Endovascular neurosurgery in Europe: an International Survey and future perspectives

BACKGROUND

Recent advancements in neurosurgery have transformed patient care through minimally invasive procedures and led to a notable surge in endovascular treatments. However, the regulatory landscape governing these procedures across European countries varies, impacting treatment access and collaboration. This paper discusses the results of a survey on European legislation regarding endovascular neurosurgery, exploring current practices and speculating on the field's future.

METHODS

An e-mail survey was distributed to 41 European countries, targeting European member societies within the EANS. Thirty-seven completed questionnaires were returned, providing insights into neuroendovascular treatment legislation and restrictions.

RESULTS

Legislation and certification varied across the surveyed countries, with only two countries prohibiting endovascular neurosurgery. Eight countries required specific fellowship programs. Resistance from radiologists was noted in many countries.

CONCLUSIONS

Despite growing support for neurosurgeons performing endovascular treatments in Europe, challenges persist. Specialized care, improved access, and a broadening spectrum of treatable conditions contribute to the argument for involvement of neurosurgeons.

Frequency of brain ventricular enlargement among patients with diabetes mellitus

AIMS

To determine the prevalence of dilated ventricles and concomitant high blood glucose measures.

METHODS

We retrieved blood glucose measures from the emergency department database and selected a subgroup of individuals having both the radiological marker Evans' index (EI) values and blood glucose measures.

RESULTS

Out of 1221 consecutive patients submitted to axial Computed Tomography scans, a blood glucose measure was detected in 841 individuals. 176 scans (21 %) showed an EI > 0.30. According to the blood glucose categorization, diabetic patients were 104 (12 %), 25 of them (24 %) were dilated (mean EI 0.33). The age difference between dilated and not-dilated ventricles is about ten years in not-diabetic participants, whereas it is five years in diabetic participants. The age difference between dilated and not-dilated ventricles is about 10 years in diabetic men, whereas it zero in diabetic women.

CONCLUSIONS

Pathological ventricular enlargement is more frequent in men and in the elderly. In diabetic patients (especially women), the cerebral ventricles enlarge faster than in non-diabetic individuals. Age, sex, and diabetes may interact in determining how cerebral ventricle size changes over time, especially in diabetic women, making routine brain imaging advisable in these patients after the age of 70 years.

Revitalizing neurosurgical frontiers: The EANS frontiers in neurosurgery committee's strategic framework

Introduction

The field of neurosurgery faces challenges with the increasing involvement of other medical specialties in areas traditionally led by neurosurgeons. This paper examines the implications of this development for neurosurgical practice and patient care, with a focus on specialized areas like pain management, peripheral nerve surgery, and stereotactic radiosurgery.

Research question

To assess the implications of the expanded scope of other specialties for neurosurgical practice and to consider the response of the EANS Frontiers in Neurosurgery Committee to these challenges.

Materials and methods

Analysis of recent trends in neurosurgery, including the shift in various procedures to other specialties, demographic challenges, and the emergence of minimally invasive techniques. This analysis draws on relevant literature and the initiatives of the Frontiers in Neurosurgery Committee.

Results

We explore a possible decrease in neurosurgical involvement in certain areas, which may have implications for patient care and access to specialized neurosurgical interventions. The Frontiers in Neurosurgery Committee's role in addressing these concerns is highlighted, particularly in terms of training, education, research, and networking for neurosurgeons, especially those early in their careers.

Discussion and conclusion

The potential decrease in neurosurgical involvement in certain specialties warrants attention. This paper emphasizes the importance of carefully considered responses by neurosurgical societies, such as the EANS, to ensure neurosurgeons continue to play a vital role in managing neurological diseases. Emphasis on ongoing education, integration of minimally invasive techniques, and multidisciplinary collaboration is essential for maintaining the field's competence and quality in patient care.

Antithrombotic regimen in emergent carotid stenting for acute ischemic stroke due to tandem occlusion: a meta-analysis of aggregate data

BACKGROUND

The periprocedural antithrombotic regimen might affect the risk-benefit profile of emergent carotid artery stenting (eCAS) in patients with acute ischemic stroke (AIS) due to tandem lesions, especially after intravenous thrombolysis. We conducted a systematic review and meta-analysis to evaluate the safety and efficacy of antithrombotics following eCAS.

METHODS

We followed PRISMA guidelines and searched MEDLINE, Embase, and Scopus from January 1, 2004 to November 30, 2022 for studies evaluating eCAS in tandem occlusion. The primary endpoint was 90-day good functional outcome. Secondary outcomes were symptomatic intracerebral hemorrhage, in-stent thrombosis, delayed stent thrombosis, and successful recanalization. Meta-analysis of proportions and meta-analysis of odds ratios were implemented.

RESULTS

34 studies with 1658 patients were included. We found that the use of no antiplatelets (noAPT), single antiplatelet (SAPT), dual antiplatelets (DAPT), or glycoprotein IIb/IIIa inhibitors (GPI) yielded similar rates of good functional outcomes, with a marginal benefit of GPI over SAPT (OR 1.88, 95% CI 1.05 to 3.35, Pheterogeneity=0.31). Sensitivity analysis and meta-regression excluded a significant impact of intravenous thrombolysis and Alberta Stroke Program Early CT Score (ASPECTS). We observed no increase in symptomatic intracerebral hemorrhage (sICH) with DAPT or GPI compared with noAPT or SAPT. We also found similar rates of delayed stent thrombosis across groups, with acute in-stent thrombosis showing marginal, non-significant benefits from GPI and DAPT over SAPT and noAPT.

CONCLUSIONS

In AIS due to tandem occlusion, the periprocedural antithrombotic regimen of eCAS seems to have a marginal effect on good functional outcome. Overall, high intensity antithrombotic therapy may provide a marginal benefit on good functional outcome and carotid stent patency without a significant increase in risk of sICH.

Intraoperative computed tomography, navigated ultrasound, 5-amino-levulinic acid fluorescence and neuromonitoring in brain tumor surgery: overtreatment or useful tool combination?

BACKGROUND

Brain tumor surgery is routinely supported by several intraoperative techniques, such as fluorescence, brain mapping and neuronavigation, which are often used independently. Efficacy of navigation is limited by the brain-shift phenomenon, particularly in cases of large or deep-sited lesions. Intraoperative imaging was introduced also to update neuronavigation data, to try and solve the brain-shift phenomenon-related pitfalls and increase overall safety. Nevertheless, each intraoperative imaging modality has some intrinsic limitations and technical shortcomings, making its clinical use challenging. We used a multimodal intraoperative imaging protocol to update neuronavigation, based on the combination of intraoperative Ultrasound (i-US) and intraoperative Computed Tomography (i-CT) integrated with 5-ALA fluorescence and neuromonitoring-guided resection.

METHODS

This is a pilot study on 52 patients (29 men), including four children, with a mean age of 57.67 years, suffering from brain low- (N.=10) or high-grade (N.=34) glioma or metastasis (N.=8), prospectively and consecutively enrolled. They underwent 5-ALA fluorescence-guided microsurgical tumor resection and neuromonitoring was used in cases of lesions located in eloquent areas, according to preoperative clinical and neuroradiological features. Navigated B-mode ultrasound acquisition was carried out after dural opening to identify the lesion. After tumor resection, i-US was used to identify residual tumor. Following further tumor resection or in cases of unclear US images, post-contrast i-CT was performed to detect and localize small tumor remnants and to allow further correction for brain shift. A final i-US check was performed to verify the completeness of resection. Clinical evaluation was based on comparison of pre- and postoperative Karnofsky Performance Score (KPS) and assessment of overall survival (OS) and progression-free survival (PFS). Extent of tumor resection (EOTR) was evaluated by volumetric postoperative Magnetic Resonance performed within 48 h after surgery.

RESULTS

Forty-one of the 52 (78.8%) patients were alive and still under follow-up in December 2017. 5-ALA was strongly or vaguely positive in 45 cases (86.5%). Seven lesions (four low-grade glioma, one high-grade glioma, and two metastases) were not fluorescent. i-US visualized residual tumor after resection of all fluorescent or pathological tissue in 22 cases (42.3%). After i-US guided resection, i-CT documented the presence of further residual tumor in 11 cases (21.1%). Mean EOTR was 98.79% in the low-grade gliomas group, 99.84% in the high-grade gliomas group and 100% in the metastases group. KPS changed from 77.88, preoperatively, to 72.5, postoperatively. At the last follow-up, mean KPS was 84.23.

CONCLUSIONS

The combination of different intraoperative imaging modalities may increase brain tumor safety and extent of resection. In particular, i-US seems to be highly sensitive to detect residual tumors, but it may generate false positives due to artifacts. Conversely, i-CT is more specific to localize remnants, allowing a more reliable updating of navigation data.

Correlation between intravascular pressure gradients and ultrasound velocities in carotid artery stenosis: An exploratory study

INTRODUCTION

Grading of carotid stenosis is routinely performed with non-invasive techniques, such as carotid ultrasound (CUS) and computerized tomography angiography (CTA), which have limitations in grading definition. Moreover, the actual hemodynamic impact of a stenosis remains poorly defined. Preliminary studies explored the application of the resting full-cycle ratio (RFR), measured with pressure wire (PW), but the correlation between RFR and morphological/hemodynamic parameters is still undefined. This study aims to test the correlation between RFR and CUS-CTA-DSA based degree of stenosis, to define the suitability of RFR as carotid stenosis index.

METHODS

We included patients with symptomatic carotid stenosis receiving carotid artery stenting (CAS), between November 2022 and May 2023. We performed CUS and PW measurements before and after stenting, at four different sites (trans-lesion, distal cervical, petrous and supraclinoid internal carotid artery [ICA] segments). We compared CUS and PW parameters by Pearson's or Spearman test for continuous variables.

RESULTS

Among 15 patients included the mean stenosis degree was 81.3%. Trans-lesion RFR was significantly higher than other sites (0.72 ± 0.2 trans-lesion vs. 0.69 ± 0.18 distal cervical ICA vs. 0.66 ± 0.2 petrous ICA vs. 0.6 ± 0.2 intracranial ICA, p < 0.05). All RFR values significantly increased after treatment; the highest relative increase was registered at stenosis site (0.72 ± 0.2 pre-stent vs. 1.01 ± 0.1 post-stent, p < 0.01). Trans-lesion RFR was significantly associated with the CTA and DSA stenosis degree and CUS measurements.

CONCLUSIONS

Pressure wire in carotid artery stenosis seems safe and suitable. Resting full-cycle ratio has a significant correlation with CUS values and stenosis degree and might be used as carotid stenosis index during CAS.

Growth and rupture of an intracranial aneurysm: the role of wall aneurysmal enhancement and CD68

Introduction

Intracranial aneurysms occur in 3%-5% of the general population. While the precise biological mechanisms underlying the formation, growth, and sudden rupture of intracranial aneurysms remain partially unknown, recent research has shed light on the potential role of inflammation in aneurysm development and rupture. In addition, there are ongoing investigations exploring the feasibility of employing new drug therapies for controlling the risk factors associated with aneurysms. CD68, a glycosylated glycoprotein and the human homolog of macrosialin, is prominently expressed in monocyte/macrophages within inflamed tissues and has shown potential application in oncology. An observational study was conducted with the aim of comparing the histological characteristics of aneurysm walls with preoperative MRI scans, specifically focusing on CD68 activity.

Method

An observational pilot study was conducted to investigate the histological characteristics of the aneurysm wall that could be potentially associated with aneurysm growth and rupture. A total of 22 patients diagnosed with ruptured and unruptured intracranial aneurysms who had undergone conventional clipping between January 2017 and December 2022 were included in the study.

Results

A histopathological analysis of the aneurysm wall was performed in all patients, particularly focusing on the presence of CD68. A preoperative MRI with gadolinium was conducted in 10 patients with unruptured aneurysms and six patients with ruptured aneurysms. An emergency clipping was performed in the remaining six patients. The results showed that CD68 positivity and wall enhancement were significantly associated with intracranial aneurysm wall degeneration, growth, and rupture.

Conclusion

The histological and radiological inflammatory findings observed in the wall of cerebral aneurysms, as well as the CD68 positivity, are significantly associated with the risk of intracranial aneurysm growth and rupture. This study highlights the crucial importance of considering clinical and medical data when making treatment decisions for intracranial aneurysms. Furthermore, it emphasizes the relevance of evaluating wall enhancement in MRI scans as part of the diagnostic and prognostic process.

Neurophysiological monitoring during endovascular treatment of brain arteriovenous malformations: A meta-analysis

BACKGROUND

Treatment of brain arteriovenous malformations (b-AVM) carries a risk of iatrogenic injury to eloquent brain regions. Intraoperative neuro-monitoring (IONM) has increasingly been used to monitor spontaneous or evoked neural activity during neurosurgery, but its use is not as well characterized in the endovascular treatment (EVT) of b-AVMs. We aimed to provide a systematic review and meta-analysis of studies reporting any neurological deficit after b-AVM embolization with IONM, with or without provocative test (PT), and no-IONM.

METHODS

This systematic review followed the PRISMA guidelines. Medline, EMBASE, and Scopus were searched from conception until March 1, 2022 for studies evaluating EVT with IONM and PT. Primary outcome was the rate of postoperative neurological deficits in EVT with IONM versus no-IONM, while secondary outcome was the subanalysis of IONM with or without PT. Meta-analysis was performed using the Mantel-Haenszel method and random effects modeling.

RESULTS

Six studies reached synthesis. Out of a total of 192 EVT, 14 events occurred. Results demonstrated a nonsignificant trend favoring IONM compared to no-IONM to prevent neurological deficits (OR 0.09, 95% CI 0-4.68). Among the EVT with IONM, PT was done in 411 branches with 10 events (0.2%) despite a negative PT. There was a nonsignificant trend favoring IONM plus PT compared to IONM without PT (OR 0.16, 95% CI 0.02-1.07).

CONCLUSIONS

Our study suggests that b-AVM EVT with IONM plus PT might reduce rates of postprocedural neurological deficits compared with EVT without IONM. Further studies are needed to confirm these results.

Emergent carotid stenting versus no stenting for acute ischemic stroke due to tandem occlusion: a meta-analysis

BACKGROUND

Emergent carotid artery stenting (eCAS) is performed during mechanical thrombectomy for acute ischemic stroke due to tandem occlusion. However, the optimal management strategy in this setting is still unclear.

OBJECTIVE

To carry out a systematic review and meta-analysis to investigate the safety and efficacy of eCAS in patients with tandem occlusion.

METHODS

Systematic review followed the PRISMA guidelines. Medline, EMBASE, and Scopus were searched from January 1, 2004 to March 7, 2022 for studies evaluating eCAS and no-stenting approach in patients with stroke with tandem occlusion. Primary endpoint was the 90-day modified Rankin Scale score 0-2; secondary outcomes were (1) symptomatic intracerebral hemorrhage (sICH), (2) recurrent stroke, (3) successful recanalization (Thrombolysis in Cerebral Infarction score 2b-3), (4) embolization in new territories, and (5) restenosis rate. Meta-analysis was performed using the Mantel-Haenszel method and random-effects modeling.

RESULTS

Forty-six studies reached synthesis. eCAS was associated with higher good functional outcome compared with the no-stenting approach (OR=1.52, 95% CI 1.19 to 1.95), despite a significantly increased risk of sICH (OR=1.97, 95% CI 1.23 to 3.15), and higher successful recanalization rate (OR=1.91, 95% CI 1.29 to 2.85). Restenosis rate was lower in the eCAS group than in the no-stenting group (2% vs 9%, p=0.001). Recanalization rate was higher in retrograde than antegrade eCAS (OR=0.51, 95% CI 0.28 to 0.93). Intraprocedural antiplatelets during eCAS were associated with higher rate of good functional outcome (60% vs 46%, p=0.016) and lower rate of sICH (7% vs 11%; p=0.08) compared with glycoprotein IIb/IIIa inhibitors.

CONCLUSIONS

In observational studies, eCAS seems to be associated with higher good functional outcome than no-stenting in patients with acute ischemic stroke due to tandem occlusion, despite the higher risk of sICH. Dedicated trials are needed to confirm these results.

Social Media for Global Neurosurgery. Benefits and limitations of a groundbreaking approach to communication and education

Introduction

Social media have become ubiquitous and their role in medicine is quickly growing. They provide an open platform by which members share educational material, clinical experiences, and collaborate with educational equity.

Research question

To characterize the role of social media in neurosurgery, we analyzed metrics of the largest neurosurgical group (Neurosurgery Cocktail), collected relevant data about activities, impact and risks of this groundbreaking technology.

Material and methods

We extracted Facebook metrics from 60-day time sample, including users demographics and other platform-specific values such as active members and number of posts within 60 days. A quality assessment of the posted material (clinical case reports and second opinions) was obtained establishing four main quality-criteria: privacy violation; quality of imaging; clinical and follow up data.

Results

By December 2022, the group included 29.524 members (79.8% male), most (29%) between 35 and 44 years of age. Over 100 countries were represented. A total of 787 posts were published in 60 days with an average of 12.7 per day. In 173 clinical cases presented through the platform, some issue with privacy was recorded in 50.9%. The imaging was considered insufficient in 39.3%, clinical data in 53.8%; follow up data were missing in 60.7%.

Discussion and conclusion

The study provided a quantitative evaluation of impact, flaws and limitations of social medial for healthcare. Flaws were mostly data breach and insufficient quality of case reports. There are actions to correct these flaws that can be easily taken to provide a greater credibility and efficacy to the system.

Incidence of intra-procedural complications according to the timing of endovascular treatment in ruptured intracranial aneurysms

Background

Although endovascular treatment of ruptured intracranial aneurysms is well-established, some critical issues have not yet been clarified, such as the effects of timing on safety and effectiveness of the procedure. The aim of our study was to analyze the incidence of intra-procedural complications according to the timing of treatment, as they can affect morbidity and mortality.

Materials and methods

We retrospectively analyzed all patients who underwent endovascular treatment for ruptured intracranial aneurysms at three high flow center. For all patients, imaging and clinical data, aneurysm's type, mean dimension and different treatment techniques were analyzed. Intra-procedural complications were defined as thrombus formation at the aneurysm's neck, thromboembolic events, and rupture of the aneurysm. Patients were divided into three groups according to time between subarachnoid hemorrhage and treatment (<12 h hyper-early, 12-36 h early, and >36 h delayed).

Results

The final study population included 215 patients. In total, 84 patients (39%) underwent hyper-early, 104 (48%) early, and 27 (13%) delayed endovascular treatment. Overall, 69% of the patients were treated with simple coiling, 23% with balloon-assisted coiling, 1% with stent-assisted coiling, 3% with a flow-diverter stent, 3% with an intrasaccular flow disruptor device, and 0.5% with parent vessel occlusion. Delayed endovascular treatment was associated with an increased risk of total intra-procedural complications compared to both hyper-early (p = 0.009) and early (p = 0.004) treatments with a rate of complications of 56% (vs. 29% in hyper-early and 26% in early treated group-p = 0.011 and p = 0.008). The delayed treatment group showed a higher rate of thrombus formation and thromboembolic events. The increased risk of total intra-procedural complications in delayed treatment was confirmed, also considering only the patients treated with simple coiling and balloon-assisted coiling (p = 0.005 and p = 0.003, respectively, compared to hyper-early and early group) with a rate of complications of 62% (vs. 28% in hyper-early and 26% in early treatments-p = 0.007 and p = 0.003). Also in this subpopulation, delayed treated patients showed a higher incidence of thrombus formation and thromboembolic events.

Conclusions

Endovascular treatment of ruptured intracranial aneurysms more than 36 h after SAH seems to be associated with a higher risk of intra-procedural complications, especially thrombotic and thromboembolic events.

Defining activities in neurovascular microsurgery training: entrustable professional activities for vascular neurosurgery

BACKGROUND

Entrustable professional activities (EPAs) represent an assessment framework with an increased focus on competency-based assessment. Originally developed and adopted for undergraduate medical education, concerns over resident ability to practice effectively after graduation have led to its implementation in residency training but yet not in vascular neurosurgery. Subjective assessment of resident or fellow performance can be problematic, and thus, we aim to define core EPAs for neurosurgical vascular training.

METHODS

We used a nominal group technique in a multistep interaction between a team of experienced neurovascular specialists and a medical educator to identify relevant EPAs. Panel members provided feedback on the EPAs until they reached consent.

RESULTS

The process produced seven core procedural EPAs for vascular residency and fellowship training, non-complex aneurysm surgery, complex aneurysm surgery, bypass surgery, arteriovenous malformation resection, spinal dural fistula surgery, perioperative management, and clinical decision-making.

CONCLUSION

These seven EPAs for vascular neurosurgical training may support and guide the neurosurgical society in the development and implementation of EPAs as an evaluation tool and incorporate entrustment decisions in their training programs.

Flow Diverter Devices in the Treatment of Anterior Communicating Artery Region Aneurysms: Would the Regional Anatomy and the Aneurysm Location Affect the Outcomes?

BACKGROUND

In this study, the authors evaluated the efficacy and the safety of flow diverter devices (FDD) in anterior communicating artery (ACoA) region aneurysms, focusing on anatomical factors that could affect the outcome, such as the location of the aneurysm along the ACoA (centered on ACoA or decentered on the A1-A2 junction) and the anatomy of the ACoA region.

METHODS

Clinical, procedural and follow-up data were analyzed. Aneurysms were classified according to the location along the ACoA (centered or decentered on the A1-A2 junction) and on the basis of the anatomical configuration of the ACoA region. Safety was assessed by recording intraprocedural, periprocedural and delayed complications to determine the morbidity and mortality rates. The functional outcome was evaluated with the modified Rankin scale (mRS) prior to and after the endovascular procedure. To assess the efficacy, midterm and long-term clinical, angiographic and cross-sectional imaging follow-ups were recorded. Subgroup analysis according to the different ACoA regional anatomical configurations and the ACoA aneurysm locations were performed.

RESULTS

33 patients (17 males; 16 females) with ACoA region aneurysms were treated with FDDs. 27 aneurysms were located at the A1-A2 junction (82%) while the remaining six aneurysms were centered on the ACoA. No mortality was recorded. The overall morbidity rate was 6% (2/33 procedures). Major complications occurred in 33% (2/6) of ACoA aneurysms and in the 0% of A1-A2 junction aneurysms. Mid-term and long-term neuroimaging follow-ups showed the occlusion of the aneurysm in 28/33 cases (85%). Complete occlusion rates were 93% in the A1-A2 junction aneurysms and 50% in ACoA aneurysms.

CONCLUSIONS

The FDD is a safe and effective tool that can be used in the treatment of selected cases of ACoA region aneurysms. The location of the aneurysm along the ACoA and the regional anatomy of the ACoA complex could affect the efficacy and safety.

Cotinine levels influence the risk of rupture of brain aneurysms

Cotinine, the primary metabolite of nicotine, is currently regarded as the best biomarker of tobacco smoke exposure. We aim to assess whether cotinine levels are associated with (1) intracranial aneurysm and (2) intracranial aneurysm rupture.

METHODS

We performed a single-center case-control study. Cases were consecutive patients admitted with diagnosis of brain aneurysm (ruptured or unruptured). We randomly selected controls without intracranial aneurysm from the same source population that produced the cases. Smoking data were collected by questionnaire, and serum levels of cotinine were used as an objective measure of nicotine exposure. Logistic regression models were used to assess the relationship between cotinine levels and aneurysm rupture.

RESULTS

We included 86 patients with intracranial aneurysm and 96 controls. Smoking status (p < .001), cotinine levels (p = .009), and female sex (p = .006) were associated with diagnosis of intracranial aneurysm. In the multivariate analysis, controlling for sex, smoker status and age, levels of cotinine were independently associated with aneurysm rupture (OR 1.53, 95% CI 1.10-2.13, p = .012).

CONCLUSIONS

Our results suggest that high cotinine levels in smokers with brain aneurysm are significantly associated with high rupture risk, independently of smoker status, age, and sex.

The central cord syndrome in patients with cervical spinal cord tumors. A XIX century vignette from (Karl) Julius Vogel (1814-1880)

Between 1830 and 1850, (Karl) Julius Vogel was one of the most important German pathologists. He received his doctorate in medicine in 1838 from the University of Munich and habilitation in pathology in 1840. In 1846, he moved to the University of Giessen as a full professor of pathology. From 1855, he taught special pathology and therapy at the University of Halle and became director of the internal clinic. Vogel and Heinrich Adolph Karl Dittmar were the first clinicians to describe the symptoms and pathological findings of central cord syndrome in a cervical spine tumor.

European Stroke Organisation (ESO) guidelines on management of unruptured intracranial aneurysms

Unruptured intracranial aneurysms (UIA) occur in around 3% of the population. Important management questions concern if and how to perform preventive UIA occlusion; if, how and when to perform follow up imaging and non-interventional means to reduce the risk of rupture. Using the Standard Operational Procedure of ESO we prepared guidelines according to GRADE methodology. Since no completed randomised trials exist, we used interim analyses of trials, and meta-analyses of observational and case-control studies to provide recommendations to guide UIA management. All recommendations were based on very low evidence. We suggest preventive occlusion if the estimated 5-year rupture risk exceeds the risk of preventive treatment. In general, we cannot recommend endovascular over microsurgical treatment, but suggest flow diverting stents as option only when there are no other low-risk options for UIA repair. To detect UIA recurrence we suggest radiological follow up after occlusion. In patients who are initially observed, we suggest radiological monitoring to detect future UIA growth, smoking cessation, treatment of hypertension, but not treatment with statins or acetylsalicylic acid with the indication to reduce the risk of aneurysm rupture. Additionally, we formulated 15 expert-consensus statements. All experts suggest to assess UIA patients within a multidisciplinary setting (neurosurgery, neuroradiology and neurology) at centres consulting >100 UIA patients per year, to use a shared decision-making process based on the team recommendation and patient preferences, and to repair UIA only in centres performing the proposed treatment in >30 patients with (ruptured or unruptured) aneurysms per year per neurosurgeon or neurointerventionalist. These UIA guidelines provide contemporary recommendations and consensus statement on important aspects of UIA management until more robust data come available.

Tumor Embolization through Meningohypophyseal and Inferolateral Trunks is Safe and Effective

BACKGROUND AND PURPOSE

Skull base tumors are commonly supplied by dural branches of the meningohypophyseal and inferolateral trunks. Embolization through these arteries is often avoided due to technical challenges and inherent risks; however, successful embolization can be a valuable surgical adjunct. We aimed to review the success and complications in our series of tumor embolizations through the meningohypophyseal and inferolateral trunks.

MATERIALS AND METHODS

We performed a retrospective review of patients with tumor treated with preoperative embolization at our institution between 2010 and 2020. We reviewed the following data: patients' demographics, tumor characteristics, endovascular embolization variables, and surgical results including estimated blood loss, the need for transfusion, and operative time.

RESULTS

Among 155 tumor embolization cases, we identified 14 patients in whom tumor embolization was performed using the meningohypophyseal (n = 13) or inferolateral (n = 4) trunk. In this group of patients, on average, 79% of tumors were embolized. No mortality or morbidity from the embolization procedure was observed in this subgroup of patients. The average estimated blood loss in the operation was 395 mL (range, 200-750 mL). None of the patients required a transfusion, and the average operative time was 7.3 hours.

CONCLUSIONS

Some skull base tumors necessitate embolization through ICA branches such as the meningohypophyseal and inferolateral trunks. Our series demonstrates that an effective and safe embolization may be performed through these routes.

Intrasaccular Flow Disruptor-Assisted Coiling of Intracranial Aneurysms Using the Novel Contour Neurovascular Systems and NEQSTENT: A Single-Center Safety and Feasibility Study

Background: Intrasaccular flow disruptors (IFD) have been introduced in the treatment of intracranial aneurysms (IAs) to overcome the low aneurysm occlusion rate and the high recanalization rate of the coiling technique. Among them, the Contour Neurovascular System (CNS) and the Neqstent (NQS) were designed to reconstruct the aneurysmal neck and both can be used as assisting coiling devices. We aimed to report our preliminary experience with the flow disruptor-assisted coiling (IFD-AC) technique. Methods: We performed a retrospective analysis of prospectively collected data of all patients with IAs treated with the IFD-AC. Results: Between February 2021 and April 2022, we treated 15 IAs with the IFD-AC: 10 ruptured and 5 unruptured. The IFD-AC was successfully performed in 13 cases, with a post-operative RROC 1 in 12 cases (92.3%) and RROC 2 in 1 case (7.7%). There was one ischemic event (6.7%) and no hemorrhagic complications. Twelve patients underwent a mid-term radiologic follow-up: Ten IAs (83.4%) presented an adequate occlusion, while 2 (16.7%) had a recurrence. Conclusions: The IFD-AC, both with the CNS and the NQS, seems a safe technique with promising efficacy profile. The IFD-AC has proved to be safe without antiplatelet therapy in ruptured cases. Further studies are needed to confirm our preliminary results.

Principles, techniques and applications of high resolution cone beam CT angiography in the neuroangio suite

The aim of this review is to describe the acquisition and reformatting of state of the art high resolution cone beam CT (HR-CBCT) and demonstrate its role in multiple neurovascular conditions as a tool to improve the understanding of disease and guide therapeutic decisions. First, we will review the basic principle of CBCT acquisition, followed by the injection protocols and the reformatting paradigms. Next, multiple applications in different pathological conditions such as aneurysms, arteriovenous malformations, dural arteriovenous fistulas, and stroke will be described. HR-CBCT angiography, widely available, is uniquely useful in certain clinical scenarios to improve the understanding of disease and guide therapeutic decisions. It rapidly is becoming an essential tool for the contemporary neurointerventionalist.AChoAho.

Temporal Horn Enlargements Predict Secondary Hydrocephalus Diagnosis Earlier than Evans' Index

The aim of this study was to identify early radiological signs of secondary hydrocephalus. We retrieved neuroradiological data from scans performed at various times in patients who underwent surgery for secondary hydrocephalus due to severe traumatic brain injury (TBI), subarachnoid haemorrhage (SAH), or brain tumour (BT). Baseline measurements, performed on the earliest images acquired after the neurological event (T0), included Evans’ index, the distance between frontal horns, and the widths of both temporal horns. The next neuroimage that showed an increase in at least one of these four parameters—and that lead the surgeon to act—was selected as an indication of ventricular enlargement (T1). Comparisons of T0 and T1 neuroimages showed increases in Evans’ index, in the mean frontal horn distance, and in the mean right and left temporal horn widths. Interestingly, in T1 scans, mean Evans’ index scores > 0.30 were only observed in patients with BT. However, the temporal horn widths increased up to ten-fold in most patients, independent of Evans’ index scores. In conclusion temporal horn enlargements were the earliest, most sensitive findings in predicting ventricular enlargement secondary to TBI, SAH, or BT. To anticipate a secondary hydrocephalus radiological diagnosis, clinicians should measure both Evans’ index and the temporal horn widths, to avoid severe disability and poor outcome related to temporal lobe damage.

Microsurgical clipping versus newer endovascular techniques in treatment of unruptured anterior communicating artery-complex aneurysms: a meta-analysis and systematic review

The aim of this study is to compare occlusion rate, complication rate, and clinical outcome of microsurgical clipping (MC) and advanced endovascular techniques (EVT) in unruptured anterior communicating artery-complex aneurysms (ACoCAs). We reviewed the scientific literature reporting occlusion rate, time of occlusion assessment, and clinical outcome of MC and EVT in patients with unruptured ACoCAs, from January 2009 to December 2019. We included in our analysis 25 studies and 872 patients with unruptured ACoCAs (434 treated with endovascular techniques and 438 with MC). Ninety-three (10.7%), 320 (36.7%), 21 (2.4%), and 438 (50.2%) were treated with flow diverter (FD), stent-assisted coiling (SAC), endosaccular devices (ES), and microsurgical clipping (MC) respectively. FD, SAC, ES, and MC subgroups presented minor complications in 11.8%, 3.8%, 14.3%, and 7.1% of cases (p=.016), and major complications in 3.2%, 4.4%, 0%, and 7.1% (p=.136) of patients. A total occlusion rate post-treatment has been achieved in 4.3%, 87.1%, 47.6%, and 98.2% of cases (p=.000), while at 12 months' follow-up in 50%, 66%, 83.3%, and 80% of patients (p=.001). FD, SAC, ES, and MC subgroups had a good clinical outcome at 12 months in 93.5%, 90.5%, 100%, and 67.8% of cases. MC is associated with higher post-treatment total occlusion rate, but higher complication and lower good clinical outcome rates. EVT are promising in treating unruptured anterior cerebral artery aneurysms with high margin of safety and good clinical outcome, despite the lower total occlusion rate.

Simulation and virtual reality in intracranial aneurysms neurosurgical training: a systematic review

INTRODUCTION

The recent emphasis on simulation-based training in neurosurgery has led to the development of many simulation models and training courses. We aim to identify the currently available simulators and training courses for neurovascular surgery and endovascular interventions to assess their validity and determine their effectiveness to suggest widespread applicability in educational curricula.

EVIDENCE ACQUISITION

Literature research was performed on academic databases for English language articles that validate simulation or virtual reality intracranial aneurysm models. Studies for neurosurgery and interventional neuroradiology published between January 2011 and January 2021 were included. Each study was assessed according to the Medical Education Research Quality Instrument.

EVIDENCE SYNTHESIS

Between January 2011 and January 2021, 44 articles were screened and 12 were identified to be included in our research. The study involved 177 trainers. Participant trainers' characteristics reveal sensible homogeneity between studies. All studies reported a significant improvement in technical outcomes after simulator or virtual reality training. The Medical Education Research Quality Instrument average rate from 12 studies was M=11,7 (range 8,5-14,5).

CONCLUSIONS

Nowadays, the training of a medical doctor in the neurovascular field benefits from modern methods like simulators and virtual reality. With the advent of increasing neurosurgery simulators and training instruments, there is a need for more validity studies. More training tools incorporating full-immersion simulation are recommended to develop a standardized learning curve in neurovascular procedures.

Preoperative brain shift is a prognostic factor for survival in certain neurosurgical diseases other than severe head injury: a case series and literature review

Preoperative brain shift after severe brain injury is a prognostic factor for survival. The aim of this study was to determine whether preoperative brain shift in conditions other than severe head injury has significant prognostic value. We analyzed a radiological database of 800 consecutive patients, who underwent neurosurgical treatment. Brain shift was measured at two anatomical landmarks: Monro’s foramina (MF) and the corpus callosum (CC). Four hundred seventy-three patients were included. The disease exerting the highest mean brain shift was acute subdural hematoma (MF 11.6 mm, CC 12.4 mm), followed by intraparenchymal hematoma (MF 10.2 mm, CC 10.3 mm) and malignant ischemia (MF 10.4 mm, CC 10.5 mm). On univariate analysis, brain shift was a significant negative factor for survival in all diseases (p < 0.001). Analyzed individually by group, brain shift at both anatomical landmarks had a statistically significant effect on survival in malignant ischemia and at one anatomical landmark in chronic subdural and intraparenchymal hematomas. Multivariate analysis demonstrated that the only independent factor negatively impacting survival was brain shift at MF (OR = 0.89; 95% CI: 0.84–0.95) and CC (OR = 0.90; 95% CI: 0.85–0.96). Brain shift is a prognostic factor for survival in patients with expansive intracranial lesions in certain neurosurgical diseases. MF and CC are reliable anatomical landmarks and should be quoted routinely in radiological reports as well as in neurosurgical practice.

Cone-beam CT angiography to assess the microvascular anatomy of intracranial arterial dissections

BACKGROUND

Intracranial artery dissection is a rare and generally under-recognized cause of ischaemic stroke or subarachnoid haemorrhage.

OBJECTIVES

The aim of this study was to analyse the efficacy of cone-beam computed tomography angiography (CBCT-A) to detect arterial ultrastructural alterations in intracranial artery dissection.

METHOD

This is an observational and retrospective case series.

RESULTS

Between January 2018 and November 2020, four patients were admitted with an acute ischaemic stroke due to intracranial dissection studied with CBCT-A. In all cases, the CBCT-A documented vascular ultrastructural alterations related with the intracranial dissection.

CONCLUSIONS

CBCT-A is an intraprocedural diagnostic technique that is useful for the diagnosis of intracranial dissections.

Long-term follow-up of the Derivo® Embolization Device (DED®) for intracranial aneurysms: the Italian Multicentric Registry

BACKGROUND

The flow-diverter devices (FDDs) safety and effectiveness have been demonstrated by large series and meta-analyses. Due to the high occlusion rates and the acceptable morbidity rates of FDDs, the indications for their use are continuously expanding. We presented our Italian multicentric experience using the second generation of DERIVO® Embolization Device (DED^®; Acandis, Pforzheim, Germany) to cure cerebral aneurysms, evaluating both middle and long-term safety and efficacy of this device.

METHODS

Between July 2016 and September 2017 we collected 109 consecutive aneurysms in 108 patients treated using DED^® during 109 endovascular procedures in 34 Italian centers (100/109 aneurysms were unruptured, 9/109 were ruptured). The collected data included patient demographics, aneurysm location and characteristics, baseline angiography, adverse event and serious adverse event information, morbidity and mortality rates, and pre- and post-treatment modified Rankin Scale scores. Midterm and long-term clinical, angiographic and cross-sectional CT/MR follow-up were recorded and collected until December 2018.

RESULTS

In 2/109 cases, DED^® placement was classified as technical failures. The overall mortality and morbidity rates were respectively 6.5% and 5.5%. Overall DERIVO® related mortality and morbidity rates were respectively 0% and 4.6% (5 out of 108 patients). Midterm neuroimaging follow-up showed the complete or nearly complete occlusion of the aneurysm in 90% cases, which became 93% at long-term follow-up. Aneurysmal sac shrinking was observed in 65% of assessable aneurysms.

CONCLUSIONS

Our multicentric experience using DED^® for endovascular treatment of unruptured and ruptured aneurysms showed a high safety and efficacy profile, substantially equivalent or better compared to the other FDDs.

High Grade Glioma Treatment in Elderly People: Is It Different Than in Younger Patients? Analysis of Surgical Management Guided by an Intraoperative Multimodal Approach and Its Impact on Clinical Outcome

OBJECTIVE

Age is considered a negative prognostic factor for High Grade Gliomas (HGGs) and many neurosurgeons remain skeptical about the benefits of aggressive treatment. New surgical and technological improvements may allow extended safe resection, with lower level of post-operative complications. This opportunity opens the unsolved question about the most appropriate HGG treatment in elderly patients. The aim of this study is to analyze if HGG maximal safe resection guided by an intraoperative multimodal imaging protocol coupled with neuromonitoring is associated with differences in outcome in elderly patients versus younger ones.

METHODS

We reviewed 100 patients, 53 (53%) males and 47 (47%) females, with median (IQR) age of 64 (57; 72) years. Eight patients were diagnosed with Anaplastic Astrocytoma (AA), 92 with Glioblastoma (GBM). Surgery was aimed to achieve safe maximal resection. An intraoperative multimodal imaging protocol, including neuronavigation, neurophysiological monitoring, 5-ALA fluorescence, 11C MET-PET, navigated i-US system and i-CT, was used, and its impact on EOTR and clinical outcome in elderly patients was analyzed. We divided patients in two groups according to their age: <65 and >65 years, and surgical and clinical results (EOTR, post-operative KPS, OS and PFS) were compared. Yet, to better understand age-related differences, the same patient cohort was also divided into <70 and >70 years and all the above data reanalyzed.

RESULTS

In the first cohort division, we did not found KPS difference over time and survival analysis did not show significant difference between the two groups (p = 0.36 for OS and p = 0.49 for PFS). Same results were obtained increasing the age cut-off for age up to 70 years (p = 0.52 for OS and p = 0.92 for PFS).

CONCLUSIONS

Our data demonstrate that there is not statistically significant difference in post-operative EOTR, KPS, OS, and PFS between younger and elderly patients treated with extensive tumor resection aided by a intraoperative multimodal protocol.

Peritumoral Microenvironment in High-Grade Gliomas: From FLAIRectomy to Microglia-Glioma Cross-Talk

Cellular composition and molecular signatures of the glioma core compared with infiltrative margins are different, and it is well known that the tumor edge is enriched in microglia. In this review of the literature, we summarize the role of the peritumoral area in high-grade gliomas (HGGs) from surgical and biological points of view. There is evidence on the dual role of microglia in HGGs-a scavenger-tumoricidal role when microglia are activated in an M1 phenotype and a role favoring tumor growth and infiltration/migration when microglia are activated in an M2 phenotype. Microglia polarization is mediated by complex pathways involving cross-talk with glioma cells. In this scenario, extracellular vesicles and their miRNA cargo seem to play a central role. The switch to a specific phenotype correlates with prognosis and the pathological assessment of a specific microglial setting can predict a patient's outcome. Some authors have designed an engineered microglial cell as a biologically active vehicle for the delivery of intraoperative near-infrared fluorescent dye with the aim of helping surgeons detect peritumoral infiltrated areas during resection. Furthermore, the pharmacological modulation of microglia-glioma cross-talk paves the way to more effective therapies.

Recurrent high-grade glioma surgery: a multimodal intraoperative protocol to safely increase extent of tumor resection and analysis of its impact on patient outcome

OBJECTIVE

No consensus exists on the best treatment for recurrent high-grade glioma (HGG), particularly in terms of surgical indications, and scant data are available on the integrated use of multiple technologies to overcome intraoperative limits and pitfalls related to artifacts secondary to previous surgery and radiotherapy. Here, the authors report on their experience with the integration of multiple intraoperative tools in recurrent HGG surgery, analyzing their pros and cons as well as their effectiveness in increasing the extent of tumor resection. In addition, they present a review of the relevant literature on this topic.

METHODS

The authors reviewed all cases in which recurrent HGG had been histologically diagnosed after a first surgery and the patient had undergone a second surgery involving neuronavigation with MRI, intraoperative CT (iCT), 11C-methionine-positron emission tomography (11C-MET-PET), 5-aminolevulinic acid (5-ALA) fluorescence, intraoperative neurophysiological monitoring (IONM), and intraoperative navigated ultrasound (iUS). All cases were classified according to tumor functional grade (1, noneloquent area; 2, near an eloquent area; 3, eloquent area).

RESULTS

Twenty patients with recurrent HGG were operated on using a multimodal protocol. The recurrent tumor functional grade was 1 in 4 patients, 2 in 8 patients, and 3 in the remaining 8 patients. In all patients but 2, 100% EOTR was obtained. Intraoperative 5-ALA fluorescence and navigated iUS showed low specificity and sensitivity. iCT detected tumor remnants in 3 cases. Postoperatively, 6 patients (30%) had worsening neurological conditions: 4 recovered within 90 days, 1 partially recovered, and 1 experienced a permanent deficit. The median Karnofsky Performance Status remained substantially unchanged over the follow-up period. The mean progression-free survival after the second surgery was 7.7 months (range 2-11 months). The mean overall survival was 25.4 months (range 10-52 months), excluding 2 long survivors. Two patients died within 60 days after surgery, and 3 patients were still under follow-up at the end of this study.

CONCLUSIONS

This is the first study reporting the integration of neuronavigation, 5-ALA fluorescence, iUS, iCT, 11C-MET-PET, and IOM during microsurgical resection of recurrent glioma. The authors believe that the proposed multimodal protocol is useful to increase the safety, effectiveness, and EOTR in patients with recurrent HGG and brain alterations secondary to radio- and chemotherapy.

Intracranial meningioma and concomitant cavernous malformation: A series description and review of the literature

OBJECTIVES

Intracranial meningioma with concomitant cavernous malformation has been rarely described in the literature. This study aimed to investigate the correct neurosurgical conduct.

PATIENTS AND METHODS

We retrieved clinical and radiological data for 39 outpatients or patients that underwent surgery (mean age: 60 years; n = 25 females) for a single or multiple meningiomas and concomitant single or multiple cavernous malformations. Cavernous malformations were classified according to Zabramski's type scale. Our results were compared to results published in the literature.

RESULTS

All patients had at least one meningioma and at least one concomitant cavernous malformation. Most meningiomas and cavernous malformations were located in the supratentorial region. Nine patients (23 %) had multiple meningiomas and nine had concomitant multiple cavernous malformations. Cavernous malformations were classified as type I (n = 0), type II (n = 9), type III (n = 11), or type IV (n = 19). The surgical priority was meningioma removal. A single patient underwent simultaneous removal of a meningioma and a contiguous cavernous malformation. In the postoperative period and long term follow-up, no complications occurred related to cavernous malformations, intra- or extra-lesional bleeding, or morphology/size changes. Years after surgical treatment, a new type IV cavernous malformation occurred in two patients.

CONCLUSION

Our findings corroborate that meningioma removal should take priority in patients with intracranial meningioma and concomitant cavernous malformation. Concomitant cavernous malformations showed no change in morphology or size; therefore, they should merely be observed during follow-up. In patients that harbor a single meningioma, a type IV cavernous malformation should preferably be considered a concomitant cerebral microbleed.

Radial Arterial Access for Thoracic Intraoperative Spinal Angiography in the Prone Position

BACKGROUND

Verification of complete occlusion or resection of neurovascular lesions is often performed using intraoperative angiography. Surgery for spinal vascular lesions such as arteriovenous malformations (AVMs) and arteriovenous fistulas (AVFs) is typically performed with the patient in the prone position, making intraoperative angiography difficult. No standardized protocol is available for intraoperative angiography during spinal surgery with the patient in the prone position. We have described our experience using radial artery access for intraoperative angiography in thoracic spinal neurovascular procedures performed with the patient in the prone position.

METHODS

We reviewed the data from all patients who had undergone surgical resection of spinal vascular lesions in the prone position with radial artery vascular access for intraoperative angiography. The patients were treated in a hybrid endovascular operating room.

RESULTS

A total of 4 patients were treated in the prone position using transradial artery access intraoperative angiography for confirmation of complete resection of the vascular lesions. Of the 4 patients, 2 had undergone surgery for a dural AVF, 1 for a pial AVF, and 1 for an AVM of the filum terminale. None of the patients had experienced any procedural complications.

CONCLUSION

Radial artery access for intraoperative angiography during spinal neurovascular procedures in which selective catheterization of a thoracic branch is necessary is feasible, safe, and practical.

Possible Empirical Evidence of Glymphatic System on Computed Tomography After Endovascular Perforations

BACKGROUND

The glial-lymphatic pathway is a fluid-clearance pathway consisting of a para-arterial route for the flow of cerebrospinal fluid along perivascular spaces and subsequently toward the brain interstitium. In this case series, we aim to investigate an empirical demonstration of glymphatic clearance of extravasated iodine following perforation incurred during endovascular therapy on serial computed tomography.

METHODS

Six consecutive cases of endovascular perforation during thrombectomy performed between 2005 and 2018 were retrospectively collected by searching our internal database of total 446 thrombectomies. Two cases were excluded because care was withdrawn shortly following the procedure and no follow-up imaging was available. One case was excluded because a ventricular drain was placed. Three cases were hence included in this analysis.

RESULTS

All 3 cases demonstrated progressive absorption of contrast by the brain parenchyma with eventual contrast disappearance.

CONCLUSIONS

We described a likely in vivo computed tomography correlate of the glymphatic system in a cohort of patients who sustained intraprocedural extravasation during thrombectomy for acute ischemic stroke.

Mechanical Thrombectomy of Distal Occlusions Using a Direct Aspiration First Pass Technique Compared with New Generation of Mini-0.017 Microcatheter Compatible-Stent Retrievers: A Meta-Analysis

BACKGROUND

There are no current evidence-based recommendations on mechanical thrombectomy (MT) in M2 or other distal occlusions. The objective of this paper was to investigate clinical and radiologic outcomes of MT in distal locations using the new generation of mini-0.017 microcatheter compatible-stent retrievers (SRs) compared with a direct aspiration first pass technique (ADAPT) MT.

METHODS

A systematic search was performed for studies published from January 2016 to March 2019. According to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, we included studies that reported clinical and radiologic outcomes of patients undergoing MT using new generation of SRs or ADAPT in distal locations. The cumulative prevalence was estimated for each outcome. Heterogeneity of the data was assessed by the Higgins index (I²), and a random-effects model was applied.

RESULTS

Fifteen studies and 494 patients were included; 7 studies reported on patients treated with a new SR and 8 studies analyzed patients treated with ADAPT. The rate of thrombolysis in cerebral infarction score 2b-3 after MT for distal occlusions was 80.6% (383 of 494; 95% confidence interval [CI], 74.8%-86.3%; I² = 64.4%). Successful recanalization was comparable after SR use with low-profile devices and ADAPT (176 of 226; 82%; 95% CI, 72.6%-1.5%; I² = 70.5% vs. 207 of 268; 79.4%; 95% CI, 71.8%-86.9%; I² = 60.8%, respectively; P = 0.4). The rate of the modified Rankin scale score of 0-2 at 3 months was higher in the ADAPT group (160 of 251; 68.9%; 95% CI, 51.8%-85.9%; I² = 92.2%) than the SR group (92 of 177; 58.7%; 95% CI, 37.3%-80%; I² = 58.7%; P = 0.01). The mortality rate was lower among the ADAPT group (20 of 251; 5.4%; 95% CI, 1.4%-9%; I² = 63%) than the SR group (16 of 108; 13%; 95% CI, 6%-19%; I² = 13%; P = 0.008).

CONCLUSIONS

MT in distal locations using the new generation of SR yields comparable results compared with ADAPT in terms of recanalization; however, the use of SR is associated with lower functional independence and higher mortality rate.

Pros and cons of a minimally invasive percutaneous subdural drainage system for evacuation of chronic subdural hematoma under local anesthesia

OBJECTIVE

Chronic subdural hematoma (CSH) is a common neurosurgical disease among elderly population with concomitant degenerative neurological disorders. This is a retrospective series-control analysis of prospectively collected data, aiming to show advantages and indications of a minimally invasive, percutaneous drainage system for CSH.

PATIENTS AND METHODS

We retrospectively analyse the clinical and radiological data of a minimally invasive, percutaneous draining system (Integra ™) used in fifteen patients (Group A; mean age: 75.7) with CSH, and compare them with those obtained from two retrospective series of patients: the first one (Group B 15 patients, mean age 77.1) treated with standard, single-burr hole technique for subdural drainage under general anaesthesia; the second one (Group C 15 patients, mean age 76.4) treated with standard, single-burr hole technique for subdural drainage under local anaesthesia and mild sedation. All The percutaneous procedures (Group A) were performed under local anaesthesia.

RESULTS

Mean follow-up was 10.9 (range 3-14), 18.2 (range 10-29) and 15.2 (range 8-28) months in Group A, B and C respectively. Three of 15 and in Group B experienced a worsening of pre-existing neurodegenerative disorders after general anaesthesia. One patient in group C suffering from Parkinson's disease experienced a worsening of gait disturbances. Post-operative CT scans were performed at 48 h and 21 days after the operation. An early post-operative CT-scan, obtained immediately after surgical procedure, was performed in all Group A patients. No differences in CSH evacuation were observed comparing the three groups. Two recurrent hematomas, one in group A and one in group B, required revision. Post-operative hospitalization was similar (5.1 vs 5.7 vs 5.6 days, respectively, in group A, B and C) but analgesics use was lower in Group A.

CONCLUSION

Pre-operative evaluation of radiological features of CSDHs is crucial in determining the right indication for a minimally invasive drainage. Minimally invasive treatments of CSH may reduce the use of anaesthetic drugs and worsening of pre-existing neurodegenerative disorders.

Supramarginal resection of glioblastoma: 5-ALA fluorescence, combined intraoperative strategies and correlation with survival

INTRODUCTION

Glioblastoma treatment requires a multidisciplinary approach involving oncologists, radiotherapists and surgeons. Surgery constitutes the initial step of the therapeutic strategy and its efficacy is dependent on the extent of resection (EOR). Over the last decade, the goal of surgical treatment was the resection of the contrast enhancement on T1 MRI, defined as gross-total resection (GTR). More recently, an increasing number of studies reports a positive impact on survival parameters of a more aggressive surgical strategy aiming to resect all peri-tumoral infiltrated areas. These areas are histologically characterized by the presence of pathological cells infiltrating normal white matter and surround the neoplastic core of glioblastoma identified by gadolinium enhancement in T1-weighted MR. Intuitively, the major risk of the so called supramarginal resection is related to the possibility of resecting functionally eloquent brain tissue. Several strategies have been proposed to maximize the safety of resection and minimize the occurrence of postoperative functional deficits. The aim of this review was to focus on the clinical impact of supramarginal resection of glioblastomas, highlighting the role of image-guided surgery combined with neuromonitoring to increase surgical safety and efficacy.

EVIDENCE ACQUISITION

The MEDLINE database has been queried for the literature research.

EVIDENCE SYNTHESIS

Ten studies matched the inclusion criteria, reporting a global number of 3221 patients.

CONCLUSIONS

The current evidence suggests a positive correlation between a more extensive resection based on FLAIR abnormal areas and overall survival.

Endovascular Treatment of Large and Giant Carotid Aneurysms with Flow-Diverter Stents Alone or in Combination with Coils: A Multicenter Experience and Long-Term Follow-up

BACKGROUND

Although flow diverters (FDs) have been widely accepted by neurointerventionists, their safety has yet to be fully defined. Stratification by aneurysm size and location is essential for correct evaluation of treatment outcomes and risks of flow diversion.

OBJECTIVE

To compare neurological and anatomic outcomes and evaluate the risk of complications after endovascular treatment of large or giant internal carotid artery (ICA) aneurysms with FD/FDs alone or together with coil embolization.

METHODS

We reviewed all patients with large or giant, ruptured or unruptured ICA aneurysms who underwent endovascular treatment with flow diversion alone (group A) or with concomitant coiling (group B) in 4 international institutions between 2010 and 2015. Anatomic outcome was evaluated using the Byrne scale on digital subtraction angiography and/or angioMRI and/or angioCT scans 3, 6, 12, and 24 months postoperatively.

RESULTS

We collected 44 patients with large or giant ICA aneurysms. Four patients (9%) presented with aneurysmal subarachnoid hemorrhage (SAH). FD/FDs were used alone in 26 patients and in combination with coil embolization in the 18 remaining patients. The mortality rate due to procedure-related and/or neurological complications was 2.2%. Twelve months after the procedure, 88.6% (n = 39) of patients had a favorable neurological outcome. One year after the procedure, the aneurysm was completely occluded in 72.7% of patients: 61.5% (16/18) in group A and 88.9% (16/26) in group B.

CONCLUSION

Clinical outcomes and rates of intraoperative and postoperative complications did not differ significantly between the groups. Better anatomic results using FD/FDs combined with coils were documented 6 months after the procedure; this option seems to provide a higher aneurysm occlusion rate and reduce the need for retreatment.

IER-SICH Nomogram to Predict Symptomatic Intracerebral Hemorrhage After Thrombectomy for Stroke

Background and Purpose—

As a reliable scoring system to detect the risk of symptomatic intracerebral hemorrhage after thrombectomy for ischemic stroke is not yet available, we developed a nomogram for predicting symptomatic intracerebral hemorrhage in patients with large vessel occlusion in the anterior circulation who received bridging of thrombectomy with intravenous thrombolysis (training set), and to validate the model by using a cohort of patients treated with direct thrombectomy (test set).

Methods—

We conducted a cohort study on prospectively collected data from 3714 patients enrolled in the IER (Italian Registry of Endovascular Stroke Treatment in Acute Stroke). Symptomatic intracerebral hemorrhage was defined as any type of intracerebral hemorrhage with increase of ≥4 National Institutes of Health Stroke Scale score points from baseline ≤24 hours or death. Based on multivariate logistic models, the nomogram was generated. We assessed the discriminative performance by using the area under the receiver operating characteristic curve.

Results—

National Institutes of Health Stroke Scale score, onset-to-end procedure time, age, unsuccessful recanalization, and Careggi collateral score composed the IER-SICH nomogram. After removing Careggi collateral score from the first model, a second model including Alberta Stroke Program Early CT Score was developed. The area under the receiver operating characteristic curve of the IER-SICH nomogram was 0.778 in the training set (n=492) and 0.709 in the test set (n=399). The area under the receiver operating characteristic curve of the second model was 0.733 in the training set (n=988) and 0.685 in the test set (n=779).

Conclusions—

The IER-SICH nomogram is the first model developed and validated for predicting symptomatic intracerebral hemorrhage after thrombectomy. It may provide indications on early identification of patients for more or less postprocedural intensive management.

IER-START nomogram for prediction of three-month unfavorable outcome after thrombectomy for stroke

BACKGROUND

The applicability of the current models for predicting functional outcome after thrombectomy in strokes with large vessel occlusion (LVO) is affected by a moderate predictive performance.

AIMS

We aimed to develop and validate a nomogram with pre- and post-treatment factors for prediction of the probability of unfavorable outcome in patients with anterior and posterior LVO who received bridging therapy or direct thrombectomy <6 h of stroke onset.

METHODS

We conducted a cohort study on patients data collected prospectively in the Italian Endovascular Registry (IER). Unfavorable outcome was defined as three-month modified Rankin Scale (mRS) score 3-6. Six predictors, including NIH Stroke Scale (NIHSS) score, age, pre-stroke mRS score, bridging therapy or direct thrombectomy, grade of recanalization according to the thrombolysis in cerebral ischemia (TICI) grading system, and onset-to-end procedure time were identified a priori by three stroke experts. To generate the IER-START, the pre-established predictors were entered into a logistic regression model. The discriminative performance of the model was assessed by using the area under the receiver operating characteristic curve (AUC-ROC).

RESULTS

A total of 1802 patients with complete data for generating the IER-START was randomly dichotomized into training (n = 1219) and test (n = 583) sets. The AUC-ROC of IER-START was 0.838 (95% confidence interval [CI]): 0.816-0.869) in the training set, and 0.820 (95% CI: 0.786-0.854) in the test set.

CONCLUSIONS

The IER-START nomogram is the first prognostic model developed and validated in the largest population of stroke patients currently candidates to thrombectomy which reliably calculates the probability of three-month unfavorable outcome.

Low-intensity focused ultrasound for the treatment of brain diseases: safety and feasibility

The use of focused ultrasound (FUS) as a tool for blood-brain barrier (BBB) permeabilization is opening new ways for the treatment of several pathologies, in particular brain tumors and neurodegenerative diseases. However, even if there are promising results in these fields, the efficacy and safety of this technique is unknown in long-term follow-up. The study of Blackmore et al. [Theranostics 2018; 8(22):6233-6247. doi:10.7150/thno.27941] evaluated the long-term effects of FUS on brain parenchyma in aged mice with Alzheimer's disease. This is the first study which applied a multimodal analysis to demonstrate the safety of FUS in aged brain in view of a potential introduction of this technique in common clinical practice in the future.

Comparison of Subacute Vascular Damage Caused by ADAPT versus Stent Retriever Devices after Thrombectomy in Acute Ischemic Stroke: Histological and Ultrastructural Study in an Animal Model

Objectives

To assess the delayed (15 days) histological and ultrastructural changes occurring following endovascular treatment with a direct aspiration first pass technique (ADAPT) or stent retrievers (SRs) and to compare the findings in order to determine which is the least harmful technique and what changes occur.

Materials and Methods

Damage to the wall of swine extracranial arteries was evaluated after ADAPT with the Penumbra system or thrombectomy with various SRs. The procedures were performed using two pigs as animal models; extracranial cervical arteries were selected based on their diameters in order to reproduce the procedures as in human intracranial arteries, and endovascular thrombectomies were done after the injection of autologous thrombi. Two weeks later, the animals were euthanized, and 60 arterial samples were obtained for analysis by optical and electron microscopy.

Results

Optical and electron microscopy revealed that both techniques cause, in different way, alterations to the structure of the vessel wall.

Conclusions

Both techniques caused damage to the vessel wall. The main damages were localized at the level of the tunica media and adventitia, instead of the tunica intima as in the acute phase. Further investigation is required to better understand whether these alterations could have chronic consequences.

Active Reperfusion Hemorrhage during Thrombectomy: Angiographic Findings and Real-Time Correlation with the CT "Spot Sign"

Introduction

Symptomatic intracranial hemorrhage represents one of the most feared complications of endovascular reperfusion. We aim to describe a series of patients that experienced immediate reperfusion injury with active intraprocedural extravasation within the territory of the deep penetrating arteries and provide real-time correlation with CT "spot sign."

Methods

This was a retrospective analysis of patients that suffered reperfusion injury with active arterial extravasation during endovascular stroke treatment in two tertiary care centers.

Results

Five patients were identified. Median age was 63 (58-71) years, 66% were male. Median NIHSS was 13.5 (9.5-23.0), platelet level 212,000 (142,000-235,000), baseline systolic blood pressure 152 (133-201) mm Hg, and non-contrast CT ASPECTS 7.0 (6.5-9.0). Two patients were taking aspirin and one had received intravenous thrombolysis. There were three middle cerebral artery M1, one internal carotid artery terminus, and one vertebrobasilar junction occlusion. Three patients had anterior circulation tandem occlusions. Stroke etiology was extracranial atherosclerosis (n = 2), intracranial atherosclerosis (n = 2), and cervical dissection (n = 1). The median time from onset to puncture was 5.5 (3.9-8.6) h. Intravenous heparin was administered in all patients (median dose of 4,750 [3,250-6,000] units) and intravenous abciximab in four. All tandem cases had the cervical lesion addressed first. Four lenticulostriates and one paramedian pontine artery were involved. Intraprocedural flat-panel CT was performed in four (80%) cases and provided real-time correlation between the active contrast extravasation and the "spot sign." The bailout included use of protamine, blood pressure control, and balloon guide catheter or intracranial compliant balloon inflation plus coiling of targeted vessel. All patients had angiographic cessation of bleeding at the end of the procedure with parenchymal hemorrhage type 1 in one case and type 2 in four. Three patients had modified Rankin score of 4 and two were dead at 90 days.

Conclusions

Active reperfusion hemorrhage involving perforator arteries was observed to correlate with the CT "spot sign" and to be associated with poor outcomes.

In normal aging ventricular system never attains pathological values of Evans' index

Ventricular enlargement in normal aging frequently forces the radiological diagnosis of hydrocephalus, but the reliability of Evans' index as a radiological marker of abnormal ventricular enlargement (values > 0.30) during aging is not assessed. Here we analyze ventricular size during aging and the reliability of Evans' index as a radiological marker of abnormal ventricular enlargement. We calculated Evans' index in the axial Computed Tomography scans of 1221 consecutive individuals (aged 45-101 years) from an emergency department. Stratified analysis of one-year cohorts showed that the mean Evans' index value per class was invariably < 0.30. Roughly one out five Computed Tomography scans was associated with Evans' index values > 0.30 and Evans' index values increased with age. The risk of having an Evans' index value > 0.30 increased by 7.8% per year of age (p < 0.001) and males were at 83.9% greater risk than females (p < 0.001). Overall, this study shows that normal aging enlarges the ventricular system, but never causes abnormal ventricular enlargement. Evans' index values > 0.30 should reflect an underlying neurological condition in every individual.

Aneurysms of the Intracranial Segment of the Ophthalmic Artery Trunk: Case Report and Systematic Literature Review

Aneurysms arising from the ophthalmic artery trunk (OAT) are very rare, particularly in the artery's intracranial course. The onset of a subarachnoid hemorrhage (SAH) from a ruptured OAT aneurysm in this segment is extremely rare. We present a case and discuss the anatomy, clinical significance, and therapeutic options for an aneurysm at this site. We also retrospectively analyzed the record of a patient with a ruptured aneurysm of the intracranial segment of the OAT and conducted a comprehensive and systematic review of the PubMed and Scopus databases for literature on this pathology. Only one case report of SAH from an aneurysm of the intracranial segment of the OAT was published in the literature. Only in our case was the intracranial OAT segment aneurysm discovered in the acute phase of SAH. Conventional angiography with three-dimensional acquisition may help detect aneurysms at this level. Detailed knowledge of the anatomy of the OAT is of paramount importance for both surgical and endovascular approaches. Surgical treatment is complex because of difficulties in accessing the orbital region and the risk of optic nerve and vascular injuries. Endovascular treatment, when feasible, could be a good alternative to reduce the risk of loss of vision related to surgical manipulation.

Real-Time Distal, Multifocal, Repeated Lenticulostriate Bleeding Points during Thrombectomy in a Patient with Acute Variable M1 Occlusion: A Case Report and a Literature Review

BACKGROUND

Intracerebral hemorrhage can be classified as either primary or secondary to various conditions such as vascular anomalies or stroke. We present a case of real-time incident detected on digital subtraction angiography (DSA) during thrombectomy in a patient with acute variable M1 occlusion.

MATERIALS AND METHODS

A comprehensive literature search of the PubMed and Scopus databases was conducted: this is the first real-time visualization using DSA of a basal ganglia hematoma formation secondary to distal multifocal bleeding points just before a thrombectomy in a patient with acute variable M1 occlusion.

CONCLUSION

We suggest that the positions of the clot before and during the procedure be compared always.