Search

Background Cerebello-pontine AVMs (CPAVMs) and petrous apex dural arteriovenous fistulae (DAVFs) are rare and sometimes difficult to distinguish. We report a fatal hemorrhagic complication after coil embolization of the petrosal vein draining a trigeminal AVM misdiagnosed as a DAVF. Case presentation A 73-year-old woman with a petrous apex arteriovenous shunt with dual dural and pial arterial supply presented with posterior fossa hemorrhage. The draining petrosal vein was catheterized and coiled via the superior petrosal sinus. Two episodes of contrast extravasation occurred during coiling, but the lesion was completely occluded at the end of the procedure. The patient developed a fatal posterior fossa hemorrhage in the recovery room. Microscopic pathology revealed numerous dilated vessels within the trigeminal nerve. Conclusion CPAVMs and DAVFs with pial drainage should be distinguished pre-operatively. Occlusion of a pial vein (as opposed to a sinus) in the treatment of an arteriovenous shunt carries hemorrhagic risk if a liquid embolic agent is not used to completely occlude all pathological vessels.

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

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

The Comprehensive Aneurysm Management (CAM) study is a pragmatic trial designed to manage unruptured intracranial aneurysm (UIA) patients within a care research framework.CAM is an all-inclusive study. Management options are allocated according to an algorithm combining pre-randomization and clinical judgment. Eligible patients are offered 1:1 randomized allocation of intervention versus conservative management and 1:1 randomization allocation of surgical versus endovascular treatment. Ineligible patients are registered. The primary outcome is survival without dependency (modified Rankin Scale score3) at 10 years. All UIA patients at 1 center are reported.Between February 2020 and July 2021, 403 UIA patients were recruited: 179 (44%) in one of the randomized controlled trials (RCTs) and 224 (56%) in one of the registries. Conservative management was recommended for 205 of 403 patients (51%); of 198 (49%) patients considered for curative treatment, 159 (80%) were randomly allocated conservative (n = 81) or curative treatment (n = 78). These patients were younger and had larger aneurysms than those in the observation registry (P = 0.004). In 39 of 198 patients (20%), conservative management was not considered reasonable (17 patients were recommended endovascular, 2 surgery, and 20 the RCT comparing endovascular with surgical treatment). In total, 70 patients were recruited in the RCT comparing surgery and endovascular treatment. After informed discussion at time of consent, 141 of 159 patients (89%) agreed with the randomly allocated management plan, while 11% crossed over to the alternative management option.CAM was successfully integrated into routine practice. Meaningful conclusions can be obtained if multiple centers actively participate in the trial.

Background Aneurysms of spinal arteries not associated with any known predisposing condition are referred to as isolated spinal aneurysms (SAs). In our series, an SA was found in 2 patients during the postpartum period. The goal of this study is to determine whether an occurrence of an SA may be related to puerperium. Methods In a retrospective analysis of our consecutive series of 10 cases of SAs from 2008 to 2020, we identified 2 cases of SAs during puerperium. Patients' charts and imaging were reviewed, for potential predisposing factors. Results In both cases, angiography showed fusiform aneurysms of the anterior SA with concomitant bilateral vertebral artery (VA) dissections. Serum vasculitis and inflammatory panel and genetic testing for collagen disorders were negative in both cases. Review of the literature showed that pregnancy is associated with an increased risk of arterial dissections in various locations and supports the hypothesis that hemodynamic and hormonal changes may play a role in the formation of SAs. Conclusions Pregnancy and peripartum state may be a distinct cause of the formation of SAs, possibly as a result of increased hemodynamic stress and hormonal changes that may alter the arterial wall. It would be appropriate to add pregnancy as a subgroup in the classification of SAs. In our series, both cases were associated with bilateral VA dissections; it is possible that the bilateral VA stenosis may have contributed to the formation of the SAs. It is important to recognize this possibility when considering the occlusion of a dissected VA.

BACKGROUND AND PURPOSE: Noninvasive angiography is commonly used to assess the outcome of surgical or endovascular treatment of intracranial aneurysms in clinical series or randomized trials. We sought to assess whether a standardized 3-grade classification system could be reliably used to compare the CTA and MRA results of both treatments. MATERIALS AND METHODS: An electronic portfolio composed of CTAs of 30 clipped and MRAs of 30 coiled aneurysms was independently evaluated by 24 raters of diverse experience and training backgrounds. Twenty raters performed a second evaluation 1 month later. Raters were asked which angiographic grade and management decision (retreatment; close or long-term follow-up) would be most appropriate for each case. Agreement was analyzed using the Krippendorff α (α(K)) statistic, and the relationship between angiographic grade and clinical management choice, using the Fisher exact and Cramer V tests. RESULTS: Interrater agreement was substantial (α(K) = 0.63; 95% CI, 0.55–0.70); results were slightly better for MRA results of coiling (α(K) = 0.69; 95% CI, 0.56–0.76) than for CTA results of clipping (α(K) = 0.58; 95% CI, 0.44–0.69). Intrarater agreement was substantial to almost perfect. Interrater agreement regarding clinical management was moderate for both clipped (α(K) = 0.49; 95% CI, 0.32–0.61) and coiled subgroups (α(K) = 0.47; 95% CI, 0.34–0.54). The choice of clinical management was strongly associated with the size of the residuum (mean Cramer V = 0.77 [SD, 0.14]), but complete occlusions (grade 1) were followed more closely after coiling than after clipping (P = .01). CONCLUSIONS: A standardized 3-grade scale was found to be a reliable and clinically meaningful tool to compare the results of clipping and coiling of aneurysms using CTA or MRA.

Background Rupture of spinal aneurysms is a rare cause of subarachnoid hemorrhage. These aneurysms are often associated with a variety of vascular malformations that increase blood flow in the spinal circulation or with disorders that compromise the vessel wall. However, spinal aneurysms may be isolated, not associated with any known predisposing condition. The objective of this study is to explore the possible mechanisms associated with the formation and rupture of isolated spinal aneurysms (ISAs). Methods We conducted a retrospective review of a series of consecutive patients admitted for a ruptured ISA. In all cases, spinal angiography confirmed the presence of a spinal aneurysm responsible for the bleeding. Particular attention was paid to medical history and symptoms before bleeding, for potential factors predisposing to their formation and rupture. Results Between 2008 and 2020, ten cases of spinal aneurysms were seen at our institution including 4 cases of ISA. All patients with ISA were female, and in 3 cases the aneurysm involved the territory of the posterior spinal artery. In 3 of these 4 (75%) ISA cases, there was a strikingly similar history of retching and vomiting preceding the thunderclap headache. In 1 patient, the aneurysm was surgically resected; pathologic analysis revealed a fusiform dissecting aneurysm. All 4 patients had a favorable outcome. Conclusions We suggest that the straining during prolonged retching and vomiting plays a role in the formation and rupture of some ISAs, possibly because of pressure spikes, increased transmural arterial pressure, and increased wall shear stress during straining.

Results of surgical or endovascular treatment of intracranial aneurysms are often assessed using angiography. A reliable method to report results irrespective of treatment modality is needed to enable comparisons. Our goals were to systematically review existing classification systems, and to propose a 3-point classification applicable to both treatments and assess its reliability. We conducted two systematic reviews on classification systems of angiographic results after clipping or coiling to select a simple 3-category scale that could apply to both treatments. We then circulated an electronic portfolio of angiograms of clipped (n=30) or coiled (n=30) aneurysms, and asked raters to evaluate the degree of occlusion using this scale. Raters were also asked to choose an appropriate follow-up management for each patient based on the degree of occlusion. Agreement was assessed using Krippendorff’s α statistics (αK), and relationship between occlusion grade and clinical management was analyzed using Fisher’s exact and Cramer’s V tests. The systematic reviews found 70 different grading scales with heterogeneous reliability (kappa values from 0.12 to 1.00). The 60-patient portfolio was independently evaluated by 19 raters of diverse backgrounds (neurosurgery, radiology, and neurology) and experience. There was substantial agreement (αK=0.76, 95%CI, 0.67–0.83) between raters, regardless of background, experience, or treatment used. Intra-rater agreement ranged from moderate to almost perfect. A strong relationship was found between angiographic grades and management decisions (Cramer’s V: 0.80±0.12). A simple 3-point scale demonstrated sufficient reliability to be used in reporting aneurysm treatments or in evaluating treatment results in comparative randomized trials.

P2-P3 junction aneurysms are challenging to treat surgically because of their frequent complex morphology and their location deep in close proximity to the midbrain. The sub-temporal route requires significant retraction of the temporal lobe in addition to potential injury to the vein of Labbe. We describe the technique for treating such aneurysms via a lateral supra-cerebellar infra-tentorial (LSCIT) approach, which eliminates manipulation of the temporal lobe. Cadaveric dissection provided comprehensive understanding of relevant anatomy. Intraoperative video shows clipping of the aneurysm using a LSCIT approach. LSCIT approach allows safe clipping of P2-P3 aneurysms with minimal brain manipulation.

Whether the best management of middle cerebral artery (MCA) aneurysm patients is surgical or endovascular remains uncertain, with little evidence to guide decision-making. A randomized care trial offering MCA aneurysm patients a 50% chance of surgical and a 50% chance of endovascular management may optimize outcomes in the presence of uncertainty.The Middle Cerebral Artery Aneurysm Trial (MCAAT) is an investigator-initiated, multicenter, parallel group, prospective, 1:1 randomized controlled clinical trial. All adult patients with MCA aneurysms, ruptured or unruptured, amenable to surgical and endovascular treatment can be included. The composite primary outcome is "Treatment Success": (i) occlusion or exclusion of the aneurysm using the allocated treatment modality; (ii) no intracranial hemorrhage during follow-up; (iii) no retreatment of the target aneurysm during follow-up, (iv) no residual aneurysm on angiographic follow-up; and (v) independence (mRS3) at 1 year. The trial tests 2 versions of the same hypothesis (one for ruptured and one for unruptured MCA aneurysm patients): Surgical management will lead to a 15% absolute increase in the proportion of patients reaching Treatment Success from 55% to 70% (ruptured) or from 75% to 90% (unruptured aneurysm patients) compared with endovascular treatment (any method). In this pragmatic trial, outcome evaluations are by treating physicians, except for 1-year angiographic results which will be core lab assessed. The trial will be monitored by an independent data safety monitoring committee to assure safety of participants. MCAAT is registered at clinicaltrials.gov: NCT05161377.Patients with MCA aneurysms can be optimally managed within a care trial protocol.

Background and purpose Appropriate management of ruptured intracranial aneurysm (RIA) in patients eligible for surgical clipping but under-represented in or excluded from previous randomized trials remains undetermined. Methods The International Subarachnoid Aneurysm Trial-2 (ISAT-2) is a randomized care trial comparing surgical versus endovascular treatment (EVT) of RIA. All patients considered for surgical clipping but eligible for endovascular treatment can be included. The primary endpoint is death or dependency on modified Rankin score (mRS > 2) at 1 year. Secondary endpoints are 1 year angiographic results and length of hospital stay. Results An interim analysis was performed after 103 patients were treated from November 2012 to July 2017 in 4 active centers. Fifty-two of the 55 patients allocated to surgery were treated by clipping, and 45 of the 48 allocated to EVT were treated by coiling, with 3 crossovers in each arm. The main endpoint (1 year mRS > 2), available for 76 patients, was reached in 16/42 patients allocated to clipping (38%; 95%CI: 25%–53%), and 10/34 patients allocated to coiling (29%; 17%–46%). One year imaging results were available in 54 patients: complete aneurysm occlusion was found in 23/27 patients allocated to clipping (85%; 67%–94%), and 18/27 patients allocated to coiling (67%; 47%–81%). Hospital stay exceeding 20 days was more frequent in surgery (26/55 [47%; 34%–60%]) than EVT (9/48 [19%; 10%–31%]). Conclusion Ruptured aneurysm patients for whom surgical clipping may still be best can be managed in a randomized care trial, which is feasible in some centers. More participating centers are needed.

Objective There are few randomized data comparing clipping and coiling for middle cerebral artery (MCA) aneurysms. We analyzed results from patients with MCA aneurysms enrolled in the CURES (Collaborative UnRuptured Endovascular vs. Surgery) and ISAT-2 (International Subarachnoid Aneurysm Trial II) randomized trials. Methods Both trials are investigator-led parallel-group 1:1 randomized studies. CURES includes patients with 3-mm to 25-mm unruptured intracranial aneurysms (UIAs), and ISAT-2 includes patients with ruptured aneurysms (RA) for whom uncertainty remains after ISAT. The primary outcome measure of CURES is treatment failure: 1) failure to treat the aneurysm, 2) intracranial hemorrhage during follow-up, or 3) residual aneurysm at 1 year. The primary outcome of ISAT-2 is death or dependency (modified Rankin Scale score >2) at 1 year. One-year angiographic outcomes are systematically recorded. Results There were 100 unruptured and 71 ruptured MCA aneurysms. In CURES, 90 patients with UIA have been treated and 10 await treatment. Surgical and endovascular management of unruptured MCA aneurysms led to treatment failure in 3/42 (7%; 95% confidence interval [CI], 0.02–0.19) for clipping and 13/48 (27%; 95% CI, 0.17–0.41) for coiling (P = 0.025). All 71 patients with RA have been treated. In ISAT-2, patients with ruptured MCA aneurysms managed surgically had died or were dependent (modified Rankin Scale score >2) in 7/38 (18%; 95% CI, 0.09–0.33) cases, and 8/33 (24%; 95% CI, 0.13–0.41) for endovascular. One-year imaging results were available in 80 patients with UIA and 62 with RA. Complete aneurysm occlusion was found in 30/40 (75%; 95% CI, 0.60–0.86) patients with UIA allocated clipping, and 14/40 (35%; 95% CI, 0.22–0.50) patients with UIA allocated coiling. Complete aneurysm occlusion was found in 24/34 (71%; 95% CI, 0.54–0.83) patients with RA allocated clipping, and 15/28 (54%; 95% CI, 0.36–0.70) patients with RA allocated coiling. Conclusions Randomized data from 2 trials show that better efficacy may be obtained with surgical management of patients with MCA aneurysms.

In the absence of randomized evidence, the optimal management of patients with unruptured intracranial aneurysms (UIA) remains uncertain.Comprehensive Aneurysm Management (CAM) is an all-inclusive care trial combined with a registry. Any patient with a UIA (no history of intracranial hemorrhage within the previous 30 days) can be recruited, and treatment allocation will follow an algorithm combining clinical judgment and randomization. Patients eligible for at least 2 management options will be randomly allocated 1:1 to conservative or curative treatment. Minimization will be used to balance risk factors, using aneurysm size (≥7 mm), location (anterior or posterior circulation), and age60 years.The CAM primary outcome is survival without neurologic dependency (modified Rankin Scale [mRS] score3) at 10 years. Secondary outcome measures include the incidence of subarachnoid hemorrhage during follow-up and related morbidity and mortality; morbidity and mortality related to endovascular treatment or surgical treatment of the UIA at 1 year; overall morbidity and mortality at 1, 5, and 10 years; when relevant, duration of hospitalization; and, when relevant, discharge to a location other than home. The primary hypothesis for patients randomly allocated to at least 2 options, 1 of which is conservative management, is that active UIA treatment will reduce the 10-year combined neurologic morbidity and mortality (mRS score2) from 24% to 16%. At least 961 patients recruited from at least 20 centers over 4 years will be needed for the randomized portion of the study.Patients with unruptured intracranial aneurysms can be comprehensively managed within the context of an all-inclusive care trial.

OBJECTIVEThe management of brain arteriovenous malformations (bAVMs) remains controversial. The Treatment of Brain AVMs Study (TOBAS) was designed to manage patients with bAVMs within a clinical research framework. The objective of this study was to study trial feasibility, recruitment rates, patient allocation to the various management groups, and compliance with treatment allocation.METHODSTOBAS combines two randomized care trials (RCTs) and a registry. Designed to be all-inclusive, the study offers randomized allocation of interventional versus conservative management to patients eligible for both options (first RCT), a second RCT testing the role of preembolization as an adjunct to surgery or radiotherapy, and a registry of patients managed using clinical judgment alone. The primary outcome of the first RCT is death from any cause or disabling stroke (modified Rankin Scale score > 2) at 10 years. A pilot phase was initiated at one center to test study feasibility, record the number and characteristics of patients enrolled in the RCTs, and estimate the frequency of crossovers.RESULTSAll patients discussed at the multidisciplinary bAVM committee between June 2014 and June 2016 (n = 107) were recruited into the study; 46 in the randomized trials (23 in the first RCT with 21 unruptured bAVMs, 40 in the second RCT with 17 unruptured bAVMs, and 17 in both RCTs), and 61 patients in the registry. Three patients crossed over from surgery to observation (first RCT).CONCLUSIONSClinical research was successfully integrated with normal practice using TOBAS. Recruitment rates in a single center are encouraging. Whether the trial will provide meaningful results depends on the recruitment of a sufficient number of participating centers.Clinical trial registration no.: NCT02098252 (clinicaltrials.gov)

BACKGROUND AND PURPOSE: Moyamoya disease is a progressive neurovascular pathology defined by steno-occlusive disease of the distal internal carotid artery and associated with the development of compensatory vascular collaterals. The etiology and exact anatomy of vascular collaterals have not been extensively studied. The aim of this study was to describe the anatomy of collaterals developed between the ophthalmic artery and the anterior cerebral artery in a Moyamoya population. MATERIALS AND METHODS: All patients treated for Moyamoya disease from 2004 to 2016 in 4 neurosurgical centers with available cerebral digital subtraction angiography were included. Sixty-three cases were evaluated, and only 38 met the inclusion criteria. Two patients had a unilateral cervical internal carotid occlusion that limited analysis of ophthalmic artery collaterals to one hemisphere. This study is consequently based on the analysis of 74 cerebral hemispheres. RESULTS: Thirty-eight patients fulfilled the inclusion criteria. The most frequently encountered anastomosis between the ophthalmic artery and cerebral artery was a branch of the anterior ethmoidal artery (31.1%, 23 hemispheres). In case of proximal stenosis of the anterior cerebral artery, a collateral from the posterior ethmoidal artery could be visualized (16 hemispheres, 21.6%). One case (1.4%) of anastomosis between the lacrimal artery and the middle meningeal artery that permitted the vascularization of a middle cerebral artery territory was also noted. CONCLUSIONS: Collaterals from the ophthalmic artery are frequent in Moyamoya disease. Their development depends on the perfusion needs of the anterior cerebral artery territories. Three other systems of compensation could be present (callosal circle, leptomeningeal anastomosis, and duro-pial anastomoses).

BACKGROUND Treatment of thoracic spinal dural arteriovenous fistulas (DAVFs) by microsurgery has recently been approached using minimally invasive spine surgery (MISS). The advantages of such an approach are offset by difficult maneuverability within the tubular retractor and by the creation of "tunnel vision" with reduced luminosity to a remote surgical target. OBJECTIVE To demonstrate how the pitfalls of MISS can be addressed by applying 3-D endoscopy to the minimally invasive approach of spinal DAVFs. METHODS We present 2 cases of symptomatic thoracic DAVFs that were not amenable to endovascular treatment. The DAVFs were excluded solely via a minimally invasive approach using a 3-D endoscope. RESULTS Two patients underwent exclusion of a DAVF following laminotomy, one through a midline 5-cm incision and the other through a paramedian 3-cm incision using minimally invasive nonexpandable tubular retractors. The dura opening, intradural exploration, fistula exclusion, and closure were performed solely under endoscopic 3-D magnification. No incidents were recorded and the postoperative course was marked by clinical improvement. Postoperative imaging confirmed the exclusion of the DAVFs. Anatomical details are exposed using intraoperative videos. CONCLUSION When approaching DAVFs via MISS, replacing the microscope with the endoscope remedies the limitations related to the "tunnel vision" created by the tubular retractor, but at the expense of losing binocular vision. We show that the 3-D endoscope resolves this latter limitation and provides an interesting option for the exclusion of spinal DAVFs.

The best management of brain arteriovenous malformation (bAVM) patients remains unknown. Randomized allocation may be more readily accepted when there is uncertainty and disagreement regarding the management of potential participants. In planning for a trial, we aimed to assess variability and agreement among physicians managing bAVM patients.A portfolio composed of 35 patients was sent to 47 clinicians of various specialties managing bAVM patients. For each patient, physicians were asked their best management decision (surgery/embolization/radiosurgery/conservative), their confidence level, and whether they would include the patient in a randomized trial comparing conservative and curative management. Seven physicians, who had access to all images of each patient, independently responded twice, to assess inter and intra-rater agreement using kappa statistics.The inter-rater agreement (30 raters, including 16 neuroradiologists) for best management decision was only "fair" (κ [95%CI]=0.210[0.157; 0.295]). Agreement remained below 'substantial' (κ.6) between physicians of the same specialty, and when no distinctions were made between various treatments (when responses were dichotomized as conservative versus curative). With access to all images the inter-rater agreement remained fair. The intra-rater agreement reached "substantial" only for the dichotomized decisions. Responding clinicians were willing to include 54.4% of patients (mainly unruptured bAVMs) in a randomized trial.There is a lack of agreement among clinicians involved in the management of bAVM patients. In this study a substantial proportion of clinicians were willing to offer randomized allocation of management options to a substantial number of patients.

Introduction Les anevrismes du segment A1 de l’artere cerebrale anterieure (ACA) constituent environ 1 % de tous les anevrismes intracrâniens. Peu d’etudes ont analyse ces anevrismes. En effectuant une revue systematique de la litterature, l’objectif de ce travail est de mieux caracteriser la conduite therapeutique, les resultats du traitement et les facteurs pronostiques chez les patients chez qui l’on a diagnostique un tel anevrisme. Methodes Une recherche extensive de la litterature utilisant Pubmed a ete effectuee suivant les lignes directrices PRISMA. Nous avons inclus des publications de toutes les langues lorsque les resumes etaient en francais ou en anglais. Resultats Cent trente et un articles sont retenus totalisant 688 patients : 58 % sont des femmes et l’âge moyen est de 51 ans. La rupture de l’anevrisme rend compte de la presentation initiale chez 53 % des patients. Les variantes anatomiques associees les plus frequentes sont la fenestration du segment A1 et une hypoplasie/aplasie du segment A1 controlateral. On retrouve une proportion importante d’anevrismes dissequants (6 %) et d’anevrismes fusiformes (8 %) sur une majorite (86 %) d’anevrismes sacciformes. La plupart des anevrismes mesurent 5 mm ou moins. Le traitement est rapporte pour 646 anevrismes : chirurgie 374 (58 %), endovasculaire 272. Quelle que soit la modalite de traitement, l’evolution est favorable dans la majorite des cas. Les facteurs de mauvais pronostics sont : une presentation hemorragique, un mauvais grade clinique a l’arrivee, une complication ischemique ainsi qu’un anevrisme dissequant ou fusiforme. Conclusion Les anevrismes du segment A1 demeurent difficiles a caracteriser en raison de donnees manquantes ou non rapportees de facon systematique dans la litterature. Lorsque mentionnees, les echelles des resultats cliniques utilisees sont variables ; les suivis a long terme sont rarement rapportes ; les plus grandes series rapportent des donnees groupees. Des etudes prospectives avec des donnees standardisees sont necessaires.

Introduction La maladie de Moyamoya est une pathologie neuro-vasculaire steno-occlusive touchant l’artere carotide interne et ses branches principales, associee au developpement de reseaux collateraux compensatoires. La description detaillee de ces reseaux compensatoires est pauvre dans la litterature actuelle. Generalement, la circulation posterieure est peu touchee rendant possible son utilite en compensant le besoin de flux sanguin des arteres cerebrales anterieures (ACA). Le but de cette etude est de decrire precisement les anastomoses naturelles developpees entre les arteres cerebrales anterieures et posterieures pour compenser l’hypoperfusion des territoires des ACA chez les patients presentant une maladie de Moyamoya. Materiel et methodes Nous avons inclus tous les patients traites pour une maladie de Moyamoya entre 2004 et 2018 dans 4 differents centres neurochirurgicaux ayant une arteriographie cerebrale disponible. Quarante patients (80 hemispheres) avec le diagnostic de maladie ou syndrome de Moyamoya ont ete analyses angiographiquement. Resultats Trente et un hemispheres (38,75 %) presentaient une circulation collaterale entre les arteres cerebrales anterieures et posterieures. La circulation collaterale la plus frequemment retrouvee vient de l’artere calleuse posterieure (cercle calleux, 20 % des cas) et de l’artere choroidienne posterieure (20 % des cas). L’autre collaterale moins frequente (15 % des cas) est une anastomose pio-piale entre les branches corticales des arteres cerebrales anterieures et posterieures. L’observation des arteriographies nous permet aussi d’evaluer la competence de ces anastomoses pour re-perfuser les territoires des ACA que nous classifions en 4 stades. Conclusion Nous avons retrouve 3 differents types d’anastomoses entre les arteres cerebrales anterieures et posterieures, avec une abilite plus ou moins importante pour compenser l’hypoperfusion du territoire anterieur. Leur developpement depend du besoin perfusionnel des territoires de l’ACA.

Objective The management of unruptured and ruptured brain arteriovenous malformations (AVMs) remains controversial. The Treatment of Brain AVM Study (TOBAS) was designed to assess curative treatments in the management of AVMs. The purpose of our study is to provide a care trial context to brain AVM patients. Methods TOBAS is a pragmatic, prospective study including 2 randomized controlled trials and a registry. All AVM patients can be recruited. The preferred management modality will be predetermined prior to randomization by the team based on clinical judgment. Patients eligible for both conservative and interventional management will be randomly allocated conservative or curative treatment. Randomization will be stratified by a treatment modality (surgery, radiosurgery or embolization) and minimized according to a history of previous rupture and Spetzler-Martin grade. A second randomization will allocate eligible patients to embolization/no embolization prior to surgery or radiosurgery. The primary outcome of the study is death (any cause) or disabling stroke (mRS > 2) at 10 years. All patients managed according to clinical judgment alone will be included in the registry. The study is registered under: wwwTrials.gov , ID: NCT02098252 . Expected results A minimum recruitment of 540 patients is required to show that treatment can reduce the primary outcome by 10 % (from 25 to 15 %); 440 patients will be needed to show a 10 % increase in angiographic occlusion for a good clinical outcome with pre-embolization. Conclusion The trial is designed to offer optimal and verifiable care to patients with brain AVMs in spite of the uncertainty. We are currently seeking the participation of multiple centers.

Introduction La rupture d’un anevrisme spinal est une cause rare d’hemorragie sous-arachnoidienne (HSA). Ces cas representent un defi diagnostic car l’angiographie spinale ne fait pas partie du bilan d’investigation standard de l’HSA. Plusieurs cas rapportes sont associes a des conditions liees a une augmentation du flot arteriel spinal (coarctation de l’aorte, malformation arterioveineuse) ou a des maladies compromettant l’integrite de la paroi vasculaire (maladies du collagene, vasculites, maladies auto-immunes). Toutefois dans environ la moitie cas rapportes, aucune condition sous-jacente ne peut etre identifiee : il s’agit d’anevrismes spinaux isoles. L’objectif de cette etude est de reviser notre experience recente d’anevrismes spinaux rompus isoles afin de faire ressortir des elements physiopathologiques. Materiel et methodes Analyse des dossiers cliniques et radiologiques d’une serie de 3 patients admis consecutivement pour anevrisme spinal isole rompu. Etude de l’histopathologie d’un patient de cette serie opere pour un tel anevrisme. Resultats Tous les patients de cette serie ont presente un tableau systematique de vomissements repetes (de causes variees), precedent de quelques semaines a quelques mois de dorsalgies sentinelles evoluant vers une cephalee en coup de tonnerre. L’un des patients fut opere. L’examen histologique a revele la presence d’un anevrisme fusiforme dissequant avec hematome intramural. Conclusion La presence systematique dans notre serie de vomissements repetes precedant l’HSA suggerent un role des efforts de vomissements repetes dans la formation d’anevrisme spinaux et leur rupture eventuelle. Basees sur les donnees de la litterature, nous proposons que des poussees de pression lors des efforts de vomissement, combinees a la flexion du tronc, modifient les forces hemodynamiques dans les arteres spinales, augmentant les contraintes de cisaillement initiant la formation de ces anevrismes (side wall aneurysm). Cette serie met en lumiere une cause possible d’anevrismes spinaux, non associe a une malformation vasculaire ou a une maladie inflammatoire.

Introduction Les malformations caverneuses des voies optiques (MCvo) sont rares, se manifestant generalement par une atteinte subite de la vision. En revisant la litterature, l’objectif de cette etude est de mieux connaitre les aspects cliniques et radio-anatomiques ainsi que la conduite therapeutique et l’evolution chez les patients presentant cette condition. Materiel et methodes Recherche Pubmed des cas de MCvo, dans laquelle nous avons ajoute 3 cas, dont un ayant necessite une resection chirurgicale urgente. Nous avons etudie les presentations cliniques, les caracteristiques radio-anatomiques, les methodes de traitement et l’evolution sur le plan visuel. Resultats Cette serie comprend 77 patients. Il s’agit de 29 H et 48 F avec un âge moyen de 33 ans (4–63). La manifestation la plus frequente etait l’atteinte visuelle (89,6 %), unilaterale (34,7 %) ou bilaterale (65,3 %), suivie de cephalees (43,5 %). L’atteinte chiasmatique, la plus frequente, etait seule (33,8 %) ou en combinaison avec le nerf optique (53,22 %) ou la bandelette optique (13 %). Il s’agissait de lesion unique chez tous les patients a l’exception d’un patient ayant 2 lesions, sans histoire familiale. Une histoire familiale etait mentionnee chez 2 patients. Une resection complete fut realisee ans la majorite des cas (75,3 %), suivi d’une resection partielle (20,3 %) et d’une simple biopsie chez 3 patients (4 %). Quatre patients ont ete observes. Comme chez notre patient, il y a eu amelioration visuelle en postoperatoire dans la majorite des cas (84 %). Trois patients operes se sont deteriores. Parmi les 4 patients observes, un patient s’est ameliore et les trois autres patients sont restes stables. Conclusions Les MCvo se manifestent souvent par une atteinte subite de la vision. Leur resection chirurgicale relativement urgente est associee a des resultats favorables. La technique chirurgicale sera exposee a l’aide d’une video.

Introduction L’exerese chirurgicale d’une malformation caverneuse (MC) rompue du tronc cerebral represente toujours un defi malgre les avancements techniques et technologiques autorisant une attitude conservatrice apres une hemorragie meme si le taux de recidive symptomatique est eleve. Nous avons voulu analyser l’evolution post-operatoire de notre experience recente des patients operes en phase aigue et de decrire les nuances techniques. Materiel et methodes Etude des patients operes consecutivement au cours des deux dernieres annees pour une MC du tronc cerebral rompue dans les 10 jours precedant l’intervention chirurgicale. L’imagerie pre et post-operatoire ainsi que les videos operatoires ont egalement ete analysees. Resultats Cette serie comprend 8 patients, 7 femmes et un homme, avec un âge variant de 14 a 55 ans. Tous les patients presentaient un deficit en phase pre-operatoire. La localisation des malformations caverneuses etait: thalamo-mesencephalique (1), mesencephalique (1), protuberance (2) et bulbaire (4). La MC thalamo-mesencephalique a ete reseque par voie supra-cerebelleuse trans-tentorielle, celle du mesencephale par voie supra-cerebelleuse, trans-sillon mesencephalique lateral, les MC de la protuberance par voie retro-sigmoidienne ante-trigemino-faciale et les MC bulbaires par voie sous occipitale laterale (2) et mediane (2). La resection fut complete chez 5 patients et etendue chez (lesions bilaterales). Cinq patients se sont ameliores cliniquement dans les jours suivant l’operation, 1 patient est reste stable et 1 patient a presente un deficit transitoire qui s’est resorbe dans les mois suivants. Il n’y a eu aucune recidive d’hemorragie. Conclusion Les patients avec MC rompues du tronc cerebral peuvent beneficier d’un traitement en phase aigue. Les principes chirurgicaux et les nuances seront exposes a l’aide de videos.

OBJECT Blister aneurysms of the supraclinoid part of the internal carotid artery (ICA) are known for their high morbidity and mortality rates related to treatment, regardless of whether the treatment is surgical or endovascular. However, this grim prognosis is based on results that indiscriminately group all blister aneurysms together without taking into account the heterogeneous appearance of these lesions. The goal of this study was 2-fold: to determine whether different blister aneurysm morphologies present different pitfalls, which would then require different surgical strategies, as well as to determine whether there are identifiable subgroups of these types of aneurysms based on morphology. METHODS The authors reviewed the charts, cerebral catheter angiograms, surgical reports, and intraoperative videos of all ICA blister aneurysms treated surgically at the Centre Hospitalier de l'Université de Montréal from 2005 to 2012 to investigate whether there was a relationship between morphology and pitfalls, and whether different surgical strategies had been used according to these pitfalls. During this review process the authors noted 4 distinct morphological aspects. These 4 aspects led to a review of the English and French literature on blister aneurysms in which imaging was available, to determine whether other cases could also be classified into the same 4 subgroups based on these morphological aspects. RESULTS The retrospective review of the authors’ series of 10 patients allowed a division into 4 distinct subtypes: Type I (classic), Type II (berry-like), Type III (longitudinal), and Type IV (circumferential). These subtypes may at times be progressive stages in the arterial anomaly, and could represent a continuum. Each subtype described in this paper presented its own pitfalls and required specific surgical adaptations. Upon reviewing the literature the authors retained 35 studies involving a total of 61 cases of blister aneurysms, and all cases were able to be classified into 1 of these 4 distinct subtypes. CONCLUSIONS Although they share some common characteristics, blister aneurysms may be divided into distinct subtypes, suggestive of a continuum. Such a classification with a detailed description of each type of blister aneurysm would allow for better recognition to anticipate complications during intervention and better assess the different treatment strategies according to the subtypes.

a b s t r a c t Objective: Posterior fossa arteriovenous malformations (pAVMs) are rare and because of their location at or close to vital structures, their treatment remains challenging despite overall improvements in the management of cerebrovascular lesions. We reviewed our recent series of ruptured pfAVMs in search of guiding principles in the management of these complex lesions. Methods: This is a retrospective series of consecutive patients admitted for a ruptured pfAVM from 2002 to 2013. We analyzed clinical and radiological data, as well as initial and definitive management. Outcome was assessed using the modified Rankin Scale (mRS) at 6 months. Results: The study included 34 patients (19 women and 15 men). Upon admission, 79% of patients pre- sented with an intra-cerebellar hematoma, 42% of which required urgent drainage. Hydrocephaly was also present in 82% of patients, 56% of which required emergency ventriculostomy. There was an aneurysm associated with the AVM in 47% of cases. In 38% of the cases, the aneurysm was the source of the hemor- rhage. Only 68% of patients were amenable to undergo treatment of the AVM: 24% exclusively by surgery, 9% by embolization, 3% by radiosurgery, and 32% using combined means. Five patients died within the first week: one as a direct result of the severity of the hemorrhage, and the other four due to re-bleeding before treatment. Outcome was favorable (mRS 0-2) in 71% of patients. Conclusion: Patients with a ruptured pfAVM are often comatose upon admission, requiring emergency live-saving surgical treatment. An associated aneurysm is often the source of bleeding which if dealt with immediately, offers time to plan the most appropriate strategies to eliminate the AVM. Nevertheless, early re-bleeding is frequent, and a cause of concern as it often leads to death. Despite the gravity of the clinical condition upon admission, outcome is favorable for those amenable to treatment.

Background Tamoxifen is an estrogen-receptor modulator frequently used in the treatment of non-metastatic breast cancer. Side effects of this treatment are well evaluated but unproven side effects are suspected by case reports. Only one case report evokes a possible association between tamoxifen and dural arteriovenous fistula (dAVF). Authors report in this study their experience on dAVF in women exposed to tamoxifen. Methods From 2005 to 2015, 294 patients with a dural arteriovenous fistula were referred to our department. Among these cases, 10 women who harbored 12 dAVFs were under a treatment of tamoxifen at the time of the diagnosis of the dAVF or had a treatment of tamoxifen in the past. There is no exclusion criterion for this observational study. Results Ten women were included in this series (mean age: 64). Seven women were under treatment when the first symptom occurred and the three others had already finished their treatment. The mean delay between the initiation of tamoxifen and the occurrence of symptom was 32 months. The most frequent clinical symptom was a tinnitus (8 patients, 80%) followed by headache (3 cases, 30%), chemosis (2 cases, 20%), oculomotor palsy (2 patients, 20%), and ocular hypertension (1 case, 10%). One patient presented a cerebellar hemorrhage and arrived in a comatose state. The fistulous point was located in the transverse sinus (TS) in 9 cases (75%) and in the cavernous sinus in 3 cases (25%). Conclusions Our observational study suggests that the occurrence of cranial dAVF could be influenced by tamoxifen. It will be very difficult to establish a causal link between them but a larger comparative study could help.

Cavernous malformations in the midbrain can be accessed via several safe entry zones. The accepted rule of thumb is to enter at the point where the lesion is visible at the surface of the brainstem to pass through as little normal brain tissue as possible. However, in some cases, in order to avoid critical neural structures, this rule may not apply. A different safe entry zone can be chosen. Our video presents a case of a ruptured cavernous malformation in the midbrain reaching its anterior surface which was successfully resected via a posterolateral route using the supracerebellar infratentorial approach.The video can be found here: https://youtu.be/7kt-OQuBmz0.

Thalamomesencephalic cavernous malformations are located high in the brainstem and may be difficult to reach. We present a case of such a lesion which was successfully approached via the supracerebellar transtentorial route. Our enclosed video provides elements to justify this posterior approach and illustrates the steps required for the cavernoma’s safe removal, which include opening of the tentorium and gentle retraction of the exposed temporal lobe.The video can be found here: https://youtu.be/Ex5OfLyBzPY.

Background Unruptured intracranial aneurysms (UIAs) are increasingly diagnosed and are commonly treated using endovascular treatment or microsurgical clipping. The safety and efficacy of treatments have not been compared in a randomised trial. How to treat patients with UIAs suitable for both options remains unknown. Methods We randomly allocated clipping or coiling to patients with one or more 3–25 mm UIAs judged treatable both ways. The primary outcome was treatment failure, defined as: initial failure of aneurysm treatment, intracranial haemorrhage or residual aneurysm on 1-year imaging. Secondary outcomes included neurological deficits following treatment, hospitalisation >5 days, overall morbidity and mortality and angiographic results at 1 year. Results The trial was designed to include 260 patients. An analysis was performed for slow accrual: 136 patients were enrolled from 2010 through 2016 and 134 patients were treated. The 1-year primary outcome, available for 104 patients, was reached in 5/48 (10.4% (4.5%–22.2%)) patients allocated surgical clipping, and 10/56 (17.9% (10.0%–29.8%)) patients allocated endovascular coiling (OR: 0.54 (0.13–1.90), p=0.40). Morbidity and mortality (modified Rankin Scale>2) at 1 year occurred in 2/48 (4.2% (1.2%–14.0%)) and 2/56 (3.6% (1.0%–12.1%)) patients allocated clipping and coiling, respectively. New neurological deficits (15/65 vs 6/69; OR: 3.12 (1.05–10.57), p=0.031), and hospitalisations beyond 5 days (30/65 vs 6/69; OR: 8.85 (3.22–28.59), p=0.0001) were more frequent after clipping. Conclusion Surgical clipping or endovascular coiling of UIAs did not show differences in morbidity at 1 year. Trial continuation and additional randomised evidence will be necessary to establish the supposed superior efficacy of clipping.

Introduction La maladie de Moya-Moya est une pathologie caracterisee par la stenose progressive de la partie supraclinoidienne de l’artere carotide interne ainsi que des arteres cerebrales anterieure et moyenne. L’epargne de l’artere ophtalmique lui permet de developper des anastomoses vasculaires avec des branches a destinee parenchymateuse afin de maintenir de la perfusion cerebrale. L’analyse anatomique de ces anastomoses naturelles n’est pas decrite dans la litterature. Patients et methodes Les donnees cliniques et angiographiques des patients porteurs d’une maladie de Moya-Moya de 4 centres ont ete recoltees retrospectivement. Soixante-trois patients ont ete evalues dont 38 presentaient les criteres d’inclusion (maladie de Moya-Moya, angiographie cerebrale 6 axes disponible). Deux des patients presentaient une stenose unilaterale de l’artere carotide commune rendant impossible l’analyse vasculaire de l’hemisphere cerebral. L’angiographie de 74 hemispheres cerebraux etait donc analysable (grade de Suzuki ; description de collaterales leptomeningees, periventriculaires et duropiales ; anastomoses provenant de l’artere ophtalmique). Resultats L’âge median est de 38 ans avec une predominance feminine (2,8/1). Parmi les patients, 60,5 % se sont presentes avec une ischemie cerebrale. Le score de Sukuzi etait de 0 pour 9 cotes (Moya-Moya unilateral), I pour 10 hemispheres, II pour 10, III pour 14, IV pour 15, V pour 5 et VI pour 11 hemispheres. La presence de collaterales venant de l’artere ophtalmique est retrouvee dans 35 cas (47,3 %). L’anastomose la plus frequente (31 %) est l’anastomose entre l’artere ethmoidale anterieure et l’artere callosomarginale via l’artere falcine anterieure. L’anastomose entre l’artere ethmoidale posterieure et l’artere orbitofrontale est retrouvee dans 21 % des cas. L’artere lacrymale peut aussi reperfuser un territoire de l’artere cerebrale moyenne via l’artere meningee recurrente (1 cas, 1,4 %). Conclusion L’artere ophtalmique peut, via ces 3 anastomoses, participer a la vascularisation du parenchyme cerebral. Le developpement de ces anastomoses semble se produire, dans notre serie, avant la formation des anastomoses duropiales venant de l’artere meningee moyenne.

Appendix. (DOCX 27 kb)

Objectives: To define the natural history of spontaneous intracranial vertebral artery dissections (VADs) and to review current treatment strategies. Material and methods: We searched the MEDLINE database for all existing English and French literature on VADs through January 2008. Keywords employed were intradural/intracranial vertebral artery dissection, vertebral artery dissection, and vertebral artery dissection treatment. We also reviewed our series of patients with spontaneous VAD treated in the past 5 years. Data were collected, categorized, and analyzed. Results: In our sample of 457 patients, men were more frequently affected than women, and the mean age was 51.8 years. The majority of patients (79%) presented with subarachnoid hemorrhage (SAH). We experienced a high incidence (37%) of recurrent SAH, particularly within the first 24 hours after SAH first occurred. Angiographic fusiform dilatation and pearl-and-string lesions were the most common finding. Patients who presented with SAH fared worse than those who presented with ischemia. Conclusions: Due to a high rate of recurrent bleeding, we concluded that early treatment by either surgical or endovascular route is indicated in patients who present with SAH secondary to spontaneous intradural VADs. Treatment decisions should take into account the site and type of dissection, vertebral artery dominance, and involvement of posterior inferior cerebellar artery.

Unlike most posterior circulation aneurysms, posterior cerebral artery (PCA) aneurysms can be surgically approached, we believe, without significant technical difficulty or procedural morbidity. We report our recent experience to assess procedural complications and clinical outcomes for PCA aneurysms.In our retrospective review of 15 consecutive patients with PCA aneurysms, six patients underwent surgical treatment, six patients had endovascular coiling, (three patients from the endovascular group also underwent surgical revascularization), and three patients were treated conservatively (medical or observation) (2001-2007). Clinical records were reviewed for: patient demographics; clinical presentation; aneurysm location, size, and morphology; treatment; procedural complications; outcome (clinical and angiographic).Complete aneurysm obliteration with parent vessel or bypass patency was demonstrated by intraoperative angiography in all patients. One patient died and two patients suffered procedure-related permanent neurologic injury. Considering both surgical end endovascular treatment modalities, mortality was 8.3% and permanent morbidity was 16.6%. At mean clinical follow-up of 2-96 months (15.8 +/- 10.5 months), nine of ten patients had a Glasgow Outcome Score of 4 or 5. In patients who underwent bypass procedures, computed tomographic (CT) angiography or cerebral angiography demonstrated a patent functional bypass before the PCA occlusion.Our findings for these 15 patients suggest the value of a multimodality of treatments for PCA aneurysms. Revascularization of the PCA can be performed with favorable technical results and clinical outcomes when the patency of the PCA cannot be preserved.

This study evaluates the utility and practical limitations of microcomputerized X-ray tomography (CT) as a research tool for examination of the cerebral circulation in mice. Six micro CT angiograms of the circle of Willis (COW) from six mice were obtained by scanning whole head and brain specimen perfused with a radio-opaque silicone contrast agent. Two-dimensional volume rendered images were postprocessed from three-dimensional image datasets using a partially automated high-throughput model that generated 10 surface projections for each specimen. The image processing model employed a straightforward global thresholding and computerized component labeling software algorithm. Postprocessed images were analyzed and results correlated with microdissection. Micro CT demonstration of COW vessels and their branch anatomy was assessed. 71% of COW vessels were completely demonstrated, 26% were partially demonstrated, and 3% were not demonstrated. All cases of nondemonstration and most cases of partial demonstration resulted from scan coverage or postprocessing clip error. Thresholding effect caused pseudostenosis of 8% of COW vessels and accounted for a minority of partial demonstration cases. No imaging artifacts were caused by contrast extravasation or ineffective contrast perfusion. Volume averaging caused minor angioarchitectural distortion of 58% of COW vessels. Ninety-five percent of COW ≥50 μm and 52% of COW vessels

Introduction L’evolution technologique en neurochirurgie a permis le developpement de systeme de magnification de plus en plus performant. C’est le cas des microscopes operatoires et de l’endoscopie. L’endoscopie 3D VisionSense ® est actuellement disponible. Nous avons souhaite montrer l’utilisation de cette nouvelle technologie dans le cas du traitement des fistules arterio-veineuses (FAV). Materiel et methode Nous presentons 3 cas de FAV, 2 cas de FAV medullaire thoracique et un cas de FAV de fosse posterieure. Dans les trois cas le traitement a ete chirurgical, exclusivement sous endoscopie 3D. L’analyse peroperatoire de l’anatomie est presentee sous forme de video. Resultats Une fois exposee, dans chaque cas la fistule a pu etre aisement exclue sous magnification avec l’endoscope 3D. L’intervention s’est deroulee sans incident et les suites operatoires ont ete marquees par une amelioration clinique. Les angiographies ont confirme l’exclusion de la fistule durale. Conclusion L’endoscopie 3D permet une magnification importante tout en preservant la profondeur de champ pour une excellente visualisation et appreciation des rapports vasculaires et nerveux. Dans le cas d’une fistule durale l’exploration est facilitee en raison de la maniabilite de l’optique, contrairement au microscope.

Introduction: Patients presenting with high grade (HG) subarachnoid hemorrhage (SAH) from aneurysmal rupture may have persisting neurologic deficits which may lead to questioning the decision of treating aggressively. The objective of this study aims at analyzing outcome and long-term quality of life (QOL) of patients with HG SAH treated surgically. Methods: Retrospective study of patients with Hunt Hess (HH) grade IV or V SAH treated surgically at our institution. Long-term outcome was evaluated based on the modified Rankin Scale (mRS) at 3 years. Survivors were evaluated for QOL using various scales. Results: 63 patients (mean age of 52 year-old) were included. Intraparenchymal hemorrhage (IPH) was found in 85% of cases. 19 patients died. Predictive factors of poor prognosis and mortality were initial cerebral ischemia (p=0.003) and IPH (p=0.007). Favourable outcome (mRS 0-3) was found in 41% of patients. QOL questionnaires revealed that 80 % of responders showed more than 50% recovery. Mild or absent depression was observed in 78% of patients. Conclusion: In this surgical series, performed in an endovascular era, nearly all patients presented with SAH-associated IPH at admission. Despite the presence of such negative prognostic factor and the poor condition at admission, a high rate of favourable outcome and QOL was observed, therefore justifying aggressive surgical treatment.

Introduction: Tele-medicine has gained in popularity worldwide, particularly to help offer medical expertise, healthcare delivery and education to developing nations. There is little literature reporting the implementation or analysis of tele-assitance in the setting of surgical education. We have implemented a tele-assistance system, called Remote Education, Augmented Communication, Training and Supervision (REACTS), as a tool to augment mentor-student education in the operating room. This system allows the mentor to observe the student during surgery remotely through screen sharing technology with integrated visual and audio interaction. The goal of this study is to assess the safety and the benefit of REACTS as an educational tool. Methods: Prospective observational study to evaluate the safety and qualitative benefit of REACTS. Results: REACTS was used in 20 cases, including 5 placement of EVDs, 5 pterional craniotomies, 5 Sylvian fissures dissection, 5 lumbar discectomies, and 5 lumbar spine decompressions. No untoward or adverse events were observed. It was judged to be a positive influence on resident and fellow education by the mentors. The main pitfall in its use is to appropriately select the learner for a given procedure. Conclusion: REACTS surgical system is a safe, and a useful adjunct tool for neurosurgical operative education.

compression s’etendait sur 6 etages dans un cas, sur 2 etages dans 3 cas, et sur un etage dans les autres cas. Le traitement consistait en une laminectomie et une ablation du ligament jaune ossifie. Le resultat etait bon dans 4 cas avec amelioration des signes cliniques, inchange dans 2 cas, et il y a eu une aggravation dans un cas. La myelopathie par ossification est rare en Afrique, mais probablement sous-diagnostiquee. Le diagnostic repose sur la TDM et l’IRM. Le traitement est chirurgical. Le pronostic depend de la duree d’evolution avant la prise en charge et de la presence de signes de souffrance medullaire.