Search

Objective: Analyzing occlusion, complications rate, and clinical results in unruptured saccular middle cerebral artery aneurysms (MCAAs) comparing clipping with the most advance and newer endovascular techniques., Methods: We conducted a literature research from January 2009 to December 2018 to evaluate the efficacy and safety of microsurgical clipping or endovascular treatment with new devices (such as Flow-diverter or Woven EndoBridge) in patients with unruptured MCAAs. We extracted data involved: study and intervention features, occlusion rate; time of occlusion assessment; and clinical outcome., Results: A total of 29 studies and 1552 patients with unruptured saccular MCAAs were included in our analysis (464 patients included in the endovascular group, 1088 patients in the surgical group). Overall, the rate of long-term complete/near-complete occlusion was 78.1% (311/405, 95% confidence interval [CI], 69%-87.1%) and 95.7% (113/118, 95% CI, 92%-99.3%) after endovascular and surgical treatments, respectively (P = 0.001). The long-term complete occlusion rate was 60% (153/405, 95% CI, 45%-74%) and 95% (112/118, 95% CI, 90%-98%) after endovascular and surgical treatments, respectively (P = 0.001). The overall rate of treatment-related complications was 5.6% (33/464, 95% CI, 3.6%-7.7%) and 2.9% (37/1088, 95% CI, 0.8%-5%) among the endovascular and surgical groups, respectively (P = 0.001). Endovascular treatments were associated with higher rates of good neurologic outcome (283/293 [97%], 95% CI, 95%-98% vs. 570/716 [84%], 95% CI, 67%-98%; P = 0.001). No difference was found for the mortality (3/464 [1.5%], 95% CI, 0.4%-2.6% vs. 1/1088, 95% CI, 0.1%-0.6%; P = 0.5)., Conclusions: Treatment-related complication and mortality are comparable among these techniques and the risk of aneurysm rupture seems very low for both strategies. The endovascular approach seems to increase the probability of good functional outcome after treatment, compared with surgery., (Copyright © 2019 Elsevier Inc. All rights reserved.)

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., (Copyright © 2020 Elsevier Inc. All rights reserved.)

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 (I 2 ), 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%; I 2  = 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%; I 2  = 70.5% vs. 207 of 268; 79.4%; 95% CI, 71.8%-86.9%; I 2  = 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%; I 2  = 92.2%) than the SR group (92 of 177; 58.7%; 95% CI, 37.3%-80%; I 2  = 58.7%; P = 0.01). The mortality rate was lower among the ADAPT group (20 of 251; 5.4%; 95% CI, 1.4%-9%; I 2  = 63%) than the SR group (16 of 108; 13%; 95% CI, 6%-19%; I 2  = 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., (Copyright © 2019 Elsevier Inc. All rights reserved.)

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., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: Despite the progress achieved in recent years, the prognosis of patients with primary brain tumors remains poor. Research efforts have therefore focused on identifying more effective and minimally invasive treatment methods. Magnetic resonance-guided transcranial focused ultrasonography (MRgFUS) is a consolidated minimally invasive therapeutic technique, which has recently acquired a role also in the treatment of some nononcologic intracranial diseases., Methods: We reviewed the latest studies to take stock of the potential of MRgFUS., Results: The objective of the research in the last decade was to apply FUS also to the treatment of intracranial neoplastic diseases, using both the thermal effects (thermal ablation) and, above all, the ability to permeabilize the blood-brain barrier and modify the tumor microenvironment. This strategy may allow the use of drugs that are poorly active on the central nervous system or active selectively at high doses, minimize the side effects, and substantially modify the prognosis of patients affected by these diseases., Conclusions: In the future, targeted drug delivery, immunotherapy, and gene therapy will probably become main players in the treatment of brain neoplasms, with the aid of MRgFUS. In this way, it will be possible to directly intervene on tumor cells and preserve healthy tissue., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Background: There is uncertainty about the optimal method for measuring the decompressive craniectomy (DC) surface area and how large the DC should be., Methods: A radiological technique for measuring the surface area of removed bone flaps in a series of 73 DCs was developed. Preoperative and early postoperative computed tomography scans of each patient were evaluated. Midline shift (MLS) was considered the key factor for successful DC and was assigned to either normal (0-4 mm) or pathological (≥5 mm) ranges. The association between postoperative MLS and patient survival at 12 months was assessed., Results: Measurements of all removed bone flaps yielded a mean surface area of 7759 mm 2 . The surface area of the removed bone flap did not influence survival (surviving 7643 mm 2 vs. deceased 7372 mm 2 ). The only factor associated with survival was reduced postoperative MLS (P < 0.034). Risk of death was 14.4 (3.0-70.1)-fold greater in patients with postoperative shift ≥5 mm (P < 0.001)., Conclusion: The ideal surface area for "large" square bone flaps should result in an MLS of <5 mm. Enlargement of the craniectomy edges should be considered for patients in whom MLS ≥5 mm persists according to early postoperative computed tomography scans., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Objective: To describe the history of vascular and endovascular neurosurgery., Methods: A literature research was conducted including historical events from 2000 bc to the twenty-first century ad, and a timetable was filled with information regarding the most representative historical landmarks regarding vascular and endovascular neurosurgery., Results: Starting from approaches limited to the cervical carotid artery, vascular neurosurgery gained its way through the intracranial and finally endovascular space thanks to the introduction of both innovative and progressively less invasive procedures. With the invention of cerebral angiography in 1927, Egas Moniz paved the way for modern endovascular neurosurgery., Conclusions: Numerous pioneers have been described through this historical reconstruction. Their genius, effort, dedication, and passion brought a massive contribution to vascular and endovascular neurosurgery as we know it today., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Background: The lateral mesencephalic vein (LMV) represents an important connection between the infratentorial and supratentorial compartments. It joins the basal vein of Rosenthal and the petrosal system. In our experience with management of tentorial dural arteriovenous fistulas (DAVFs) we have often noted involvement of the lateral mesencephalic vein (LMV) in the venous drainage of these fistulas., Methods: We reviewed the clinical and angiographic findings of 26 patients with tentorial DAVFs to study the incidence and pattern of drainage through the LMV. In addition, we reviewed the pertinent literature on the anatomy of the LMV., Results: The LMV was involved in the venous drainage of 31% (8/26) of patients with tentorial DAVFs. The direction of venous drainage through the LMV is more commonly from the infratentorial to the supratentorial compartment. There were no specific clinical symptoms/signs associated with tentorial DAVFs involving the LMV compared with those without LMV involvement. When involved in DAVF drainage, the LMV could be invariably identified on noninvasive imaging studies. We present illustrative clinical/angiographic cases and provide a detailed review of the pertinent clinical anatomy of this important but often neglected intracranial vein., Conclusions: The LMV is a constant venous anastomosis between the supratentorial and infratentorial compartments. Detailed knowledge of the most common variations of the LMV surgical and radiological anatomy has important clinical implications. The vein is an important anatomic landmark during surgery of midbrain lesions. It is often involved in the tentorial DAVF drainage, and it is critical in understanding some "unexpected" venous complications during surgery for posterior fossa lesions., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Objective: Blister-like aneurysms (BLAs) were originally described to arise typically along the nonbranching segment of the dorsal wall of the internal carotid artery (ICA); however, BLAs located in areas other than the dorsal ICA have been described more recently. We present a case series of "atypical" BLAs and a systematic review of the literature on this subject., Methods: We conducted a literature search using the key word "blister-like aneurysm." Studies reporting BLAs in locations other than the dorsal ICA wall were selected. Clinical presentation, treatment modality, complications, and outcomes (modified Rankin Scale for neurologic outcomes and Roy scale for radiologic outcomes) were extracted from each study. We also reviewed our single-institution experience with atypical BLAs and analyzed the topography and outcomes of all the atypical BLAs according to each specific treatment modality., Results: Atypical BLAs were observed in the anterior communicating, middle cerebral, basilar, posterior cerebral, anterior cerebral, and posterior inferior cerebellar arteries. Surgery was the treatment in 65% of patients, an endovascular approach was used in 30%, and a combined approach was used in 5%. A good outcome (modified Rankin Scale 0-1-2) was experienced by 88% and 55% of the patients in the endovascular and surgical groups, respectively. There were 4 deaths, 2 in the endovascular group and 2 in the surgical group., Conclusions: Endovascular treatment of BLAs seems to be associated with reduced morbidity and mortality and to provide a better outcome compared with surgical approaches. Further prospective studies are needed to confirm these results. It is important for clinicians to remember that BLAs may also occur in sites other than the typical ICA location., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Objective: This study aimed to identify specific findings related to acute post-traumatic atlanto-axial rotatory subluxation in pediatric patients., Methods: We studied 14 children with acute atlanto-axial rotatory subluxations after a craniocervical injury admitted to a hospital during a 6-year period. Clinical and radiologic findings were reviewed to identify new findings related to atlanto-axial rotatory subluxation., Results: Most patients exhibited a typical picture of atlanto-axial rotatory subluxation, but 1 child also experienced transient blindness that was related to peculiar anatomic findings on neuroradiologic images. A characteristic C2-C3 anterior pseudosubluxation was detected among the radiographic signs. Magnetic resonance imaging showed no clear break in the alar ligaments, which were oriented horizontally. However, unlike the case in adult anatomy, in these children, the alar ligaments were laterally attached at the occipital condyle-axis condylar joints. In all children, atlanto-axial rotatory subluxation spontaneously reduced within a few hours after short bed rest without halter traction but with a cervical collar. No recurrence was observed during follow-up., Conclusions: Acute post-traumatic atlanto-axial rotatory subluxation in pediatric-aged patients is a rapidly resolving disease of the craniocervical junction. The disease appears to be related to an elasticity of the contralateral alar ligament, which is attached to the occipital condyle-axis condylar joint. Neurological symptoms (blindness) occurred in 1 patient when the vertebrobasilar blood flow was impaired and no compensation was provided from the anterior circulation. Use of a cervical collar and short bed rest without halter traction is recommended, based on our observations of complete recovery and no recurrence after the use of this treatment strategy., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Background: The cerebrovascular discipline has undergone dramatic changes in recent years. This has been made possible by the work of pioneers in the fields of neurosurgery and neuroradiology., Methods: In this article we review the evolution and fundamental stages that led to the birth of endovascular treatment and discuss why, also in Europe, this treatment must be included in neurosurgery, encouraging the training of endovascular neurosurgeons who can collaborate with their interventional neuroradiology colleagues in order to form unbiased surgeons who understand the disease from both the endovascular as well as the surgical prospective. We examine how the new generation of European cerebrovascular specialists, including neurosurgeons, neuroradiologists, and some neurologists, will attain their requisite endovascular training. Finally, we briefly review the current state of endovascular neurosurgery in Europe and in Italy and speculate about what its role will be in the near and distant future., Conclusions: To remain at the forefront of evaluating, caring for, and treating patients with cerebrovascular disease, vascular neurosurgery must evolve toward a specialty, mastering the knife as well as the catheter. We think it is time for European neurosurgeons to start training residents in endovascular neurosurgery in the same way we train neurosurgeons in every other neurosurgical discipline. • Peer-Review Report., (Copyright © 2012 Elsevier Inc. All rights reserved.)