Transarterial Embolization of Dural Arteriovenous Fistulas: Conventional, Pressure Cooker, and Microballoon Catheter Embolization Techniques.

BACKGROUND AND OBJECTIVES: Dural fistulas are abnormal connections between dural arteries and intracranial veins treated mainly endovascularly in most settings. The aim was to examine a single-institution experience of microballoon catheter transarterial embolization (TAE) of dural arteriovenous fistulas (dAVFs) and compare it with other TAE techniques. METHODS: We retrospectively identified all dAVFs treated at our institution between 2017 and 2022 with microballoon, conventional, and pressure cooker TAE. We studied occlusion and retreatment rates, treatment-related complications, and radiation doses. RESULTS: During the study period, 66 patients underwent 75 TAE procedures to treat 68 dAVFs: 47 conventional TAE, 14 pressure cooker TAE, and 14 microballoon TAE. Median age of the study population was 63 years with 32% females. The most common dAVF location was the transverse sinus and 20% of dAVFs presented with hemorrhage. At 3-month follow-up, stable complete occlusion of the dAVF was seen in 72% (n = 34) after conventional TAE, 79% (n = 11) after pressure cooker TAE, and 86% (n = 12) after microballoon TAE. Retreatment was required in 19% (n = 9) after conventional TAE, 7% (n = 1) after pressure cooker TAE, and 7% (n = 1) after microballoon TAE. Treatment-related complications occurred in 17% (n =) after conventional TAE, 29% (n = 4) after pressure cooker TAE, and 7% (n = 1) after microballoon TAE. CONCLUSION: In our experience, microballoon TAE of dAVFs resulted in better initial and 3-month angiographic outcomes and required less retreatment than conventional TAE. Microballoon TAE also resulted in fewer treatment-related complications than other techniques. In our experience, microballoon TAE is a reliable and safe endovascular technique to treat dAVFs.

The Lateral Supraorbital Approach: 2-Dimensional Operative Video.

INDICATIONS: The lateral supraorbital approach (LSO), a minimally invasive alternative to the pterional approach, can be used for anterior circulation aneurysms (except distal anterior cerebral artery), some posterior circulation aneurysms, and tumors located around the sellar and suprasellar regions. ANATOMIC ESSENTIALS: Performing one-layer myocutaneous flap that is retracted anteriorly, exposure of the superior temporal line, and zygomatic process of the frontal bone and the inferior limit of the craniotomy represent the upper edge of the Sylvian fissure, exposing the anterolateral skull base. ESSENTIALS STEPS: Skin incision behind the hairline, one-layer myocutaneous flap retracted anteriorly, minimal detachment of the temporalis muscle, burr hole over the superior temporal line, and craniotomy of 4 cm in diameter (inferior limit of the craniotomy represents the Sylvian fissure). PITFALLS/AVOIDANCE OF COMPLICATIONS: Potential risks include opening of the frontal sinus, entering the orbit and exposure of the orbital fat, wrong craniotomy location, and limited exposure. Inadequate craniotomy size limits instruments maneuverability. To avoid complication, identification of anatomic landmarks, sinus closure, preoperative evaluation of computed tomography scans, and use of neuronavigation are necessary. This requires surgical expertise and familiarity of minimal invasive craniotomies. VARIANTS/REASONS: Anatomic limitations of the LSO include temporomesial region, distal Sylvian +/-, posterior communicating artery aneurysms medial projection, retro carotid space, and carotid cave. For pathologies requiring an additional lateral trajectory, we use an extended LSO, drilling the sphenoid wing through the fronto-pterio-orbital window without drilling of the temporal bone. Additional variations include performing an intradural or extradural clinoidectomy. The patient consented to the procedure and to the publication of their image.

Intraoperative intraarterial indocyanine green video-angiography for disconnection of a perimedullary arteriovenous fistula: illustrative case.

BACKGROUND: Intraarterial (IA) indocyanine green (ICG) angiography is an intraoperative imaging technique offering special and temporal characterization of vascular lesions with very fast dye clearance. The authors' aim is to demonstrate the use of IA ICG angiography to aid in the surgical treatment of a perimedullary thoracic arteriovenous fistula (AVF) in a hybrid operating room (OR). OBSERVATIONS: A 31-year-old woman with a known history of spinal AVF presented with 6 weeks of lower-extremity weakness, gait imbalance, and bowel/bladder dysfunction. Magnetic resonance imaging revealed an extensive series of flow voids across the thoracic spine, most notably at T11-12. After partial embolization, she was taken for surgical disconnection in a hybrid OR. Intraoperative spinal digital subtraction angiography was performed to identify feeding vessels. When the target arteries were catheterized, 0.05 mg of ICG in 2 mL of saline was injected, and the ICG flow in each artery was recorded using the microscope. With an improved surgical understanding of the contributing feeding arteries, the authors achieved complete in situ disconnection of the AVF. LESSONS: IA ICG angiography can be used in hybrid OR settings to illustrate the vascular anatomy of multifeeder perimedullary AVFs and confirm its postoperative disconnection with a fast dye clearance.

Difference in Clinical Phenotype, Mutation Position, and Structural Change of RNF213 Rare Variants Between Pediatric and Adult Japanese Patients with Moyamoya Disease.

It is unclear how rare RNF213 variants, other than the p.R4810K founder variant, affect the clinical phenotype or the function of RNF213 in moyamoya disease (MMD). This study included 151 Japanese patients with MMD. After performing targeted resequencing for all coding exons in RNF213, we investigated the clinical phenotype and statistically analyzed the genotype-phenotype correlation. We mapped RNF213 variants on a three-dimensional (3D) model of human RNF213 and analyzed the structural changes due to variants. The RNF213 p.R4810K homozygous variant, p.R4810K heterozygous variant, and wild type were detected in 10 (6.6%), 111 (73.5%), and 30 (19.9%) MMD patients, respectively. In addition, 15 rare variants were detected in 16 (10.6%) patients. In addition to the influence of the p.R4810K homozygous variant, the frequency of cerebral infarction at disease onset was higher in pediatric patients with other rare variants (3/6, 50.0%, P = 0.006) than in those with only the p.R4810K heterozygous variant or with no variants (2/51, 3.9%). Furthermore, on 3D modelling of RNF213, the majority of rare variants found in pediatric patients were located in the E3 module and associated with salt bridge loss, contrary to the results for adult patients. The clinical phenotype of rare RNF213 variants, mapped mutation position, and their predicted structural change differed between pediatric and adult patients with MMD. Rare RNF213 variants, in addition to the founder p.R4810K homozygous variant, can influence MMD clinical phenotypes or structural change which may contribute to the destabilization of RNF213.

Anatomical considerations regarding a high-flow arteriovenous fistula below the conus medullaris in a patient with hereditary hemorrhagic telangiectasia: Case report.

BACKGROUND AND IMPORTANCE: Cauda equina radicular arteriovenous fistulas are rare "low flow" shunting lesions characterized by direct communication between the radicular artery and vein of a cauda equina nerve root. None have been associated with hereditary hemorrhagic telangiectasia and a high-flow cauda equina radicular arteriovenous fistula has never been reported. We present a unique case of a high-flow cauda equina radicular arteriovenous fistula in a patient with hereditary hemorrhagic telangiectasia. Marked flow-induced vascular remodeling posed significant diagnostic and therapeutic challenges which will be highlighted in this report. CLINICAL PRESENTATION: A 39-year-old female with genetically confirmed hereditary hemorrhagic telangiectasia presented with progressive thoracic myelopathy secondary to a high-flow single-hole arteriovenous fistula below the conus. The feeding artery, arising from the anterior spinal artery, and draining vein had a paramedian course, favoring the diagnosis of a cauda equina radicular arteriovenous fistula (supplied by a proximal radicular artery) over a filum terminale arteriovenous fistula. Transarterial embolization was attempted but significant elongation and tortuosity of the anterior spinal artery precluded microcatheter access to the fistulous point. Surgical disconnection was successfully performed. The intraoperative findings supported the diagnosis of cauda equina radicular arteriovenous fistula. Delayed neurologic deterioration secondary to overshooting venous thrombosis was observed. She recovered after the initiation of therapeutic anticoagulation. CONCLUSION: To the best of our knowledge, we hereby report the first high-flow cauda equina radicular arteriovenous fistula. The accurate differentiation of cauda equina radicular arteriovenous fistula from filum terminale arteriovenous fistulas, while challenging, is important to avoid treatment-related complications. Careful preoperative planning, the use of specialized endovascular and surgical techniques, and meticulous postoperative care can ensure the safe and complete disconnection of high-flow cauda equina radicular arteriovenous fistulas.

A meta-analysis of Lateral supraorbital vs mini Pterional approach in the outcome of rupture and unruptured noncomplex aneurysms’ surgery / Metaanálisis entre el abordaje subfrontal y minipterional en los aneurismas cerebrales no complejos

To determine the characteristics and to compare the functional outcomes and safety of different subfrontal approaches versus mini Pterional (MPT) approaches mainly for the treatment of ruptured noncomplex intracranial aneurysms. This meta-analysis included articles comparing outcomes of brain aneurysms (BAs) – most for the anterior circulation–, using Lateral supraorbital & Supraorbital keyhole (LSO) versus MPT approach. There were six articles left into the final article pool and the total number of patients was 683 (322 in LSO and 361 in the MPT group). In terms of the early and late time of surgery, the LSO seems to be superior over the MPT approach but with heterogeneity (OR −0.21, CI 95% −0.59 to 0.18, and p=0.04) or (OR −0.21, CI 95% −0.69 to 0.28, and p=0.05), and (p=0.02 and I2=68.97%) or (p=0.05 and I2=61.74%) respectively. Regarding the subgroup of patients with the supra-early time of surgery, surgical duration, completed occlusion, technical intraoperative complications, postoperative infection, intraoperative rupture, vasospasm, good and poor neurological outcomes and clinical deterioration, there was no superiority of the one method over the other. Mini or keyhole craniotomy even challenging might be a good option for neurosurgeons. Particularly in ruptured noncomplex aneurysms’ surgery LSO seems to be superior over the MPT approach in terms of the early time and in the late time of surgery but with heterogeneity (AU)

Determinar las características, comparar los resultados funcionales y la seguridad de los diferentes abordajes subfrontales vs. los abordajes minipterionales (MPT) en el tratamiento principalmente de aneurismas intracraneales rotos. Este metaanálisis incluye artículos que comparan los resultados quirúrgicos de los aneurismas cerebrales (mayoría de circulación anterior), utilizando un abordaje supraorbitario o supraorbitario lateral (LSO) frente un abordaje MPT. En el análisis quedaron seis artículos con un número total de pacientes de 683 (322 en el grupo LSO y 361 en el MPT). En cuanto al tiempo de cirugía precoz y tardío de la cirugía, el LSO parece ser superior al abordaje MPT pero con heterogeneidad (OR -0.21, IC 95% -0.59 - 0.18, y p = 0,04) o (OR -0,21, IC 95% -0,69 - 0,28, y p = 0,05), y (p = 0,02 e 12 = 68,97%) o (p = 0,05 e 12 = 61,74%), respectivamente. En cuanto al subgrupo de pacientes con tiempo de cirugía supraprecoz, la duración quirúrgica, la oclusión completa, las complicaciones técnicas intraoperatorias, la infección postoperatoria, la rotura intraoperatoria, el vasoespasmo, los resultados neurológicos y el deterioro, no hubo diferencias en superioridad de un método sobre el otro. Los resultados muestran que tanto la craneotomía MPT como el LSO, podrían ser una buena opción. Particularmente en la cirugía de aneurismas rotos no complejos el abordaje LSO parece ser superior al abordaje MPT en términos del momento inicial y tardío de la cirugía, aunque existe una heterogeneidad en los resultados (AU)

Application of protective superficial temporal artery to middle cerebral artery bypass through the lateral supraorbital approach: Technical note.

OBJECTIVE: The lateral supraorbital (LSO) approach is a minimally invasive craniotomy widely used in the surgical treatment of intracranial aneurysms (IAs). A protective bypass is considered a safety measure in high-risk and complex clipping procedures to maintain distal cerebral flow. However, the protective bypass has so far only been applied through a pterional or larger craniotomy. We aimed to describe the characteristics of the superficial temporal artery to middle cerebral artery (STA-MCA) bypass through the LSO craniotomy to treat complex IAs. METHODS: We retrospectively identified six patients with complex IAs who underwent clipping and a protective STA-MCA bypass through the LSO approach between January 2016 and December 2020. The STA donor artery was harvested through the same curvilinear skin incision with a small extension, and it was anastomosed to the opercular segment of the MCA. Subsequently, aneurysm clipping followed standardized steps. RESULTS: Anastomosis was successful in all patients. Despite requiring temporary occlusion of the parent artery, all aneurysms were successfully clipped without any neurological deterioration. CONCLUSIONS: A protective STA-MCA bypass is feasible through the LSO approach with certain technical modifications. This technique helps protect distal cerebral flow for safe clip placement in the treatment of complex IAs with the associated benefits of a less invasive craniotomy.

Case Report: Curative effect of OA-PICA protected bypass in severe PICA-complicated vertebral artery stenosis treatment: Results in 3 cases.

Objectives: We aimed to explore the results of OA-PICA-protected bypass grafting in patients with severe stenosis of the vertebral artery combined with PICA. Methods: Three patients with vertebral artery stenosis involving the posterior inferior cerebellar artery, treated by the Department of Neurosurgery of Henan Provincial People's Hospital from January 2018 to December 2021, were retrospectively analyzed. All the patients underwent Occipital Artery-Posterior Inferior Cerebellar Artery (OA-PICA) bypass surgery followed by elective vertebral artery stenting. Intraoperative indocyanine green fluorescence angiography (ICGA) showed patency of the bridge-vessel anastomosis. Postoperatively, the ANSYS software was used to assess the flow pressure changes and vascular shear in combination with the reviewed DSA angiogram. CTA or DSA was reviewed 1-2 years postoperatively, and the prognosis was evaluated by the modified Rankin Scale (mRS) one year postoperatively. Results: OA-PICA bypass surgery was completed in all patients, with intraoperative ICGA showing a patent bridge anastomosis, followed by stenting of the vertebral artery, and a review of the DSA angiogram. We also employed ANSYS software evaluation of the bypass vessel, which showed stable pressure and low turnover angle, suggesting a low rate of long-term occlusion of the vessel. All patients had no procedure-related complications during their hospitalization, and were followed up for a mean of 24 months postoperatively, with a good prognosis (mRS score of 1) at 1 year postoperatively. Conclusion: OA-PICA-protected bypass grafting is an effective treatment for patients with severe stenosis of the vertebral artery combined with PICA.

A meta-analysis of Lateral supraorbital vs mini Pterional approach in the outcome of rupture and unruptured noncomplex aneurysms' surgery.

To determine the characteristics and to compare the functional outcomes and safety of different subfrontal approaches versus mini Pterional (MPT) approaches mainly for the treatment of ruptured noncomplex intracranial aneurysms. This meta-analysis included articles comparing outcomes of brain aneurysms (BAs) - most for the anterior circulation-, using Lateral supraorbital & Supraorbital keyhole (LSO) versus MPT approach. There were six articles left into the final article pool and the total number of patients was 683 (322 in LSO and 361 in the MPT group). In terms of the early and late time of surgery, the LSO seems to be superior over the MPT approach but with heterogeneity (OR -0.21, CI 95% -0.59 to 0.18, and p=0.04) or (OR -0.21, CI 95% -0.69 to 0.28, and p=0.05), and (p=0.02 and I2=68.97%) or (p=0.05 and I2=61.74%) respectively. Regarding the subgroup of patients with the supra-early time of surgery, surgical duration, completed occlusion, technical intraoperative complications, postoperative infection, intraoperative rupture, vasospasm, good and poor neurological outcomes and clinical deterioration, there was no superiority of the one method over the other. Mini or keyhole craniotomy even challenging might be a good option for neurosurgeons. Particularly in ruptured noncomplex aneurysms' surgery LSO seems to be superior over the MPT approach in terms of the early time and in the late time of surgery but with heterogeneity.

Corrigendum: Clinical value and prognosis of C reactive protein to lymphocyte ratio in severe aneurysmal subarachnoid hemorrhage.

[This corrects the article DOI: 10.3389/fneur.2022.868764.].

Risk factors and predictive models of poor prognosis and delayed cerebral ischemia in aneurysmal subarachnoid hemorrhage complicated with hydrocephalus.

Objective: To evaluate the correlation of serum biological markers and related scales to the occurrence of delayed cerebral ischemia and clinical prognosis in patients with aneurysmal subarachnoid hemorrhage (aSAH) complicated with acute hydrocephalus before admission. Methods: The clinical data of 227 patients with pre-admission aSAH complicated with acute hydrocephalus admitted to Henan Provincial People's Hospital from April 2017 to December 2020 were retrospectively analyzed. Patients were grouped according to the presence or absence of delayed cerebral ischemia (DCI) after surgery and the prognosis at 6 months after discharge. Univariate and multivariable logistic regression analysis were performed to analyze the relationship between serum biological indicators combined with aneurysm related clinical score scale and the occurrence and prognosis of delayed cerebral ischemia. ROC curves and nomogram were drawn. Results: Multivariable Logistic regression analysis showed that high Hunt-Hess grade and surgical clipping were independent risk factors for postoperative DCI (P < 0.05). Older age, higher Hunt-Hess grade, higher CRP and neutrophil levels were independent risk factors for poor prognosis at 6 months after surgery (P < 0.05). ROC curve analysis showed that the area under the curve (AUC) of Hunt-Hess grade and surgical method for predicting DCI in patients with aSAH combined with hydrocephalus after surgery were 0.665 and 0.593. The combined AUC of Hunt-Hess grade and surgical method was 0.685, the sensitivity was 64.9%, and the specificity was 64.7%. The AUC of CRP, neutrophil, age and Hunt-Hess grade for predicting poor prognosis in patients with aSAH combined with hydrocephalus at 6 months after surgery were 0.804, 0.735, 0.596, 0.757, respectively. The combined AUC of CRP, neutrophil, age, Hunt-Hess grade was 0.879, the sensitivity was 79%, and the specificity was 84.5%. According to the correction curve, the predicted probability of the nomogram is basically consistent with the actual probability. Conclusion: Hunt-Hess grade and surgical method are independent predictors of postoperative DCI in patients with aSAH complicated with hydrocephalus. "CRP," "neutrophil," "age" and "Hunt-Hess grade" at admission are independent predictors of clinical prognosis in patients with aSAH complicated with hydrocephalus. The combination of the above indicators has high predictive value.

Clinical Value and Prognosis of C Reactive Protein to Lymphocyte Ratio in Severe Aneurysmal Subarachnoid Hemorrhage.

Objective: To investigate the relationship between CLR and disease severity and clinical prognosis of aSAH. Methods: The authors retrospectively analyzed the clinical data of 221 patients with aSAH, who were admitted to the intensive care unit from January 2017 to December 2020. The indicators of inflammatory factors in the first blood routine examination within 48 h of bleeding were obtained. The prognosis was evaluated by mRS score at discharge, mRS>2 was a poor outcome. Through the receiver operating characteristic (ROC) curve, the area under the curve was calculated and the predicted values of inflammatory factors (CLR, CRP, WBC, and neutrophils) were compared. Univariate and multivariable logistic regression analyses were used to evaluate the relationship between CLR and the clinical prognosis of patients. ROC curve analysis was performed to determine the optimal cut-off threshold, sensitivity, and specificity of CLR in predicting prognosis at admission. Results: According to the mRS score at discharge, 139 (62.90%) patients were classified with poor outcomes (mRS>2). The inflammatory factor with the best predictive value was CLR, which had an optimal cut-off threshold of 10.81 and an area under the ROC curve of 0.840 (95%CI.788-0.892, P < 0.001). Multivariable Logistic regression analysis showed that the Modified Fisher grade, Hunt-Hess grade, and CLR at admission were independent risk factors for poor outcomes of patients with aSAH (P < 0.05). According to Hunt-Hess grade, patients were divided into a mild group (Hunt-Hess ≤ 3) and a severe group (Hunt-Hess > 3), and the CLR value was significantly higher in severe patients with aSAH than in mild patients. The optimal cut-off threshold of CLR in the severe group was 6.87, and the area under the ROC curve was 0.838 (95% CI.752-0.925, P < 0.001). Conclusions: The CLR value at the admission of patients with aSAH was significantly associated with Hunt-Hess grade, The higher Hunt-Hess grade, the higher the CL R-value, and the worse the prognosis. Early CLR value can be considered as a feasible biomarker to predict the clinical prognosis of patients with aSAH.

Coagulation Technique for Remodeling Anastomosis Spaces in Bypass Surgery.

Cerebrovascular bypass techniques are the current cornerstone methods to achieve cerebral revascularization for moyamoya disease or syndrome and select cases of vascular pathologies, such as intracranial atherosclerotic occlusive disease and complex aneurysms. Factors influencing bypass efficiency include graft patency, short temporary occlusion time, and precise anastomosis. On the basis of our senior author's vast experience with 1300 bypasses, we recommend performing the anastomosis with the minimal number of stitches as achievable to avoid stenosis of the artery's internal lumen that may occur with unnecessary, additional stitches, preserving patency. After completing the anastomosis, when a leak occurs between the sutures, cottonoid tamponade, hemostatic materials, or adding 1 or 2 sutures to the space is often enough to close the gap. However, additional suture placement can be difficult, which might cause stenosis of the anastomosis and reduce blood flow. In this video, we introduce a bipolar coagulation technique for remodeling the anastomosis orifices, as an alternative manner, when minor leakages occur between the knots (Video 1). We demonstrate this technique in an adult moyamoya disease patient who underwent a superficial temporal artery-to-middle cerebral artery bypass, in this case coagulation of the donor artery wall at the anastomosis made possible to adapt the edges of the donor artery precisely to the recipient artery wall by shrinking its redundancy between the stitches. The most important task is to coagulate the donor side orifice precisely with low-power bipolar coagulation and never coagulate the recipient artery. This coagulation technique is a simple alternative to stop further leakage, and it prevents placing an additional suture and reduces temporary occlusion time.

Post-traumatic brain injury glioma: Characteristics, report of 2 cases report and literature review.

BACKGROUND: Traumatic brain injury (TBI) as a pathogenetic factor in glioma remains controversial, and currently there is still no clear mechanism behind post-TBI glioma. Thus, we provide two case reports of post-TBI glioma contributing power to this research, and we provide a summary of the mechanisms of post-TBI glioma through literature review. METHODS: We report two cases of brain gliomas that developed in the scar of a previous brain trauma. Both patients were male and both had suffered prior traumatic brain injuries (time interval 10-20 years), and postoperative pathological findings reported glioblastoma and WHO grade III glioma, respectively. RESULTS: These two cases further support the association of between traumatic brain injury and gliomas development. CONCLUSION: Although the epidemiological investigation between TBI and glioma is still controversial, there are still some important aspects here that can determine the possibility between TBI and gliomagenesis. Besides, we found that the reparative response of neural stem cells and the dysregulation of inflammatory cells are timportant theories of the mechanism of post-TBI glioma.

Occlusion of the Anterior Cerebral Artery Mimicking a Cerebral Aneurysm: Clinical Presentation and Literature Review.

BACKGROUND: Intracranial aneurysms may be misdiagnosed with other vascular lesions such as vascular loops, infundibulum, or the stump of an occluded artery (very rare and reported compromising only the middle cerebral artery and the posterior circulation territory). Our aim was to describe a unique case of occlusion of an anterior cerebral artery mimicking a cerebral aneurysm in a probable moyamoya disease patient, and to highlight its clinical presentation, diagnosis, and management, and to perform an extensive literature review. CASE: A 67-year-old man suffering from recurrent dizziness for 3 months. Previous medical history was unremarkable. Brain magnetic resonance angiography (MRA) and digital subtraction angiography (DSA) demonstrated occlusion of the right middle cerebral artery (MCA) associated with a "probable moyamoya disease" and an aneurysm-like shadow protruding lesion at the anterior communicating artery (AcomA). Perfusion images showed ischemia along the right temporo-occipital lobe. Due to MCA occlusion with perfusion deficits and unspecific symptoms, we offered a right side encephalo-duro-myo-synangiosis (EDMS) and clipping of the AcomA aneurysm in one session. Intraoperatively, there was no evidence of the AcomA aneurysm; instead, this finding corresponded to the stump of the occluded right anterior cerebral artery (A1 segment). This segment appeared to be of yellowish color due to atherosclerosis and lacked blood flow. The patient underwent as previously planned a right side EDMS and the perioperative course was uneventful without the presence of additional ischemic attacks. CONCLUSION: Arterial branch occlusions can sometimes present atypical angiographic characteristics that can mimic a saccular intracranial aneurysm. It is relevant to consider this radiographic differential diagnosis, especially when aneurysm treatment is planned.

Surgical treatment of brainstem cavernous malformations: an international Delphi consensus.

OBJECTIVE: Indication for surgery in brainstem cavernous malformations (BSCMs) is based on many case series, few comparative studies, and no randomized controlled trials. The objective of this study was to seek consensus about surgical management aspects of BSCM. METHODS: A total of 29 experts were invited to participate in a multistep Delphi consensus process on the surgical treatment of BSCM. RESULTS: Twenty-two (76%) of 29 experts participated in the consensus. Qualitative analysis (content analysis) of an initial open-ended question survey resulted in 99 statements regarding surgical treatment of BSCM. By using a multistep survey with 100% participation in each round, consensus was reached on 52 (53%) of 99 statements. These were grouped into 4 categories: 1) definitions and reporting standards (7/14, 50%); 2) general and patient-related aspects (11/16, 69%); 3) anatomical-, timing of surgery-, and BSCM-related aspects (22/37, 59%); and 4) clinical situation-based decision-making (12/32, 38%). Among other things, a consensus was reached for surgical timing, handling of associated developmental venous anomalies, handling of postoperative BSCM remnants, assessment of specific anatomical BSCM localizations, and treatment decisions in typical clinical BSCM scenarios. CONCLUSIONS: A summary of typical clinical scenarios and a catalog of various BSCM- and patient-related aspects that influence the surgical treatment decision have been defined, rated, and interpreted.

Case Report: Internal Carotid Artery Thrombosis: A Rare Complication After Fibrin Glue Injection for Cavernous Sinus Hemostasis.

Background: Fibrin glue injection within the cavernous sinus (CS) is a demonstrably safe and simple technique to control venous bleeding with a low complication rate. However, this technique does have inherent risks. We illustrate 2 cases of internal carotid artery (ICA) thrombosis after fibrin glue injection in the CS for hemostasis. Methods: After encountering this complication recently, we conducted a retrospective review of the surgical database of 2 senior neurosurgeons who specialize in cerebrovascular and skull base surgery to identify patients with any complications associated with the use of fibrin glue injection for hemostasis. Approval was given by respective institutional review boards, and patient consent was obtained. Results: Of more than 10,000 microsurgery procedures performed by 2 senior neurosurgeons with a combined experience of 40 years, including procedures for aneurysms and skull base tumors, 2 cases were identified involving ICA thrombosis after fibrin glue injection in the CS for hemostasis. Both cases involved severe ischemic complications as a result of the ICA thrombosis. In this article, we present their clinical presentation, characteristics, management, and outcomes. Conclusion: Direct injection of fibrin glue into the CS for hemostasis can effectively control venous bleeding and facilitate complex dissections. However, it can be associated with ICA thrombosis, with subsequent serious ischemia and poor prognosis. Although this complication appears to be rare, increased awareness of this problem should temper the routine use of fibrin glue in anterior clinoidectomy and transcavernous approaches.

Safety and Efficacy of Coils in Conjunction With the Pipeline Flex Embolization Device for the Treatment of Cerebral Aneurysms.

Background: Flow diverters (FD) have shown promising results in the treatment of intracranial aneurysms (IAs). However, there is still controversy whether pipeline flex embolization device (PED flex)-assisted coils can facilitate the curing of aneurysms. Our aim was to assess the safety and effectiveness of PED flex adjunctive with coils (PED flex + coil) in the treatment of IAs. Method: Patients who underwent PED flex treatment in combination with coiling between January 2018 and June 2020 were included in this study. The clinical and radiographic characteristics before and after treatments were retrospectively evaluated. The study cohort comprised of 125 patients with 140 IAs, which was subdivided into two subgroups: one group included patients treated only through PED alone, and the other group included patients treated through PED flex adjunctive with coil. Patient baseline characteristics, aneurysm characteristics, treatment-related factors, and outcomes were analyzed to determine the effectiveness of both techniques. Results: Aneurysms in the PED flex + coil group were larger (10.0 ± 5.8 mm, P < 0.001) and wider (7.2 ± 4.6 mm, P = 0.002) compared with those in the PED flex group. There was no statistical difference in the perioperative complication rate between the two groups. The overall complete occlusion rate was 75.7% at 6.2 months, with 71.7% at 6.2 ± 1.7 months in the PED flex group and 85.4% at 6.2 ± 1.8 months in the PED flex + coil group, respectively. A higher percentage of satisfactory angiography results was found in the PED flex + coil group during follow-up (92.7 vs. 78.8%, P = 0.047). Conclusion: PED flex placement with adjunctive coil embolization represents a safe alternative option for the treatment of IAs. In these cases, coil embolization increases the occlusion rate in PED flex-treated patients without increasing the periprocedural complications.

Outcome in Patients with Spinal Cavernomas Presenting with Symptoms Due to Mass Effect and/or Hemorrhage: Conservative versus Surgical Management: Meta-analysis of Direct Comparison of Approach-Related Complications.

OBJECTIVE: We sought to examine the conservative treatment of symptomatic spinal cavernomas and evaluate the efficacy and safety of surgical management of spinal cord cavernous malformations. METHODS: This meta-analysis included articles comparing outcomes of conservative treatment and surgical management of spinal cavernomas, published in the full-text form (from 2000 to June 31, 2020). Collected variables included first author name, country, covered study period, publication year, the total number of patients and at follow-up, bleeding, motor weakness, pain, bladder and/or bowel dysfunction neurologic improvement or deterioration after discharge, and the need for reintervention after subtotal surgical resection or hemorrhage. RESULTS: After the initial searching and applying all exclusion and inclusion criteria, there were 9 articles left in the final article pool. The total number of patients was 396 with 264 (66.6%) undergoing surgical resection and 132 (33.4%) electing conservative management. Regarding motor weakness, bladder/bowel dysfunction, deterioration, and reintervention, the final results demonstrated no potential significant difference between the 2 groups. In regard to the subgroup of patients with bleeding, improvement, and pain, the results of the analysis showed a statistically significant difference between the 2 groups. CONCLUSIONS: Patients who have experienced a hemorrhagic episode should consider surgical intervention, which decreases the risk of recurrent hemorrhage and further neurologic deterioration. In addition, surgical decompression obtained by resection of the hemorrhage and cavernoma seems to lead to slight neurologic improvement in some patients. In nonhemorrhagic cavernomas, conservative treatment might be optimal due to surgery-related morbidity risks.