysms, ruptured or unruptured, amenable to surgical and endovascular treatment can be included. The composite primary outcome is "Treatment Success": (i) occlusion or exclusion of the aneurysm using the allocated treatment modality; (ii) no intracranial hemorrhage during follow-up; (iii) no retreatment of the target aneurysm during follow-up, (iv) no residual aneurysm on angiographic follow-up; and (v) independence (mRS <3) at 1 year. The trial tests 2 versions of the same hypothesis (one for ruptured and one for unruptured MCA aneurysm patients): Surgical management will lead to a 15% absolute increase in the proportion of patients reaching Treatment Success from 55% to 70% (ruptured) or from 75% to 90% (unruptured aneurysm patients) compared with endovascular treatment (any method). In this pragmatic trial, outcome evaluations are by treating physicians, except for 1-year angiographic results which will be core lab assessed. The trial will be monitored by an independent data safety monitoring committee to assure safety of participants. MCAAT is registered at clinicaltrials.gov: NCT05161377. CONCLUSIONS: Patients with MCA aneurysms can be optimally managed within a care trial protocol.

Interhemispheric transcallosal approach: going further based on the vascular anatomy.

Preserving cortical frontal bridging veins draining into the superior sagittal sinus is a factor of good neurological outcome in anterior interhemispheric transcallosal approaches, classically performed to reach intraventricular tumors. Challenging the idea that veins are utterly variable, we propose a statistical analysis of 100 selective cerebral angiographies to determine where to place the craniotomy in order to expose the most probable vein-free area. The mean distance to the first pre-coronal vein was 6.66 cm (± 1.73, 1.80 to 13.00) and to the first post-coronal vein 0.94 cm (± 0.92, 0 to 3.00) (p < 0.001). The probability of absence of bridging veins was 92.0% at 4 cm anterior to the coronal suture versus 37.5% at 1 cm and 12.5% at 2 cm posteriorly. The length of the surgical corridor (distance between the first pre-coronal and post-coronal vein) was 7.60 cm (± 1.72, 3.00 to 14.10). Overall, the ideal centering point of the craniotomy was 2.86 cm (± 1.08, - 0.65 to 6.50) ahead of the coronal suture. The mean number of veins within 6 cm behind the coronal suture was 8.47 (± 2.11, from 3 to 15) versus 0.530 (± 0.82, from 0 to 3) ahead of the coronal suture (p < 0.001). These findings support a purely pre-coronal 5 cm craniotomy for interhemispheric approaches.

Posterior Midline Approach for a C2 Schwannoma: 2-Dimensional Operative Video.

C2 schwannomas are rare lesions that may develop in the spinal canal, in the area of the C2 ganglion situated posterior to the C1C2 articulation, in the extraspinal area or in a combination of these 3 sectors.1,2 The surgical removal of these lesions is delicate because of the intimate relationships the schwannomas develop with the V3 segment of the vertebral artery. A variety of lateral, far-lateral, or extreme lateral approaches have been described in order to tackle these lesions. We use a posterior midline approach that takes advantage of the predominantly extradural development of C2 schwannomas. In this technique, the main step is the debulking of the posterior articular sector of the tumor, which is easily accessible through a midline posterior approach and necessitates minimal bone removal. In most cases, removal of the homolateral posterior arch of C1 is sufficient in order to create an adequate access. These maneuvers create the necessary space for dissecting both the intradural and extraspinal sectors of the schwannoma. We present this technique through a case with a minimal intradural component exerting mainly a lateral compression of the spinal cord. The tumor was operated through the midline mini-invasive posterior approach with a favorable result. We demonstrate the surgical technique in video and discuss the nuances.

Multimodal Management of a Ruptured Right Medial Parietal Arteriovenous Malformation: 2-Dimensional Operative Video.

Arteriovenous malformations (AVM) of the medial surface of the cerebral hemispheres are challenging because of the limited access to the interhemispheric fissure, the presence of the bridging veins, and the difficult control of arterial feeders and deep venous drainage. We present a 20-yr-old patient with a grade 3 Spetzler Martin ruptured right medial parietal AVM revealed by headaches, left hemiparesis, and ataxia. We highlight the importance of a detailed and selective study of AVM angioarchitecture with new sequences as XperCT (Philips Medical) viewing which permits a better understanding of the anatomy and pathology and a better therapeutical planning. Selective embolization of arterial feeders with Glubran2 (GEM) allows a better control of selected sectors of the AVM which may be difficult to access at surgery. This type of planning is especially important when the AVM is in close relationship with an important sulcus, as was the case of this patient whose AVM was adherent to the postcentral sulcus. We present the surgical nuances concerning patient positioning, craniotomy, AVM dissection, and resection. Early identification and interruption of the main arterial feeders facilitate further dissection. We discuss the timing of deep venous drainage interruption in AVMs with mixed superficial and deep venous drainage. The postoperative course was favorable and the postoperative angiogram showed complete resection of the AVM. At the last follow-up, the patient had only slight left ataxia. Multimodal management with planned selective embolization may facilitate microsurgical resection of AVMs. Given the retrospective nature of this report, informed consent was not required.

Chordoid Glioma Infiltrating Optic Structures.

Chordoid glioma of the third ventricle (CGTV) is a rare, slow-growing, World Health Organization Grade II glial tumor, with stereotyped localization in the anterior third ventricle. Despite being considered a noninvasive tumor, CGTV is usually associated with a poor clinical outcome due to its close proximity to important cerebral structures, such as the hypothalamus and visual pathways. Our patient with CGTV experienced visual involvement, but after subtotal surgical resection showed no evidence of progression at 5-year follow-up.

Multiple Aneurysms Clipping Through the Eyebrow Approach: 2-Dimensional Operative Video.

The eyebrow approach is a versatile technique that may apply to various vascular and tumoral pathologies of the anterior skull base. We present a case of multiple aneurysms clipping through the eyebrow approach and we discuss the nuances of this technique. A 44-yr-old patient presented with incidentally found aneurysms. Angiography showed 2 4.5-mm aneurysms on the left middle cerebral artery (MCA) and internal carotid artery (ICA) bifurcations. At surgery, the patient is positioned supine with the head elevated, slightly rotated, and extended in order to obtain good access and gravity retraction of the brain. A 3-cm incision is placed in the eyebrow and a small supraorbital bone flap is raised. The floor of the orbit and the edges of the craniotomy are thoroughly drilled in order to maximize the working space. After dural opening, the sylvian fissure was widely dissected and the MCA aneurysm was identified. A large opening of the sylvian and carotid cistern allows retractor free surgery. The ICA bifurcation aneurysm is then dissected and clipped. The MCA aneurysm is treated last in order to avoid a conflict between instruments especially during clipping. Aneurysms occlusion and vessel permeability is verified by Doppler ultrasonography and indocyanine green (ICG) angiography. After achieving hemostasis, the dura is closed and a subcuticular continuous suture is used at the skin. The postoperative course was uneventful. The eyebrow approach allows simultaneous treatment of multiple aneurysms of the anterior circle of Willis in selected cases. Proper positioning, drilling of the orbital floor and extensive arachnoid dissection are the key steps of this procedure.