Neurosurgical implications of the Jugular Vein Nutcracker

In the last ten years, a new variant of Eagle Syndrome is emerging and being described: Styloid Jugular Nutcracker (SJN). In SJN, an elongated or vertically directed styloid process causes jugular vein stenosis by compressing the vein against the arch of C1. The clinical consequences appear to be various and misunderstood, ascribable mainly to venous flow impairment and consequent intracranial hypertension. The aim of this paper is to create an overview of Jugular Vein Nutcracker and to focus on its neurosurgical implications. A PRISMA-based literature search was performed to select the most relevant papers on the topic and to realize a mini-review. Future searches in the neurosurgical field should focus on collecting data about further causes of jugular stenosis compression and the association of SJN with cerebrovascular diseases. It would also be interesting to investigate the potential role of primary and secondary prevention, which is unknown so far

The triangle inequality constraint in similarity judgments

Since Tversky's (1977) seminal investigation, the triangle inequality, along with symmetry and minimality, have had a central role in investigations of the fundamental constraints on human similarity judgments. The meaning of minimality and symmetry in similarity judgments has been straightforward, but this is not the case for the triangle inequality. Expressed in terms of dissimilarities, and assuming a simple, linear function between dissimilarities and distances, the triangle inequality constraint implies that human behaviour should be consistent with Dissimilarity (A,B) + Dissimilarity (B,C) ≥ Dissimilarity (A,C), where A, B, and C are any three stimuli. We show how we can translate this constraint into one for similarities, using Shepard's (1987) generalization law, and so derive the multiplicative triangle inequality for similarities, Sim(A,C)≥Sim(A,B)(dot operator)Sim(B,C) where 0≤Sim(x,y)≤1. Can humans violate the multiplicative triangle inequality? An empirical demonstration shows that they can

Acute subdural hematoma in the elderly. outcome analysis in a retrospective multicentric series of 213 patients

OBJECTIVE: The objective of this study was to analyze the risk factors associated with the outcome of acute subdural hematoma (ASDH) in elderly patients treated either surgically or nonsurgically. METHODS: The authors performed a retrospective multicentric analysis of clinical and radiological data on patients aged ≥ 70 years who had been consecutively admitted to the neurosurgical department of 5 Italian hospitals for the management of posttraumatic ASDH in a 3-year period. Outcome was measured according to the Glasgow Outcome Scale (GOS) at discharge and at 6 months' follow-up. A GOS score of 1-3 was defined as a poor outcome and a GOS score of 4-5 as a good outcome. Univariate and multivariate statistics were used to determine outcome predictors in the entire study population and in the surgical group. RESULTS: Overall, 213 patients were admitted during the 3-year study period. Outcome was poor in 135 (63%) patients, as 65 (31%) died during their admission, 33 (15%) were in a vegetative state, and 37 (17%) had severe disability at discharge. Surgical patients had worse clinical and radiological findings on arrival or during their admission than the patients undergoing conservative treatment. Surgery was performed in 147 (69%) patients, and 114 (78%) of them had a poor outcome. In stratifying patients by their Glasgow Coma Scale (GCS) score, the authors found that surgery reduced mortality but not the frequency of a poor outcome in the patients with a moderate to severe GCS score. The GCS score and midline shift were the most significant predictors of outcome. Antiplatelet drugs were associated with better outcomes; however, patients taking such medications had a better GCS score and better radiological findings, which could have influenced the former finding. Patients with fixed pupils never had a good outcome. Age and Charlson Comorbidity Index were not associated with outcome. CONCLUSIONS: Traumatic ASDH in the elderly is a severe condition, with the GCS score and midline shift the stronger outcome predictors, while age per se and comorbidities were not associated with outcome. Antithrombotic drugs do not seem to negatively influence pretreatment status or posttreatment outcome. Surgery was performed in patients with a worse clinical and radiological status, reducing the rate of death but not the frequency of a poor outcome

Role of Indocyanine Green Videoangiography in Identification of Donor and Recipient Arteries in Cerebral Bypass Surgery

The identification and preparation of a very good quality donor artery is a crucial step in every superficial temporal artery to middle cerebral artery (STA-MCA) bypass.For flow-preservation bypass performed for trapping of complex MCA aneurysms, the key element is the correct target of the recipient artery. When a cortical recipient artery (M4 segment of the MCA) is selected, this vessel must be a terminal branch of the artery whose sacrifice is necessary for definitive aneurysmal treatment.In this chapter we report on two techniques for (1) intraoperative mapping and preparation of good quality STA branch as the donor artery for STA-MCA bypass (mostly in the case the frontal branch of the STA needs to be used) and (2) selective identification of the correct superficial (M4 cortical) "recipient" artery in flow-preservation STA-MCA bypass performed for managing complex MCA aneurysms.Both techniques are based on the use of microscope-integrated indocyanine green videoangiography (ICG-VA), an intraoperative tool allowing observation and real-time assessment of blood flow in large and small vessels, with distinct evaluation of arterial, capillary, and venous phases.The two techniques contribute, respectively, to (1) reduce the risk of erroneous identification or injury of the donor artery in STA-MCA bypass procedures and (2) eliminate the risk of erroneous revascularization of a non-involved arterial territory in flow-preservation bypass surgery for managing complex MCA aneurysms

Cognitive and behavioural effects of chronic stimulation of the subthalamic nucleus in patients with Parkinson's disease

Objective: To investigate cognitive and behavioural effects of bilateral lead implants for high frequency stimulation (HFS) of the subthalamic nucleus in patients with Parkinson's disease; and to discriminate between HFS and the effects of surgical intervention on cognitive function by carrying out postoperative cognitive assessments with the stimulators turned on or off. Methods: Motor, cognitive, behavioural, and functional assessments were undertaken in 20 patients with Parkinson's disease before implantation and then at three, six, and 12 months afterwards. Nine patients were also examined 18 months after surgery. Postoperative cognitive assessments were carried out with stimulators turned off at three and 18 months, and turned on at six and 12 months. Results: Cognitive assessment showed a significant postoperative decline in performance on tasks of letter verbal fluency (across all postoperative assessments, but more pronounced at three months) and episodic verbal memory (only at three months, with stimulators off). At three, six, and 12 months after surgery, there was a significant improvement in the mini-mental state examination and in a task of executive function (modified Wisconsin card sorting test). On all postoperative assessments, there was an improvement in parkinsonian motor symptoms, quality of life, and activities of daily living while off antiparkinsonian drugs. A significant postoperative decrease in depressive and anxiety symptoms was observed across all assessments. Similar results were seen in the subgroup of nine patients with an 18 month follow up. Following implantation, three patients developed transient manic symptoms and one showed persistent psychic akinesia. Conclusions: Bilateral HFS of the subthalamic nucleus is a relatively safe procedure with respect to long term cognitive and behavioural morbidity, although individual variability in postoperative cognitive and behavioural outcome invites caution. Stimulation of the subthalamic nucleus does not per se appear to impair cognitive performance in patients with Parkinson's disease and may alleviate the postpoperative decline in verbal fluency

Early postoperative MRI overestimates residual tumour after resection of gliomas with no or minimal enhancement

Standards for residual tumour measurement after resection of gliomas with no or minimal enhancement have not yet been established. In this study residual volumes on early and late postoperative T2-/FLAIR-weighted MRI are compared. A retrospective cohort included 58 consecutive glioma patients with no or minimal preoperative gadolinium enhancement. Inclusion criteria were first-time resection between 2007 and 2009 with a T2-/FLAIR-based target volume and availability of preoperative, early (<48 h) and late (1-7 months) postoperative MRI. The volumes of non-enhancing T2/FLAIR tissue and diffusion restriction areas were measured. Residual tumour volumes were 22% smaller on late postoperative compared with early postoperative T2-weighted MRI and 49% smaller for FLAIR-weighted imaging. Postoperative restricted diffusion volume correlated with the difference between early and late postoperative FLAIR volumes and with the difference between T2 and FLAIR volumes on early postoperative MRI. We observed a systematic and substantial overestimation of residual non-enhancing volume on MRI within 48 h of resection compared with months postoperatively, in particular for FLAIR imaging. Resection-induced ischaemia contributes to this overestimation, as may other operative effects. This indicates that early postoperative MRI is less reliable to determine the extent of non-enhancing residual glioma and restricted diffusion volumes are imperativ

Iodine-125 brachytherapy for brain tumours - a review

Iodine-125 brachytherapy has been applied to brain tumours since 1979. Even though the physical and biological characteristics make these implants particularly attractive for minimal invasive treatment, the place for stereotactic brachytherapy is still poorly defined

Letter: C1 transverse process resection for management of jugular stenosis

No abstract availabl

Is less always better? Keyhole and standard subtemporal approaches: Evaluation of temporal lobe retraction and surgical volume with and without zygomatic osteotomy in a cadaveric model

OBJECTIVE The subtemporal approach is one of the surgical routes used to reach the interpeduncular fossa. Keyhole subtemporal approaches and zygomatic arch osteotomy have been proposed in an effort to decrease the amount of temporal lobe retraction. However, the effects of these modified subtemporal approaches on temporal lobe retraction have never been objectively validated. METHODS A keyhole and a classic subtemporal craniotomy were executed in 4 fresh-frozen silicone-injected cadaver heads. The target was defined as the area bordered by the superior cerebellar artery, the anterior clinoid process, supraclinoid internal carotid artery, and the posterior cerebral artery. Once the target was fully visualized, the authors evaluated the amount of temporal lobe retraction by measuring the distance between the base of the middle fossa and the temporal lobe. In addition, the volume of the surgical and anatomical corridors was assessed as well as the surgical maneuverability using navigation and 3D moldings. The same evaluation was conducted after a zygomatic osteotomy was added to the two approaches. RESULTS Temporal lobe retraction was the same in the two approaches evaluated while the surgical corridor and the maneuverability were all greater in the classic subtemporal approach. CONCLUSIONS The zygomatic arch osteotomy facilitates the maneuverability and the surgical volume in both approaches, but the temporal lobe retraction benefit is confined to the lateral part of the middle fossa skull base and does not result in the retraction necessary to expose the selected target