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Supported by preliminary anatomical and clinical studies exploring the feasibility and usefulness of approaching many ventral pathologies of the craniocervical junction (CCJ) using the endoscopic endonasal approach, four European centres have joined forces to accumulate and share their growing surgical experience of this advanced technique. By describing the steps that led to the development and continuous refinement of this approach to the CCJ, this article delves deeply into an analysis of the cases operated on since 2010 at these four institutions, and discusses in detail the operative nuances that so far have allowed achievement of successful outcomes with excellent perioperative patient comfort and satisfactory long-term quality of life.

Compression syndromes of the vertebral artery that occur at the craniocervical junction are extremely rare causes of haemodynamic insufficiency of the posterior cerebral circulation. The aetiology of the compression syndrome may be a malformation, trauma, tumour, infection or degenerative pathology. This may lead to dynamic vertebral artery occlusion where the vessel courses around the atlas and the axis-the so-called V3 segment. This in turn may result in insufficient collateral flow to the posterior fossa. The clinical picture is a vertebrobasilar insufficiency syndrome of variable expression ranging from vertigo to posterior fossa stroke. The typical clinical presentation is syncope occurring during rotation of the head, also known as 'bow hunter's syndrome'. The workup is based on dynamic angiography and computed tomography angiography. The treatment of choice is surgical vascular decompression, resulting in a good clinical outcome. However, in some instances, atlantoaxial fusion may be indicated. Alternatively, conservative and endovascular options have to be considered in inoperable patients.

Objective: To investigate the impact on functional outcome and postoperative pain of a modified C-shaped skin incision and muscle flaps in patients undergoing mini-craniotomy via a retrosigmoid approach (mCRSA)., Methods: Enrolled patients were studied prospectively and divided/assigned to group A, with a standard straight/lazy S-shaped incision, or to group B, with a modified C-shaped incision. The latter consisted of a 4-cm C-shaped skin incision with medial convexity (placed 8 cm lateral to the external occipital protuberance, with the lower edge terminating 1.5-2 cm above the mastoid tip), followed, after subperiosteal dissection, by superior and inferior reflection of the muscle flaps by stitches., Results: Eighty patients, 40 in each group, were enrolled in the study. The overall complication rate was significantly lower (P < 0.0001) in group B. The incidence of cerebrospinal fluid (CSF) leak was 4% in group B versus 12% in group A; furthermore, no wound infection was recorded in group B, whereas 2 cases (4%) occurred in group A. Overall, group B patients had a higher satisfaction rate (P = 0.0002), and the prevalence of postoperative retroauricular pain/neck discomfort was significantly higher (P = 0.0002) in group A (30% vs. 0%)., Conclusions: The modified C-shaped skin incision and muscle flaps technique provides superior surgical exposure with advantages over the standard straight/lazy S-shaped incision including no need for a self-retaining retractor and a shorter working distance. This study supports the research hypothesis that the landmarks-based design of the C-shaped incision may decrease the risk of occipital muscle/cutaneous nerve injuries and CSF leak, resulting in better functional outcomes., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Background: The incidence of venous thromboembolism (VT) in neurosurgical practice is astonishingly high, representing a major cause of morbidity and mortality. Prophylaxis strategies include elastic stockings, low-molecular-weight heparin (LMWH), and intermittent pneumatic compression (IPC) devices., Objective: To assess the safety and efficacy of 2 different VT prophylaxis protocols implemented in a European neurosurgical center., Methods: All patients admitted for neurosurgical intervention between 2012 and 2016 were stratified as low, moderate, and high risk of VT and received a combination of elastic stockings and LMWH. The protocol was modified in 2014 with the inclusion of perioperative IPC devices for all patients and only in the high-risk group also postoperatively., Results: At time of post-hoc analysis, data obtained from patients included in this study before 2014 (Protocol A, 3169 patients) were compared with those obtained after the introduction of IPC (Protocol B, 3818 patients). Among patients assigned to protocol A, 73 (2.3%) developed deep-vein thrombosis (DVT) and 28 (0.9%) developed pulmonary embolism (PE), 9 of which were fatal (0.3%). Among patients assigned to protocol B, 32 developed DVT (0.8%) and 7 (0.18%) developed PE, with 2 eventually resulting in the death of the patient. A post-hoc analysis confirmed that the use of preoperative LMWH was not associated with a statistically significant greater risk of postoperative bleeding., Conclusions: This study, despite its limitations of the nonrandomized design, seems to suggest that perioperative IPC devices are a non-negligible support in the prophylaxis of clinically symptomatic DVT and PE., (Copyright © 2017 Elsevier Inc. All rights reserved.)

The authors report the case of a 45-year-old woman who presented to our institution with 10 days history of confusion and signs of progressive raised intracranial pressure as a result of a minor head injury occurred 4 weeks before. A brain CT-scan showed a large right hemispheric chronic subdural haematoma which was, as routinely, treated by burr-hole craniostomy and closed-drainage. Although the procedure was uneventful, the next day the patient developed a mild left hemiparesis associated to a slight global status worsening. A brain CT scan showed an intracerebral position of the drain with diffuse brain oedema and midline shift. Following drain removal the patient developed a serious neurological deterioration dropping the Glasgow coma scale to 8/15 as the result of an intracerebral and intraventricular haemorrhage along the removed drain trajectory. The clinical features of this iatrogenic complication are reported analysing also globally chronic subdural haematoma management and discussing pertinent literature.

The aging of the population in westernized countries constitutes an important issue for the health systems struggling with limited resources and increasing costs. Morbidity and mortality rates reported for neurosurgical procedures in the elderly vary widely. The lack of data on risk benefit ratios may result in challenging clinical decisions in this expanding group of patients. The aim of this paper is to analyze the elderly patients cohort undergoing neurosurgical procedures and any trend variations over time. The medical records of elderly patients (defined as an individual of 70 years of age and over) admitted to the Neurosurgical and Neuro-ICU Departments of a major University Hospital in Paris over a 25-year period were retrospectively reviewed. The analysis included: (1) number of admissions, (2) percentage of surgically treated patients, (3) type of procedures performed, (4) length of hospital stay, and (5) mortality. The analysis showed a progressive and significant increase in the proportion of elderly presenting for neurosurgical elective and/or emergency procedures over the last 25 years. The number of procedures on patients over 70 years of age increased significantly whereas the mortality dropped. Though the length of hospital stay was reduced, it remained significantly higher than the average stay. The types of procedures also changed over time with more craniotomies and endovascular procedures being performed. Age should not be considered as a contraindication for complex procedures in neurosurgery. However, downstream structures for postoperative elderly patients must be further developed to reduce the mean hospital stay in neurosurgical departments because this trend is likely to continue to grow.

Objective: En plaque sphenoid wing meningiomas are complex tumors involving the sphenoid wing, the orbit, and sometimes the cavernous sinus. Complete removal is difficult, so these tumors have high rates of recurrence and postoperative morbidity. The authors report a series of 71 patients with sphenoid wing meningiomas that were managed surgically., Methods: The clinical records of 71 consecutive patients undergoing surgery for sphenoid wing meningiomas at Lariboisière Hospital, Paris, were prospectively collected in a database during a 20-year period and analyzed for presenting symptoms, surgical technique, clinical outcome, and follow-up., Results: Among the 71 patients (mean age, 52. 7 years; range, 12-79 years), 62 were females and 9 were males. The most typical symptoms recorded were proptosis in 61 patients (85.9%), visual impairment in 41 patients (57.7%), and oculomotor paresis in 9 patients (12.7%). Complete removal was achieved in 59 patients (83%). At 6 months of follow-up, magnetic resonance imaging scans revealed residual tumor in 12 patients (9 in the cavernous sinus and 3 around the superior orbital fissure). Mean follow-up was 76.8 months (range, 12-168 months). Tumor recurrence was recorded in 3 of 59 patients (5%) with total macroscopic removal. Among the patients with subtotal resection, tumor progression was observed in 3 of 12 patients (25%; 2 patients with grade III and 1 patient with grade IV resection). Mean time to recurrence was 43.3 months (range, 32-53 months)., Conclusion: Surgical management of patients with sphenoid wing meningiomas cannot be uniform; it must be tailored on a case-by-case basis. Successful resection requires extensive intra- and extradural surgery. We recommend optic canal decompression in all patients to ameliorate and/or preserve visual function.