Changing clinical and therapeutic trends in tentorial dural arteriovenous fistulas: a systematic review

BACKGROUND AND PURPOSE: Tentorial dural arteriovenous fistulas are characterized by a high hemorrhagic risk. We evaluated trends in outcomes and management of tentorial dural arteriovenous fistulas and performed a meta-analysis evaluating clinical and angiographic outcomes by treatment technique. MATERIALS AND METHODS: We performed a comprehensive literature search for studies on surgical and endovascular treatment of tentorial dural arteriovenous fistulas. We compared the proportion of patients undergoing endovascular, surgical, and combined endovascular/surgical management; the proportion of patients presenting with ruptured tentorial dural arteriovenous fistulas; and proportion of patients with good neurologic outcome across 3 time periods: 1980-1995, 1996-2005, and 2006-2014. We performed a random-effects meta-analysis, evaluating the rates of occlusion, long-term good neurologic outcome, perioperative morbidity, and resolution of symptoms for the 3 treatment modalities. RESULTS: Twenty-nine studies with 274 patients were included. The proportion of patients treated with surgical treatment alone decreased from 38.7% to 20.4% between 1980-1995 and 2006-2014. The proportion of patients treated with endovascular therapy alone increased from 16.1% to 48.0%. The proportion of patients presenting with ruptured tentorial dural arteriovenous fistulas decreased from 64.4% to 43.6%. The rate of good neurologic outcome increased from 80.7% to 92.9%. Complete occlusion rates were highest for patients receiving multimodality treatment (84.0%; 95% CI, 72.0%-91.0%) and lowest for endovascular treatment (71.0%; 95% CI, 56.0%-83.0%; P < .01). Long-term good neurologic outcome was highest in the endovascular group (89.0%; 95% CI, 80.0%-95.0%) and lowest for the surgical group (73.0%; 95% CI, 51.0%-87.0%; P < .03). CONCLUSIONS: Patients with tentorial dural arteriovenous fistulas are increasingly presenting with unruptured lesions, being treated endovascularly, and experiencing higher rates of good neurologic outcomes. Endovascular treatment was associated with superior neurologic outcomes but lower occlusion rate

Principles and strategies for step-by-step AVM excision

Arteriovenous malformations (AVMs) are some of the most challenging surgical entities. Like any challenging surgical procedure, AVM surgery is a series of basic but fundamental steps, each with its own nuances. Despite a myriad of published material regarding AVMs, there are few succinct illustrated summaries of these steps with an accompanying elucidation of the most common pitfalls. This paper provides a step-by-step description and illustration of the basic surgi-cal principles of AVM microsurgical resection, focusing on the main key points and addressing the critical issues that surround this surgery. Deep anatomical knowledge and presurgical planning of these basic steps, combined with good contingency management skills, are paramount for an effective and safe AVM surgery

Symptomatic Cavernous Malformation Presenting with Seizure without Hemorrhage: Analysis of Factors Influencing Clinical Presentation

BACKGROUND: Supratentorial cavernous malformations (CMs) can be epileptogenic lesions. However, little is known about clinical comorbidities, medication use, and radiologic features that predict a first seizure presentation without associated CM hemorrhage.METHODS: We queried a prospective registry of consecutive patients with CM established in January 2015. Data regarding clinical presentation, comorbid conditions, daily medication use, and radiologic CM characteristics were collected. Univariate and multivariate regression analysis was performed assessing variables for presentation with seizure without hemorrhage with P values, odds ratios, and 95% confidence intervals reported.RESULTS: Of 202 patients, 58.4% were women, and the average age at diagnosis was 43.7 +/- 16.5 years. Of the patients, 59.4% were symptomatic. In 40.6%, the CM was an incidental finding. Of the 30 patients who presented with a first-time seizure without concomitant hemorrhage, the mean age at diagnosis was 38.4 +/- 14.6 years, and 56.7% were women. Compared with incidental CM, patients with seizure without hemorrhage were younger, had a cortically based, supratentorial lesion, and were less likely to have chronic inflammatory disease or to use aspirin, vitamin D, or statin. Compared with other supratentorial lesions, patients with seizure without hemorrhage more commonly had a temporal lobe CM.CONCLUSIONS: These prospective data provide possible clues to radiologic factors, clinical comorbidities, and medication influences on seizure presentation in patients with CM. Further multicenter studies would be helpful to determine if disease-modifying agents in addition to epileptic medications or surgery might be helpful

How I do it: resection of spinal cord cavernous malformation

Background Spinal cord cavernous malformations (CMs) account for 5 to 12% of all spinal vascular malformations. Surgical removal is indicated in symptomatic patients, especially if the CM comes close to the dorsal or lateral surface of the spinal cord. Spinal cord CMs pose critical challenges for the potential of severe disabling complications. Method We described the step-by-step surgical principles of spinal cord CM microsurgical resection. The main surgical steps are also illustrated in an accompanying operative video. Conclusion Pre-surgical planning of the basic steps and good contingency management skills are paramount for an effective and safe spinal cord CM excision

Endogenous Coactivator ARA70 Interacts with Estrogen Receptor α (ERα) and Modulates the Functional ERα/Androgen Receptor Interplay in MCF-7 Cells

Overexpression of androgen receptor (AR) decreases estrogen receptor alpha (ERalpha) transactivation, which plays a basic role in hormone-dependent breast cancer. This transcriptional interference can be due to shared coactivators. Here we demonstrated that in MCF-7 cells ARA70, an AR-specific coactivator, interacted with endogenous ERalpha, increasing its transcriptional activity, and it was recruited to the pS2 gene promoter. Moreover, a dominant negative ARA70 down-regulated ERalpha transcriptional activity as well as pS2 mRNA. ARA70 overexpression reversed the AR down-regulatory effect on ERalpha signaling. However, in the presence of a progressive increase of transfected AR, ARA70 switched into enhancing the inhibitory effect of AR on ERalpha signaling. These opposite effects of ARA70 were further evidenced by coimmunoprecipitation assay in MCF-7wt, MCF-7-overexpressing AR, and HeLa cells, exogenously expressing an excess of ERalpha with respect to AR or an excess of AR with respect to ERalpha. Thus, ARA70 is a coactivator for ERalpha and may represent a functional link between ERalpha/AR modulating their cross-talk in models of estrogen signaling in MCF-7 and HeLa cells

The precuneal interhemispheric, trans-tentorial corridor to the pineal region and brainstem, surgical anatomy, and case illustration

Background The pineal region and dorsal midbrain are among the most challenging surgical targets. To approach lesions in this region that harbor a superior to inferior long axis, we describe the basic steps of the precuneal, interhemispheric, trans-tentorial approach and illustrate anatomical landmarks of this established, but not so popular, surgical trajectory.Method To study the anatomical landmarks and safety of this approach, the neurovascular anatomy was studied on 22 sides of 11 formalin-fixed latex-injected anatomical specimens. A step-by-step dissection of the precuneal interhemispheric trans-tentorial approach and study of the key anatomical landmarks was performed. An illustrative clinical case of a pontomesencephalic cavernous malformation (CM) resected through this approach is also detailed.Results The mean distance from the transverse sinus to the most posterior cortical vein draining into the superior sagittal sinus was 6.4 cm. The mean distance from the calcarine sulcus to the most posterior cortical vein was 5.3 cm. Key steps of the dissection are as follows: craniotomy exposing the posterior aspect of the superior sagittal sinus (SSS), durotomy and gentle retraction of the SSS edge, dissection of the interhemispheric fissure, linear incision of the tentorium that extends anteriorly to the incisura and lateral reflection of the tentorium, and arachnoidal dissection and exposure of the cerebellomesencephalic fissure.Conclusion The precuneal, interhemispheric, trans-tentorial approach affords excellent access to the falcotentorial junction, splenium, pineal region, quadrigeminal cistern, and dorsal pons once the cerebellomesencephalic fissure has been dissected

A Novel Transformer-Based IMU Self-Calibration Approach through On-Board RGB Camera for UAV Flight Stabilization

During flight, unmanned aerial vehicles (UAVs) need several sensors to follow a predefined path and reach a specific destination. To this aim, they generally exploit an inertial measurement unit (IMU) for pose estimation. Usually, in the UAV context, an IMU entails a three-axis accelerometer and a three-axis gyroscope. However, as happens for many physical devices, they can present some misalignment between the real value and the registered one. These systematic or occasional errors can derive from different sources and could be related to the sensor itself or to external noise due to the place where it is located. Hardware calibration requires special equipment, which is not always available. In any case, even if possible, it can be used to solve the physical problem and sometimes requires removing the sensor from its location, which is not always feasible. At the same time, solving the problem of external noise usually requires software procedures. Moreover, as reported in the literature, even two IMUs from the same brand and the same production chain could produce different measurements under identical conditions. This paper proposes a soft calibration procedure to reduce the misalignment created by systematic errors and noise based on the grayscale or RGB camera built-in on the drone. Based on the transformer neural network architecture trained in a supervised learning fashion on pairs of short videos shot by the UAV’s camera and the correspondent UAV measurements, the strategy does not require any special equipment. It is easily reproducible and could be used to increase the trajectory accuracy of the UAV during the flight

The Effect of Mechanical Thrombectomy on the Incidence of Poststroke Cognitive Impairment: A Systematic Review of Inhomogeneous Literature

Introduction: The aim of this study was to evaluate the effect of mechanical thrombectomy (MT) on the incidence of poststroke cognitive impairment (PSCI) in anterior circulation stroke. Methods: Literature research was performed on PubMed/OVID/Cochrane CENTRAL for studies published in 2015-2022. A review of the references of the included papers was performed for further eligible articles. Clinical characteristics, NIHSS, dementia tests, and outcomes were recorded. The exclusion criteria were nonhuman and non-English. Studies qualities were assessed with MINORS/RoB2 and GRADE. A meta-analysis was performed using the standardized mean difference (Cohen's d) to measure effect size. Results: Four studies were included in the systematic review after screening 749 articles. No significant differences were found for age and gender (years: 66.70 +/- 11.14 vs. 67.59 +/- 10.11, p = 0.37; male 53.8% vs. 56.4%, p = 0.57). MT patients had a more severe stroke than that of the control group (NIHSS: 14.70 +/- 4.31 vs. 11.17 +/- 4.12; p &lt; 0.0001). The control group consisted of medical therapy-alone patients in all studies. I-2 was 76.95%, and Q was 43.4%. MT patients have better performance in overall cognition (d = 0.33 [0.074-0.58]) and in several cognitive domains than in the control group (TMT-A, d = 0.37 [0.04-0.70]; TMT-B, d = 0.35 [0.12-0.58]; digit span test [backward], d = 0.61 [0.18-1.06]; colored progressive matrices, d = 0.48 [0.05-0.91]; Stroop test [word reading], d = 0.60 [0.17-1.03]; color naming, d = 0.51 [0.08-0.94]; Rey-Osterrieth Complex Figure [immediate recall], d = 0.79 [0.35-1.23]; Rey Auditory Verbal Learning Test [immediate recall], d = 0.79 [0.36-1.23]; delayed recall, d = 0.46 [0.035-0.89]; and MOCA, d = 0.46 [-0.04 to 0.96]). Medical therapy patients had a higher score in coping strategy than MT patients (COPE-28 acceptance, d = -1.00 [-1.53 to -0.48]). Conclusions: The incidence of PSCI is lower in MT patients than in the control group. (c) 2023 S. Karger AG, Base

Outcomes of carotid artery stenting versus historical surgical controls for radiation-induced carotid stenosis

PurposeTo evaluate the outcomes of carotid artery stenting (CAS) and open surgical repair (OR) for treatment of radiation-induced carotid stenosis (RICS).MethodsWe retrospectively reviewed 60 patients treated for 73 RICSs from a group of 5,824 patients who had carotid interventions between 1992 and 2009. Thirty-three patients (37 arteries) were treated with CAS and 27 patients (36 arteries) with OR. CAS was performed using embolic protection as part of a prospective institutional registry since 2003. End-points included mortality, stroke, myocardial infarction (MI), cranial nerve injury (CNI), wound complication, restenosis, and reintervention.ResultsDemographics and cardiovascular risk factors were similar in both groups, with the exception of higher rates (P < .05) of hyperlipidemia (81% vs 56%) and coronary artery disease (63% vs 33%) in OR patients. There were more patients with tracheostomy (31% vs 4%) and time interval from irradiation to intervention was longer in the CAS group. There were no early deaths. At 30 days, OR was associated with one (3%) stroke, two (5.5%) MIs, six (17%) CNIs, and three (8%) wound complications. OR patients with prior radical neck dissections had more wound complications (14% vs 5%) and CNIs (28% vs 9%) compared with those without neck dissections. In the CAS group, there were two (6%) strokes and no MIs, CNIs, or wound complications. Mean length of hospital stay was longer after OR than CAS (4.1 ± 3.7 days vs 2.4 ± 2.1 days; P = .02). Median follow-up was 58 months. At 7 years, OR was associated with higher patient survival (75% ± 15% vs 29% ± 13%, P = .008) and freedom from neurological events (100% vs 57% ± 9.5%, P = .058), but similar freedom from restenosis (80% ± 10% vs 72% ± 9%) and reinterventions (87% ± 10% vs 86% ± 9%) compared with CAS.ConclusionCarotid artery stenting for radiation-induced stenosis has the advantages of no CNI or wound complications with similar early stroke rate compared with open carotid repair. However, the lower freedom from neurological events may offset the early benefits of carotid stenting in patients who are considered good candidates for open surgery