Microsurgical Disconnection of Ruptured Intracranial Pial Arteriovenous Fistula Guided by Indocyanine Green Videoangiography.

Intracranial arteriovenous fistulas, rare causes of spontaneous intracerebral bleeding, are direct communications between an arterial feeder and an arterialized vein that drains a normal brain. Arteriovenous disconnection is the only effective treatment for this type of vascular malformation, which is often reached microsurgically due to the difficult endovascular access. Intraoperative indocyanine green videoangiography (ICG-VA) is a valuable help in identifying the arterialized draining vein and its direct communication with the arterial feeder and in confirming real-time interruption of the fistula. We describe the case of a 46-year-old man presenting with sudden onset of headache and left arm motor and sensory deficits associated with a frontoparietal hematoma evacuated 1 week earlier in another institution. Digital subtraction angiography showed a direct communication between an anterior parietal branch of the right middle cerebral artery and a parietal vein. Given the difficulty to reach the point of the fistula endovascularly because of the small caliber and tortuosity of the arterial feeder, as well as the short and relatively rapid flow through the arteriovenous communication, we decided to proceed with microsurgical treatment. Under intraoperative neurophysiologic monitoring the fistula was located with the aid of ICG-VA and interrupted (Video 1). Both control ICG-VA and postoperative angiogram confirmed resolution of the fistula. At a 3-month follow-up the patient had a complete neurologic recovery

Extended Endoscopic Endonasal Approach for Craniopharyngioma Removal.

javax.xml.bind.JAXBElement@5557f33c  Endoscopic transsphenoidal extended endoscopic approach (EEA) represents a valid alternative to microsurgery for craniopharyngiomas removal, especially for retrochiasmatic lesions without large parasellar extension. The present video illustrates the salient surgical steps of the EEA for craniopahryngioma removal. javax.xml.bind.JAXBElement@15153a37  A 52-year-old man presented with a bitemporal hemianopia and a bilateral decreased visual acuity. MRI showed a Kassam type III cystic craniopharyngioma with a solid component ( Fig. 1 , panels A and B). javax.xml.bind.JAXBElement@6796b562  The head is rotated 10 degrees toward the surgeons. The nasal step is started through the left nostril with a middle turbinectomy. A nasoseptal flap is harvested and positioned in the left choana. The binostril approach allows a large sphenoidotomy to expose the key anatomic landmarks. The craniotomy boundaries are the planum sphenoidale superiorly, the median opticocarotid recesses, the internal carotid artery laterally and the clival recess inferiorly. After dural opening and superior intercavernous sinus coagulation, the tumor is entirely removed ( Fig. 2 , panels A and B). Skull base reconstruction is ensured by fascia lata grafting and nasoseptal flap positioning. javax.xml.bind.JAXBElement@65eac187  Postoperative MRI showed the complete tumor resection ( Fig. 1 , panels C and D). At 3 months postoperatively, the bitemporal hemianopia regressed and the visual acuity improved. A novel left homonymous hemianopia developed secondary to optic tract manipulation. javax.xml.bind.JAXBElement@f4e1015  The extended EEA is a valid surgical approach for craniopharyngioma resection. A comprehensive knowledge of the sellar and parasellar anatomy is mandatory for safe tumor removal with decreased morbidity and satisfactory oncologic results. The link to the video can be found at: https://youtu.be/NrCPPnVK2qA

Direct cochlear nerve stimulation monitoring through evoked muscle responses during retrosigmoid vestibular schwannoma resection surgery: technical note.

Cochlear nerve preservation during surgery for vestibular schwannoma (VS) may be challenging. Brainstem auditory evoked potentials and cochlear compound nerve action potentials have clearly shown their limitations in surgeries for large VSs. In this paper, the authors report their preliminary results after direct electrical intraoperative cochlear nerve stimulation and recording of the postauricular muscle response (PAMR) during resection of large VSs. The details for the electrode setup, stimulation, and recording parameters are provided. Data of patients for whom PAMR was recorded during surgery were prospectively collected and analyzed. PAMRs were recorded in all patients at the ipsilateral vertex-earlobe scalp electrode, and in 90% of the patients they were also observed in the contralateral electrode. The optimal stimulation intensity was found to be 1 mA at 1 Hz, with a good cochlear response and an absent response from other nerves. At that intensity, the ipsilateral cochlear response had an initial peak at a mean (± SEM) latency of 11.6 ± 1.5 msec with an average amplitude of 14.4 ± 5.4 µV. One patient experienced a significant improvement in his audition, while that of the other patients remained stable. PAMR monitoring may be useful in mapping the position and trajectory of the cochlear nerve to enable hearing preservation during surgery

Bone cylinder plug and coil technique for accurate pedicle localization in thoracic spine surgery: A technical note.

Intraoperative identification of the correct level during thoracic spine surgery is essential to avoid wrong-level procedures. Despite technological progress, intraoperative imaging modalities for identifying the correct thoracic spine level remain unreliable and often lead to wrong-level surgery. To counter potential wrong-level operations, here, we have proposed a novel pedicle/bone cylinder marking technique for use in the thoracic spine utilizing biplanar fluoroscopy and confirmed with computed tomography (CT). First, under fluoroscopic guidance, a bone cylinder is removed from the correct thoracic pedicle. Next, endovascular coils are packed into the cancellous bone defect followed by reinsertion of the bony plug. The patient then undergoes a CT scan of the entire thoracolumbosacral spine to precisely identify the marked level before surgery. We utilized this bone cylinder plug/coil technique to identify the T9-T10 level in a 56-year-old female with a soft thoracic disc herniation. The index thoracic pedicle was successfully localized before performing the unilateral minimally invasive laminectomy followed by the transpedicular thoracic disc excision. The bone cylinder plug/coil technique is a safe and effective method for marking the correct level in thoracic spine surgery, while also reducing the operative time

Obstructive Hydrocephalus in Newborn Due to Cerebral Atrium Diverticulum Formation: Complete Resolution After Subdural Hematoma Evacuation.

Cerebral atrium diverticula are focal enlargements of the ventricular system that may develop in the presence of persistent intracranial hypertension, but they are rarely described in cases of acute intracranial hypertension. Here we present a unique case of obstructive hydrocephalus in a newborn due to the formation of a cerebral atrium diverticulum compressing the ventricular system. A preterm 38-week-old boy was born with urgent caesarian section due to severe hydrocephalus. Magnetic resonance imaging showed the presence of a subacute right subdural hematoma with secondary obstructive hydrocephalus. The cystic lesion was characterized as a right ventricular atrium diverticulum. The child underwent urgent burr-hole evacuation of the right subdural hematoma with complete regression of the obstructive hydrocephalus and right atrial diverticulum. Cerebral atrium diverticula are rare focal dilatations of the ventricular system, and their radiologic diagnosis may be challenging. Accurate diagnosis of atrial diverticula and understanding of the underlying physiopathology is mandatory to establish the appropriate operative strategy

Implementation of cisternostomy as adjuvant to decompressive craniectomy for the management of severe brain trauma.

To evaluate the value of an adjuvant cisternostomy (AC) to decompressive craniectomy (DC) for the management of patients with severe traumatic brain injury (sTBI). A single-center retrospective quality control analysis of a consecutive series of sTBI patients surgically treated with AC or DC alone between 2013 and 2018. A subgroup analysis, "primary procedure" and "secondary procedure", was also performed. We examined the impact of AC vs. DC on clinical outcome, including long-term (6 months) extended Glasgow outcome scale (GOS-E), the duration of postoperative ventilation, and intensive care unit (ICU) stay, mortality, Glasgow coma scale at discharge, and time to cranioplasty. We also evaluated and analyzed the impact of AC vs. DC on post-procedural intracranial pressure (ICP) and brain tissue oxygen (PbO <sub>2</sub> ) values as well as the need for additional osmotherapy and CSF drainage. Forty patients were examined, 22 patients in the DC group, and 18 in the AC group. Compared with DC alone, AC was associated with significant shorter duration of mechanical ventilation and ICU stay, as well as better Glasgow coma scale at discharge. Mortality rate was similar. At 6-month, the proportion of patients with favorable outcome (GOS-E ≥ 5) was higher in patients with AC vs. DC [10/18 patients (61%) vs. 7/20 (35%)]. The outcome difference was particularly relevant when AC was performed as primary procedure (61.5% vs. 18.2%; p = 0.04). Patients in the AC group also had significant lower average post-surgical ICP values, higher PbO <sub>2</sub> values and required less osmotic treatments as compared with those treated with DC alone. Our preliminary single-center retrospective data indicate that AC may be beneficial for the management of severe TBI and is associated with better clinical outcome. These promising results need further confirmation by larger multicenter clinical studies. The potential benefits of cisternostomy should not encourage its universal implementation across trauma care centers by surgeons that do not have the expertise and instrumentation necessary for cisternal microsurgery. Training in skull base and vascular surgery techniques for trauma care surgeons would avoid the potential complications associated with this delicate procedure

Semi-quantitative assessment of flow dynamics during indocyanine green video-angiography in the treatment of intracranial dural arteriovenous fistulas: how I do it.

BACKGROUND: Indocyanine green video-angiography (IG-VA) is applied for intraoperative localisation and verification of surgical disconnection of intracranial dural arteriovenous fistulas (iDAVFs). METHOD: We describe the technique of semiquantitative flow analysis using Flow800 software that implements conventional IG-VA. Our method relies on simple comparison of the fluorescence curves of the exposed vessels, allowing precise localisation of the DAVF draining vein and verification of its surgical disconnection. CONCLUSIONS: Semi-quantitative flow analysis with Flow800 software during IG-VA is a reproducible technique that may overcome the limitations of conventional IG-VA in the surgical treatment of DAVFs