Role of the patient comorbidity in the recurrence of chronic subdural hematomas.

Chronic subdural hematoma (CSDH) is an old blood collection between the cortical surface and the dura. Recurrence of CSDH after surgical evacuation occurs in up to a quarter of patients. The association between patient premorbid status and the rate of recurrence is not well known, and some previous results are contradictory. We aim to determine the impact of patient comorbidities in the risk of recurrence after surgical evacuation of CSDH. Retrospective data of a single institution's surgically evacuated CSDH cases followed up for at least 6 months were analyzed, and univariate and multivariate analyses were performed to identify the relationships between recurrence of CSDH and factors such as age, gender, CSDH thickness, neurological impairment at admission (NIHSS score), location of the CSDH (unilateral vs bilateral), Charlson Comorbidity Index (CCI), prothrombin time (PT), hemoglobin levels, and platelet count. A total of 90 patients (71 men and 19 women), aged 41-100 years (mean age, 76.4 ± 11.2 years), were included. CSDH recurred in 17 patients (18.9%). A higher CCI correlated with higher scores in the NIHSS. In the univariate analysis, recurrence was associated with a higher CCI (2.39 vs 1.22, p = 0.002), higher NIHSS scores (6.5 vs 4, p = 0.034), and lower PT levels (9.9 vs 13.4, p = 0.007). In multivariate analysis, only PT and CCI demonstrated to be independent risk factors for CSDH recurrence after surgical evacuation (p = 0.033 and p = 0.024, respectively). Patients with more comorbidities have a higher risk of developing recurrent CSDH. CCI provides a simple way of predicting recurrence in patients with CSDH and should be incorporated into decision-making processes, when counseling patients.

The extradural minipterional approach for the treatment of paraclinoid aneurysms: a cadaver stepwise dissection and clinical case series.

Minipterional (MPT) craniotomy has recently been added to the neurosurgical armamentarium as a less invasive alternative to the pterional craniotomy for the treatment of parasellar lesions. However, its clinical applicability in the treatment of certain complex aneurysms, such as those arising in the paraclinoid region, remains unclear. To illustrate the microsurgical anatomy of a modified extradural MPT approach, which combines a classic MPT craniotomy with an extradural anterior clinoidectomy, and to demonstrate its clinical applicability in the treatment of complex paraclinoid aneurysms. A stepwise extradural MPT approach is illustrated in a cadaver study. Clinical outcome data from a series of 19 patients with 20 paraclinoid aneurysms treated surgically using the extradural MPT approach between 2016 and 2018 were retrospectively collected. In 95% of the cases, complete aneurysm occlusion was achieved. No aneurysm recurrences were seen during follow-up with a median length of 21 months. The outcome, according to the modified Rankin Scale, was 0 points in 12 patients (63%), 1 point in 6 patients (32%), and 2 points in 1 patient (5%). Four out of 6 patients (67%) with initial visual symptoms showed improvement following treatment, whereas in two (11%), vision became worse. The extradural MPT approach ensures a sufficiently large exposure of the paraclinoid region that is comparable with conventional approaches with the advantage of being minimally invasive. Our case series demonstrates the feasibility of this approach for the treatment of complex paraclinoid aneurysms.

Intra-Arterial Alteplase Thrombolysis during Mechanical Thrombectomy for Acute Ischemic Stroke.

BACKGROUND: Intra-arterial alteplase (IA tPA) is commonly used during mechanical thrombectomy for acute ischemic stroke in patients with large-vessel occlusion, but specific indications and applications for its use remain undefined. METHODS: We analyzed 40 patients who underwent stent-retriever mechanical thrombectomy, 28 of whom received adjunctive IA tPA. To our knowledge, this is the largest cohort with this concomitant treatment reported in the literature in the post-mechanical thrombectomy trial era. RESULTS: Between patients with and without IA tPA, rates of hemorrhagic conversion, neurologic outcome, and mortality were equivalent, with a trend toward improved angiographic revascularization observed in the IA tPA group. CONCLUSIONS: IA tPA is a safe adjunct to mechanical thrombectomy, and more investigation is warranted to understand ideal indications and dosage methodologies.

Yield and utility of routine postoperative imaging after resection of brain metastases.

Magnetic resonance imaging (MRI) or computerized tomography (CT) is routinely performed after resection of brain metastases (BrM), regardless of whether there are specific clinical concerns about residual tumor or potential complications. Routine imaging studies contribute a significant amount to the cost of medical care, and their yield and utility are unknown. An IRB-approved retrospective chart review study was performed to analyze all craniotomies for BrM performed at our institution from 2005 to 2012. Descriptive statistics were used to quantify the yield of postoperative imaging. 218 consecutive patients underwent 226 craniotomies for BrM. In 21 cases, new or worsened neurologic deficits occurred after surgery (9.0%), and 19 of the 21 underwent postoperative imaging. 9 of the 19 patients (47%) had significant findings on postoperative imaging, and 2 patients required reoperation. 201 patients had no new neurologic deficits (91%), and 23 of these patients had no postoperative imaging. Of the 178 remaining patients, 160 underwent postoperative MRI and 18 underwent postoperative CT. 9 patients (5.1%) had unexpected adverse imaging findings; 6 had small stroke, 1 had a subdural hemorrhage and 2 had possible or definite venous sinus occlusion. None of the imaging findings led to changes in management. 182 patients underwent imaging appropriate to detect residual tumor (177 gadolinium enhanced MRI and 5 contrast enhanced CT). Of these patients, 16 were known to have small residual tumors based on intraoperative findings. Of the remaining 166 patients felt to have had gross total tumor resection, 9 (5.4%) were found to have a small amount of residual tumor on postoperative imaging; no patient had a change in treatment plan as a result. Routine postoperative imaging in patients undergoing craniotomy for BrM has a very low yield and may not be appropriate in the absence of new neurologic deficits, or specific clinical concerns about large amounts of residual tumor or intraoperative complications.

Impact of the Extent of Microsurgical Resection in Sphenopetro-clival Meningiomas Trough a Multistaged Approach: A Volumetric Analysis.

Objective Sphenopetroclival meningiomas (SPCMs) represent a challenge for surgical treatment. The authors used an objective volumetric analysis to assess the effect of the grade of resection and different surgical strategies that may affect the outcome of this tumors. Methods Over a period of 4 years, patients with SPCMs were treated using a middle versus posterior fossa approach, or a two-stage surgery combining both approaches, based on the tumor location in relation to the petrous ridge and tumor volume. Retrospectively, all cases were analyzed with regard to tumor volume, extent of resection (EOR), functional outcome, and complications. Results Twenty-seven patients with SPCMs met the inclusion criteria, and the mean follow-up was 24.8 months. Eleven patients underwent a two-stage surgery, while 16 patients had their SPCMs resected via a single craniotomy. Mean EOR was 87.6% and gross total resection was achieved in 48% of patients. Patients with greater EOR had better functional outcomes ( r = 0.81, p < 0.01). Greater EOR was not accompanied by a significant increase in surgical complications. There was a trend toward lower postoperative volumes and better EOR with our two-stage approach (2.2 vs. 3.2 cm 3 , p = 0.09; and 94.1 vs. 91.2%, p = 0.49, respectively), without an increase in the rate of complications (18.7 vs. 18.2%, p = 0.5). Conclusion Staging of the surgical resection of larger tumors may lead to greater EOR, and this strategy should be considered for larger tumors.

The Minimally Invasive Posterolateral Transcavernous-Transtentorial Approach. Technical Nuances, Proof of Feasibility, and Surgical Outcomes Throughout a Case Series of Sphenopetroclival Meningiomas.

OBJECTIVE: Sphenopetroclival (SPC) meningiomas are considered among the most complex skull-base neoplasms to approach surgically. We aim to determine whether some SPC meningiomas can be safely and effectively treated using a modified minimally invasive pterional posterolateral transcavernous-transtentorial approach (MIPLATTA). METHODS: Fourteen patients harboring SPC meningiomas were surgically treated through a MIPLATTA. MIPLATTA includes a minipterional craniotomy, anterior extradural clinoidectomy, peeling of the temporal fossa, decompression of cranial nerves (CNs) in the cavernous sinus, and sectioning of the tentorium to reach the upper part of the posterior fossa. RESULTS: Gross total resection was achieved in 11 of 14 patients (78%), whereas near-total resection was accomplished in the other 3 patients (22%), each of whom underwent a further complementary retrosigmoid approach for gross total tumor resection. There were no deaths, and 13 of 14 patients were independent at 6 months follow-up (modified Rankin Scale score ≤2). One patient had pontine infarction after the procedure and experienced moderate disability at follow-up (modified Rankin Scale score 3). All patients had some degree of CN impairment. Of 38 cranial neuropathies, 15 (39%) improved, 20 (53%) remained stable, and 3 (8%) worsened postoperatively. Four new CN deficits were observed postoperatively in 3 patients (fourth CN, 2 patients; third CN, 1; fifth CN, 1). CONCLUSIONS: MIPLATTA is a useful and safe treatment alternative that allows resection of large SPC tumors with dominant invasion of cavernous sinus and middle fossa, preserves hearing and facial motor function, and provides good chances of recovery of visual and oculomotor deficits.

Relationship between aspirin use and subarachnoid hemorrhage: A systematic Review and meta-analysis.

BACKGROUND: Aspirin has been associated with a decreasing risk of subarachnoid hemorrhage due to its anti-inflammatory mechanism of action and potential protective properties against aneurysm growth. OBJECTIVE: To determine the association between aneurysmal subarachnoid hemorrhage and aspirin use. METHODS: A systematic review of the literature and a meta-analysis were performed across the PubMed database. The following keywords were used: "aspirin, acetylsalicylic acid, 2-acetyloxy-benzoic acid, ruptured intracranial aneurysm, aneurysmal subarachnoid hemorrhage, spontaneous subarachnoid hemorrhage, intracerebral hemorrhage, spontaneous aneurysmal hemorrhage, spontaneous intracerebral bleeding". Studies that were performed with animals or analyzed patients with traumatic brain injury were excluded. A total of five studies were included in our meta-analysis, with a total of 19,222 patients evaluated. Statistical analysis was performed to determine the association between the use of aspirin and the risk of subarachnoid hemorrhage. RESULTS: Aspirin use reduce the risk of subarachnoid hemorrhage (odds ratio [OR] 0.51, 95 % confidence interval [CI] 0.34-0.76). CONCLUSION: Although some previous studies suggested that aspirin may potentially reduce the risk of subarachnoid hemorrhage, our meta-analysis found an association between the reduction of risk of aneurysmal subarachnoid hemorrhage.

Extradural minipterional approach for giant intracranial aneurysms.

BACKGROUND: The clinical applicability of the minipterional (MPT) craniotomy is still limited to small and superficial anterior circulation aneurysms. We discuss the technical nuances of a modified MPT approach, the extradural MPT approach (eMPTa), for the treatment of a giant intracranial aneurysm (GIA) arising from the paraclinoid carotid artery. CASE DESCRIPTION: A 44-year-old female presented with facial hypoesthesia and third cranial nerve palsy. Further investigations revealed the presence of a 27 mm aneurysm arising from the communicating segment of the internal carotid artery. The patient underwent surgical clipping through an extradural MPT craniotomy and combined anterior clinoidectomy. Postoperative angio-computed tomography demonstrated complete aneurysm occlusion and patency of the parent vessels. The patient recovered fully from her previous deficits. CONCLUSION: The skull base drilling, interdural dissection, and anterior clinoidectomy are key steps during the eMPTa that optimizes the use of the extradural corridor. Such adaptations are enough to improve the surgical maneuverability along the paraclinoid region and adapt the MPT suitability for the treatment of complex GIA.

Microsurgical clipping of multiple cerebral aneurysms in the acute phase of aneurysmal subarachnoid hemorrhage through a minipterional approach: The Chilean experience.

OBJECTIVE: The minipterional craniotomy (MPTc) has been widely accepted as a minimally invasive alternative to the pterional approach for the treatment of certain small non-ruptured anterior circulation aneurysms. The aim of this study was to determine the effectiveness and safety of the MPTc in the context of a complex and potentially harmful scenario: acute onset of subarachnoid hemorrhage (SAH) in patients harboring multiple intracranial aneurysms (MIA). METHODS: Patients harboring MIA clipped through a unilateral MPTc were selected from four retrospective databases of four high-volume neurosurgical centers. Patients with a Hunt & Hess score 4 or 5 were not considered candidates for clipping through a MPTc. Medical records and radiological images were retrospectively reviewed. Epidemiological, clinical and radiological data, as well as short-term outcome (modified Rankin scale at 6 month-follow-up) were analyzed. RESULTS: 16 patients harboring 33 aneurysms (16 ruptured, 17 non ruptured) met the inclusion criteria. Each aneurysm size was 5.7 ± 2.1 mm (range 3-11). 12 out of 33 aneurysms were located in the middle cerebral artery (MCA). Anterior communicating (ACom) and MCA aneurysms were the aneurysm locations most commonly ruptured (5 each, 62 %). Complete occlusion was achieved in 32 aneurysms (97 %) and near-complete occlusion in 1 (3%). 13 patients (93 %) were independent at 6 month-follow-up. Mortality rate was 0%. Complications included 1 cerebrospinal-fluid leakage. CONCLUSION: When indicated (Hunt Hess < 4), performing a MPTc is safe and effective in aSAH cases with multiple aneurysms.

Mechanical Embolectomy of Distally Migrated Onyx After Surgical Resection of Glomus Vagale Tumor: Technical Report and Review of Literature.

BACKGROUND: Endovascular embolization is an important tool in the management of multiple pathologies as a preoperative adjunct in the care of arteriovenous malformations or vascular tumors. CASE DESCRIPTION: We report a case of delayed distal Onyx migration after surgical resection of a glomus vagale tumor, which had been preoperatively embolized. In this report, the patient underwent successful embolectomy of the migrated Onyx fragment using manual aspiration. CONCLUSIONS: This case represents the first in the literature to describe this potential delayed complication, as well as its management strategy.

Spontaneous Regression of a True Intracanalicular Fusiform Ophthalmic Artery Aneurysm After Endovascular Treatment of an Associated Dural Arteriovenous Fistula.

BACKGROUND: Ophthalmic trunk aneurysms associated with other vascular malformations are extremely rare, and little is known regarding its natural history and options of treatment. CASE DESCRIPTION: We present the interesting case of a 51-year-old man who was admitted with progressive visual loss secondary to a concurrent fusiform ophthalmic trunk aneurysm associated with a dural arteriovenous fistula. He was treated with transarterial embolization of the fistulous point. CONCLUSIONS: A follow-up angiogram at 6 months showed complete obliteration of the dural arteriovenous fistula and regression of the ophthalmic trunk aneurysm. The literature is reviewed, and potential pathophysiologic mechanisms leading to this association and regression in this subgroup of aneurysms are discussed.

Malignant cerebral edema following cranioplasty.

Malignant cerebral edema following cranioplasty is a very rare and devastating complication. We present a case of postoperative death following cranioplasty due to malignant cerebral edema. Similar cases and possible pathogenesis are discussed. This fearsome complication should be discussed with the patients and their families as part of the informed consent procedure.

Spontaneous regression of intracranial aneurysm following remote ruptured aneurysm treatment with pipeline stent assisted coiling.

Spontaneous aneurysm regression is a rare phenomenon. We present the interesting case of a 54-year-old woman who was admitted with a Hunt/Hess grade IV, Fisher grade III subarachnoid hemorrhage and multiple intracranial aneurysms. She was treated with coiling of the largest paraclinoid aneurysm and placement of a flow diverting pipeline embolization device that covered all internal carotid artery (ICA) aneurysms. A follow-up angiogram at 6 months showed remodeling of the ICA with complete obliteration of all treated aneurysms. A distant, untreated, right frontal M2 aneurysm regressed spontaneously, after the flow was diverted away from it with the stent. The literature is reviewed, and potential pathophysiological mechanisms leading to aneurysm regression are discussed.

Analysis of vestibular schwannoma size: A literature review on consistency with measurement techniques.

INTRODUCTION: Vestibular schwannoma (VS) tumor size, a significant prognostic indicator, is closely analyzed in patients undergoing observation or treatment. It has historically been reported in terms of linear size; however, volumetric assessments can now be performed routinely. We examine the use of described measurement techniques in large published clinical series to assess their consistency. METHODS: Computerized searches of the MEDLINE database (Pubmed) from 1975 to August 2014 were conducted with the purpose of identifying large series describing the management of VSs. Articles that reported tumor size measurements were included if they described greater than 600 patients. RESULTS: 19 studies were found fitting the inclusion criteria, consisting of large retrospective studies with sample sizes ranging from 614 to 2991. A total of 17 studies reported linear measurements, while 2 studies reported volumetric assessments of tumor size. Significant variations were found regarding methods for linear measurement. Furthermore, several papers did not provide any details regarding the measurement technique. Inclusion of intracanalicular portions of the tumor was highly variable. Volume assessments were performed by segmented volume analysis. CONCLUSIONS: Among the large published series on VSs, significant variation exists regarding the utilized measurement technique to assess size. Volumetric assessments have the greatest clinical utility, sensitivity and accuracy in measuring tumor size and growth. Standardization of volume assessments will provide the best method for producing consistent literature findings.

Spontaneous regression of intracranial aneurysm following remote ruptured aneurysm treatment with pipeline stent assisted coiling.

Spontaneous aneurysm regression is a rare phenomenon. We present the interesting case of a 54-year-old woman who was admitted with a Hunt/Hess grade IV, Fisher grade III subarachnoid hemorrhage and multiple intracranial aneurysms. She was treated with coiling of the largest paraclinoid aneurysm and placement of a flow diverting pipeline embolization device that covered all internal carotid artery (ICA) aneurysms. A follow-up angiogram at 6 months showed remodeling of the ICA with complete obliteration of all treated aneurysms. A distant, untreated, right frontal M2 aneurysm regressed spontaneously, after the flow was diverted away from it with the stent. The literature is reviewed, and potential pathophysiological mechanisms leading to aneurysm regression are discussed.

Time- and cell type-specific induction of platelet-derived growth factor receptor-beta during cerebral ischemia.

During cerebral ischemia, angiogenesis occurs inside and around the infarcted area. The growth of new blood vessels may contribute to a better outcome after stroke due to accelerated and increased delivery of nutrients and oxygen to the ischemic tissue. The platelet-derived growth factor (PDGF)-B/PDGF receptor (PDGFR)-beta system, hitherto thought to contribute mainly to neuroprotection, may also support angiogenesis and vascular remodeling by mediating interactions of endothelial cells with pericytes after cerebral ischemia. While platelet-derived growth factor (PDGF)-B and its receptor PDGFR-beta are essential factors for the recruitment of pericytes to brain capillaries during embryonic development, their role in blood vessel maturation during cerebral ischemia is not clear. The aim of the present study was to investigate the time course and location of PDGF-B and PDGFR-beta expression in a mouse model of focal cerebral ischemia. In contrast to the early and continuous induction of PDGF-B, PDGFR-beta mRNA was specifically upregulated in vascular structures in the infarcted area 48 h after occlusion of the middle cerebral artery. Immunohistology and confocal microscopy analysis revealed the specific upregulation of PDGFR-beta on blood vessels and suggested expression mainly on pericytes. Our results imply PDGFR-beta as a key factor in vascular remodeling during stroke and suggest that the pleiotropic functions of PDGF-B may be regulated via the expression of its receptor. Influencing the PDGF system therapeutically might improve angiogenesis, cellular protection, and edema inhibition.

Endovascular treatment of fusiform cerebral aneurysms with the Pipeline Embolization Device.

OBJECT: Despite advances in surgical and endovascular techniques, fusiform aneurysms remain a therapeutic challenge. Introduction of flow-diverting stents has revolutionized the treatment of aneurysms with wide necks and of complex morphology. The authors report their experience with the endovascular treatment of fusiform aneurysms using the Pipeline Embolization Device. METHODS: A retrospective review of 146 patients with cerebral aneurysms treated with the Pipeline Embolization Device between June 2011 and January 2013 was performed. Twenty-four patients were identified as having fusiform aneurysms. Twenty-four aneurysms in these 24 patients were treated. The mean patient age was 59 years. There were 9 men and 15 women. Angiographic and clinical data (including the modified Rankin Scale [mRS] score) were recorded at the time of treatment and at follow-up. The aneurysms were located in the internal carotid artery in 8 patients (33.3%), middle cerebral artery in 8 patients (33.3%), anterior cerebral artery in 1 patient (4%), and vertebrobasilar circulation in 7 patients (29%). The aneurysms were smaller than 10 mm in 3 patients, 10-25 mm in 16 patients, and larger than 25 mm in 5 patients. The mean largest dimension diameter was 18 mm. RESULTS: Stent deployment was successful in all cases. The minor procedural morbidity was 4% (1 case). Morbidity and mortality related to aneurysm treatment were 4.2% and 4.2%, respectively. The mean mRS scores preoperatively and at clinical follow-up (median 6.0 months, mean 6.9 months) were 0.71 and 1.2, respectively (91.7% presented with an mRS score of 2 or better, and 79.2% had an mRS score of 2 or better at the 6.0-month follow-up). At clinical follow-up, 82.6% of patients were stable or had improved, 13.0% worsened, and 4.2% had died. Twenty-two (91.7%) of 24 patients had follow-up angiography available (mean follow-up time 6.3 months); 59% had excellent angiographic results (> 95% or complete occlusion), 31.8% had complete aneurysm occlusion, 27.3% had greater than 95% aneurysm occlusion, 18.2% had a moderate decrease in size (50%-95%), 4.5% had a minimal decrease in size (< 50%), 13.6% had not changed, and 4.5% had an increase in size. CONCLUSIONS: This series demonstrates that endovascular treatment of fusiform cerebral aneurysms with flow diversion was a safe and effective treatment. Procedural complications were low. Long-term morbidity and mortality rates were acceptable given the complex nature of these lesions.

The use of adenosine in the treatment of a high-flow vein of Galen malformation in an adult.

The treatment of high-flow vein of Galen aneurysmal malformations (VGAM) remains a therapeutic challenge for the neurosurgeon and the neurointerventionalist, as it is associated with high morbidity and mortality rates despite recent advances in open cranial surgery and interventional neuroradiology. A 37-year-old patient presented with a history of non-specific headaches. He had a history of heart failure since birth that was caused by an untreated VGAM. Intravenous boluses of adenosine were injected as an attempt to slow down the arteriovenous shunting of a VGAM prior to endovascular treatment. Adenosine can be a very useful adjunct in patients with extremely high arteriovenous shunting. n-butyl cyanoacrylate (n-BCA) should be the embolic material of choice due to its quick polymerization and adhesive properties.

Large cell neuroendocrine carcinoma of the lung metastatic to the cauda equina.

BACKGROUND CONTEXT: Large cell neuroendocrine carcinoma of the lung is an aggressive tumor with unique histopathological features. It is not known to metastasize to the spine. PURPOSE: To report a metastatic case of this rare tumor to the cauda equina. STUDY DESIGN: Case report. METHODS: Retrospective case review and review of the literature. RESULTS: The authors report a rare case of a large cell neuroendocrine lung metastasis to the lumbar spine, causing right foot drop. Magnetic resonance imaging revealed a heterogeneously enhancing intradural extramedullary mass at L2/L3 level compressing the surrounding nerve roots. During surgery, the identified nerve roots were encased by the tumor, and the dissection was tedious. Postoperatively, the patient reported significantly improved back pain and he had severe foot weakness. The functional outcome was poor because the patient lost entirely his foot function; however, his back pain improved significantly after surgery. CONCLUSIONS: This is the first published study in which the authors described a metastasis of a rather uncommon lung cancer to the cauda equina. When a lesion of the cauda equina presents with a rapid progressive neurological deficit, leptomeningeal metastasis should be in the differential diagnosis.