A new segment of the trochlear nerve: cadaveric study with application to skull base surgery

Objectives The trochlear nerve is important to preserve during approaches to the skull base. Traditionally, this nerve has been divided into cisternal, cavernous, and orbital segments. However, the authors anecdotally observed an additional segment during routine cadaveric dissections. Therefore, they performed this study to better elucidate this anatomy. Design Twenty latex-injected cadaveric sides (10 adult cadavers) were dissected with the aid of an operating microscope. Standard microdissection techniques were used to examine the course of the distal cisternal and precavernous segments of the trochlear nerve. Setting Cadaver laboratory. Main Outcome Measures Measurements were made using a microcaliper. Digital images were made of the dissections. Results The authors identified a previously undescribed segment of the trochlear nerve in all specimens. This part of the nerve coursed between the entrance of the trochlear nerve into the posterior corner of the oculomotor trigone to the posterior wall of the cavernous sinus. This segment of trochlear nerve was, on average, 4 mm in length. Conclusions The authors have identified a new segment of the trochlear nerve not previously described. They propose that this be referred to as the trigonal segment. Knowledge of the microanatomy of the trochlear nerve is useful to skull base surgeons

The Carotid Sinus Nerve and the First English Translation of Hering\u27s Original Research on this Nerve.

This paper provides a brief depiction of the life and achievements of the most iconic experiments of Heinrich Ewald Hering. The authors herein have presented a translation of his paper on the carotid sinus nerve in English; the original paper by Heinrich Ewald Hering, titled Ueber die Wand des Sinus caroticus als Reizempfänger und den Sinusnerv als zentripetale Bahn für die Sinusreflexe (1924), provides a detailed account of his experimental process and findings. He recognized that the sinus reflexes are mediated by a branch of the glossopharyngeal nerve (CN IX)

Surgical clipping compared to endovascular coiling of ruptured coil able middle cerebral aneurysms: A single-center experience

Objective: The middle cerebral artery (MCA) is the third most common site for ruptured intracranial aneurysms. Aneurysms in this location are known to be challenging to treat endovascularly and are commonly treated with microsurgery. Although advances in endovascular treatment options for cerebral aneurysms have markedly reduced the need for surgery in recent years and decades, there is no compelling scientific evidence that endovascular treatments are superior to surgical treatment. The present study aimed to determine the appropriate treatment modality in ruptured MCA aneurysms. Methods: We retrospectively evaluated and compared the treatment outcomes of 80 patients with ruptured MCA aneurysms who underwent either endovascular or microsurgical treatment in our center between 2011 and 2016. Post-treatment clinical and radiological outcomes were assessed in all patients. Furthermore, we compared intraoperative complications and the need for re-treatments between the two groups. Results: According to our findings, complete aneurysm occlusion was achieved in 90.5 and 89.2 of the patients in the clipping and coil group, respectively (p = 0.850). Moreover, 14.3 of the patients in the clipping group and 15.8 of the subjects in the coil group developed intraoperative complications (p = 0.851), including 3 cases of intraoperative hemorrhage and 3 cases of ischemia in the clipping group as well as 2 cases of thromboembolism and 4 cases of vasospasm during endovascular treatment in the coil group. There was an improvement in the modified Rankin score (mRS) at six months, with no significant difference between the two groups (p = 0.916). Conclusion: The results of coiling only with coil able MCA aneurysms were comparable to the results of clipping with difficult cases. Sufficient follow-up study of recurrence and retreatment are needed to determine the indication for coiling for ruptured MCA aneurysm. © 202

European Multicenter Study for the Evaluation of a Dual-Layer Flow-Diverting Stent for Treatment of Wide-Neck Intracranial Aneurysms: The European Flow-Redirection Intraluminal Device Study

BACKGROUND AND PURPOSE: Endoluminal reconstruction with flow-diverting stents represents a widely accepted technique for the treatment of complex intracranial aneurysms. This European registry study analyzed the initial experience of 15 neurovascular centers with the Flow-Redirection Intraluminal Device (FRED) system. MATERIALS AND METHODS: Consecutive patients with intracranial aneurysms treated with the FRED between February 2012 and March 2015 were retrospectively reviewed. Complications and adverse events, transient and permanent morbidity, mortality, and occlusion rates were evaluated. RESULTS: During the defined study period, 579 aneurysms in 531 patients (median age, 54 years;range, 13-86 years) were treated with the FRED. Seven percent of patients were treated in the acute phase (3 days) of aneurysm rupture. The median aneurysm size was 7.6 mm (range, 1-36.6 mm), and the median neck size 4.5 mm (range, 1-30 mm). Angiographic follow-up of >3 months was available for 516 (89.1%) aneurysms. There was progressive occlusion witnessed with time, with complete occlusion in 18 (20%) aneurysms followed for up to 90 14 days, 141 (82.5%) for 180 +/- 20 days, 116 (91.3%) for 1 year +/- 24 days, and 122 (95.3%) aneurysms followed for >1 year. Transient and permanent morbidity occurred in 3.2% and 0.8% of procedures, respectively. The overall mortality rate was 1.5%. CONCLUSIONS: This retrospective study in real-world patients demonstrated the safety and efficacy of the FRED for the treatment of intracranial aneurysms. In most cases, treatment with a single FRED resulted in complete angiographic occlusion at 1 year

Surgeon experience in glioblastoma surgery of the elderly : a multicenter, retrospective cohort study

Purpose To assess the impact of individual surgeon experience on overall survival (OS), extent of resection (EOR) and surgery-related morbidity in elderly patients with glioblastoma (GBM), we performed a retrospective case-by-case analysis. Methods GBM patients aged≥65 years who underwent tumor resection at two academic centers were analyzed. The experience of each neurosurgeon was quantifed in three ways: (1) total number of previously performed glioma surgeries (lifetime experience); (2) number of surgeries performed in the previous fve years (medium-term experience) and (3) in the last two years (short-term experience). Surgeon experience data was correlated with survival (OS) and surrogate parameters for surgical quality (EOR, morbidity). Results 198 GBM patients (median age 73.0 years, median preoperative KPS 80, IDH-wildtype status 96.5%) were included. Median OS was 10.0 months (95% CI 8.0–12.0); median EOR was 89.4%. Surgery-related morbidity afected 19.7% patients. No correlations of lifetime surgeon experience with OS (P=.693), EOR (P=.693), and surgery-related morbidity (P=.435) were identifed. Adjuvant therapy was associated with improved OS (PConclusion Less experienced neurosurgeons achieve similar surgical results and outcome in elderly GBM patients within the setting of academic teaching hospitals. Adjuvant treatment and avoidance of surgery-related morbidity are crucial forgenerating a treatment beneft for this cohort.Peer reviewe

Lateralization of inferior petrosal sinus sampling in Cushing's disease correlates with cavernous sinus venous drainage patterns, but not tumor lateralization

Background: Inferior petrosal sinus sampling (IPSS) is known as the gold standard to distinguish whether excessive adrenocorticotropin hormone (ACTH) production origins from the pituitary gland or an ectopic source. However, due to a number of factors, the value of IPSS for adenoma lateralization may be limited. Aim of this study was to evaluate the influence of parasellar venous drainage (VD) patterns on IPSS findings in predicting lateralization of pituitary microadenomas. Methods: We retrospectively reviewed records of confirmed cases of Cushing's disease which were evaluated by IPSS prior to endoscopic tansnasal trans-sphenoidal surgery (ETSS) to assess the ability of IPSS to predict adenoma laterality. Results: Seventeen patients with pathologically confirmed Cushing's disease were retrospectively reviewed. The median age of the included patients was 37 years. Laterality of parasellar VD perfectly associated with lateralization as measured by IPSS. Symmetrical VD was associated with symmetrical ACTH gradient on IPSS. However, lateralization measured by IPSS did not show any significant correlation with lateralization detected during ETSS. Conclusion: Our study suggests that IPSS lateralization results strongly depend on parasellar VD pattern but show no significant correlation with the adenoma lateralization found during ETSS. Thus, IPSS does not appear to be an appropriate modality to predict adenoma lateralization. © 2020 Anatomy; Neurology; Medical imaging; Endocrinology; Endocrine system; Clinical research; Inferior petrosal sinus sampling; Cushing's disease; Parasellar venous drainage; Lateralization of microadenoma © 202

Risk of Branch Occlusion and Ischemic Complications with the Pipeline Embolization Device in the Treatment of Posterior Circulation Aneurysms

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Genome-Wide Association Study of Clinical Outcome After Aneurysmal Subarachnoid Haemorrhage: Protocol

Aneurysmal subarachnoid haemorrhage (aSAH) results in persistent clinical deficits which prevent survivors from returning to normal daily functioning. Only a small fraction of the variation in clinical outcome following aSAH is explained by known clinical, demographic and imaging variables; meaning additional unknown factors must play a key role in clinical outcome. There is a growing body of evidence that genetic variation is important in determining outcome following aSAH. Understanding genetic determinants of outcome will help to improve prognostic modelling, stratify patients in clinical trials and target novel strategies to treat this devastating disease. This protocol details a two-stage genome-wide association study to identify susceptibility loci for clinical outcome after aSAH using individual patient-level data from multiple international cohorts. Clinical outcome will be assessed using the modified Rankin Scale or Glasgow Outcome Scale at 1-24 months. The stage 1 discovery will involve meta-analysis of individual-level genotypes from different cohorts, controlling for key covariates. Based on statistical significance, supplemented by biological relevance, top single nucleotide polymorphisms will be selected for replication at stage 2. The study has national and local ethical approval. The results of this study will be rapidly communicated to clinicians, researchers and patients through open-access publication(s), presentation(s) at international conferences and via our patient and public network

A Delphi study and ranking exercise to support commissioning services:Future delivery of Thrombectomy services in England

Background: Intra-arterial thrombectomy is the gold standard treatment for large artery occlusive stroke. However, the evidence of its benefits is almost entirely based on trials delivered by experienced neurointerventionists working in established teams in neuroscience centres. Those responsible for the design and prospective reconfiguration of services need access to a comprehensive and complementary array of information on which to base their decisions. This will help to ensure the demonstrated effects from trials may be realised in practice and account for regional/local variations in resources and skill-sets. One approach to elucidate the implementation preferences and considerations of key experts is a Delphi survey. In order to support commissioning decisions, we aimed to using an electronic Delphi survey to establish consensus on the options for future organisation of thrombectomy services among physicians with clinical experience in managing large artery occlusive stroke. Methods: A Delphi survey was developed with 12 options for future organisation of thrombectomy services in England. A purposive sampling strategy established an expert panel of stroke physicians from the British Association of Stroke Physicians (BASP) Clinical Standards and/or Executive Membership that deliver 24/7 intravenous thrombolysis. Options with aggregate scores falling within the lowest quartile were removed from the subsequent Delphi round. Options reaching consensus following the two Delphi rounds were then ranked in a final exercise by both the wider BASP membership and the British Society of Neuroradiologists (BSNR). Results: Eleven stroke physicians from BASP completed the initial two Delphi rounds. Three options achieved consensus, with subsequently wider BASP (97%, n=43) and BSNR members (86%, n=21) assigning the highest approval rankings in the final exercise for transferring large artery occlusive stroke patients to nearest neuroscience centre for thrombectomy based on local CT/CT Angiography. Conclusions: The initial Delphi rounds ensured optimal reduction of options by an expert panel of stroke physicians, while subsequent ranking exercises allowed remaining options to be ranked by a wider group of experts within stroke to reach consensus. The preferred implementation option for thrombectomy is conveying suspected stroke patients for CT/CT Angiography and secondary transfer of large artery occlusive stroke patients to the nearest neuroscience centre