Techniques of intracranial aneurysm wall biopsy

Current treatment modalities for the treatment of intracranial aneurysms including surgical clipping and endovascular coiling are invasive and have some treatment risks. Since not all aneurysms rupture, it is critical to detect rupture prone aneurysms. Molecular and cellular analysis of aneurysm tissue may provide understanding about pathobiology of aneurysm rupture and to develop imaging techniques to detect rupture prone aneurysms. For more than 15-years we have collected samples to identify pathological processes in the aneurysm wall itself predisposing to rupture. This has opened a new field of research leading to novel findings and multiple scientific publications. Surgical techniques of sampling the aneurysm dome have never been demonstrated so therefore many neurosurgeons are reluctant to take biopsies for research. Now we demonstrate with an intraoperative video the techniques of sampling the aneurysm dome after clipping an incidental right-sided 5-mm unruptured MCA aneurysm in a 58-year-old hypertensive male with past long history of smoking through lateral supraorbital approach. A focused opening of the Sylvian fissure was performed and the aneurysm was clipped using standard techniques. After placement of a titanium clip, ICG and Doppler were performed to ensure patency of both M2 vessels and the aneurysm was punctured. The aneurysm dome was then held in place with the suction and cut with microscissors for research purposes. Another titanium clip was placed (Video 1). The clinical course was uneventful. This technical note will help young neurosurgeons to contribute actively in aneurysm research also potentially to find non-invasive methods to prevent aneurysms from rupture.Peer reviewe

Optic canal decompression in patients with vision reduction due to tumour growth in optic canal: A technical note

Improvement of the vision is one of the main goals in skull base meningiomas compressing the optic nerve (ON) in optic canal (OC). Extracranial drilling of anterior clinoid process with extradural optic canal decompression has been demonstrated in anterior clinoid meningioma surgery. Extensive drilling of anterior clinoid has however some morbidity. Here we demonstrate the technical aspects of intradural opening of optic canal using Kerrison rongeur. This technique is effective and has no additional morbidity.Peer reviewe

Management of oculomotor nerve schwannoma: Systematic review of literature and illustrative case

BACKGROUND: Oculomotor nerve schwannoma (ONS) is an extremely rare intracranial benign tumor. Till date, there is no standard treatment of oculomotor schwannoma. Here, we present an illustrative case report of ONS, perform a systematic review of literature on surgically and radiosurgically treated cases and morbidity related to both treatment modalities. METHODS: We performed a systematic review of literature for cases with ONS treated with surgery or radiosurgery using PubMed/Ovid Medline. RESULTS: Till date, there are 60 reported cases of ONS (45 treated surgically and seven radiosurgically) with the dominance of female gender (53%) and mean age of 35.2 years (Range 1-66). In 8% of the cases, there was no involvement of cranial nerve (CN) III and 92% of the cases CN III alone or together with CN II, IV, V, and VI. In 67% of the cases a complete resection and 33% a partial resection performed. In 73% of the cases, postoperative third nerve palsy was documented, 22% improved after surgery and in around 5% of cases, the outcome was not described. In the radiosurgically treated cases of nonvestibular schwannoma including ONS, the progression-free interval of approximately 2 years was above 90%. CONCLUSION: Due to the high rate of postoperative complete oculomotor nerve palsy, a subtotal resection avoiding the nerve injury seems to be a feasible option. Radiosurgery is another option to treat small size schwannoma. A combined treatment with microsurgery followed by radiosurgery may allow effective treatment for large size oculomotor schwannoma.Peer reviewe

Catches of Ips duplicatus and other non-target Coleoptera by Ips typographus pheromone trapping

Catches of non-target Coleoptera in Ips typographus pheromone traps baited with Ipslure® were analysed along a geographic gradient running from southwestem Finland to eastern Finland and Russian Karelia. Besides I. typographus, two other bark beetles, Pityogenes chalcographus and Ips duplicatus were caught in high numbers. I. duplicatus occuned on northeastern sites only, suggesting a more restricted distribution than previously known. High numbers of Thanasimus spp. beetles indicate that I. typographus pheromone is also an effective attractant for bark beetle predators. In addition, the originally North American ambrosia beetle Gnathotrichus materiarius, now widely spread in Europe was found for the first time in nature in Finland

Ultrasound-guided percutaneous ventriculo-atrial shunt placement : Technical nuances with video demonstration

Hydrocephalic patients with abdominal pathologies often need a ventriculo-atrial (VA) shunt placement. Cutdown on the internal jugular vein has historically been used to insert a VA shunt. This technique is more time consuming and has greater complications. Less invasive methods, such as ultrasound-guided percutaneous VA shunt placement provides greater comfort for surgeon, is more rapid, and has fewer complications. However, this technique has not been demonstrated on video. Here we demonstrate ultrasound-guided and ECG-aided VA shunt catheter placement in a 70-year-old patient with normal pressure hydrocephalus. The internal jugular vein is punctured under ultrasound guidance with an 18-gauge needle. A guidewire is introduced through the needle, the needle is removed, and a small skin incision is placed at the entry point of the guidewire. A skin dilator with a sheath introducer is advanced to the vein using the guidewire and the guidewire is thereafter removed. An atrial shunt catheter (e.g. Codman (R) Medos (R) Atrial catheter) filled with sterile water is inserted through the sheath. The sheath is removed and a syringe filled with sterile aqua is connected to the catheter with a metal tip. The ECG connection of the right upper limb is connected to the tip of syringe to adjust for the optimal depth of the catheter under ECG guidance (point of highest p-wave amplitude). The catheter is clamped and tunneled to reach the site for the valve on the scalp. The ventricle catheter is placed at the Kocher point and connected to the valve (Video 1). Conclusion: Ultrasound-guided VA shunt placement is safe, comfortable, rapid, and has a reduced rate of complications.Peer reviewe

Recovery Potential of Spinal Meningioma Patients With Preoperative Loss of Walking Ability Following Surgery - A Retrospective Single-Center Study

Objective: Spinal meningiomas are neurosurgical rarities that manifest with progressive paraor tetraparesis. The effect of timing of surgery on the recovery after the loss of walking ability is poorly known. We studied the effect of timing of surgery on restoring walking ability in surgically-treated spinal meningioma patients. Methods: Using electronic health records, we retrospectively identified >= 18-year-old patients operated on during 2010-2020. The patients were followed until 30th September 2020, death or emigration. Results: We identified 108 patients (81% women) with operated spinal meningiomas. The mean age of the patients was 64 years (range, 18-94 years). A gross total resection was achieved in 101 (94%), and 21 patients (19%) suffered from perioperative complications. Of the 108 patients operated on, 49 (45%) could not walk without assistance prior to surgery. At the time of first postoperative visit (mean, 3.1 months; range, 1.3-13.1 months), 14 out of 24 patients (58%) operated on within 29 days and 8 out of 20 patients (40%) operated on later than 29 days since the loss of walking ability without assistance, were able to walk without assistance. Also, 3 out of 5 paraplegic patients who underwent surgery later than 29 days after they lost the walking ability, were able to at least walk with assistance at first postoperative visit. Conclusion: Early surgical treatment following the loss of walking ability restores walking ability in a substantial number of patients. However, even late surgery may restore walking ability.Peer reviewe

Coagulopathy and its effect on treatment and mortality in patients with traumatic intracranial hemorrhage

Background The role of coagulopathy in patients with traumatic brain injury has remained elusive. In the present study, we aim to assess the prevalence of coagulopathy in patients with traumatic intracranial hemorrhage, their clinical features, and the effect of coagulopathy on treatment and mortality. Methods An observational, retrospective single-center cohort of consecutive patients with traumatic intracranial hemorrhage treated at Helsinki University Hospital between 01 January and 31 December 2010. We compared clinical and radiological parameters in patients with and without coagulopathy defined as drug- or disease-induced, i.e., antiplatelet or anticoagulant medication at a therapeutic dose, thrombocytopenia (platelet count 1.2, or thromboplastin time <60%. Primary outcome was 30-day all-cause mortality. Logistic regression analysis allowed to assess for factors associated with coagulopathy and mortality. Results Of our 505 patients (median age 61 years, 65.5% male), 206 (40.8%) had coagulopathy. Compared to non-coagulopathy patients, coagulopathy patients had larger hemorrhage volumes (mean 140.0 mL vs. 98.4 mL, p <0.001) and higher 30-day mortality (18.9% vs. 9.7%, p = 0.003). In multivariable analysis, older age, lower admission Glasgow Coma Scale score, larger hemorrhage volume, and conservative treatment were independently associated with mortality. Surgical treatment was associated with lower mortality in both patients with and without coagulopathy. Conclusions Coagulopathy was more frequent in patients with traumatic intracranial hemorrhage presenting larger hemorrhage volumes compared to non-coagulopathy patients but was not independently associated with higher 30-day mortality. Hematoma evacuation, in turn, was associated with lower mortality irrespective of coagulopathy.Peer reviewe

Effect of Surgeon Experience on Surgical Outcome of 80-Year-Old or Older Intracranial Meningioma Patients

OBJECTIVE: Previous reports suggest that more experienced surgeons have better postoperative outcomes in neurosurgery. We studied whether this association is found in a fragile cohort of >= 80-year-old intracranial meningioma (IM) patients. METHODS: We identified 83 very old IM patients who were operated on by 12 different surgeons between 2010 and 2018. Besides general patient-and tumor-related characteristics, we collected information about the surgeons' case volume and length of surgical career (LSC). We classified neurosurgeons into 3 different categories: 1) low-volume (8 surgeons; 1-4 operations per surgeon); 2) moderate-volume (3 surgeons; 8e12 operations per surgeon); and 3) high-volume (1 reference surgeon; 37 operations). We calculated odds ratios (ORs) with 95% confidence intervals for 1-year mortality and 3-month independency (capability to live at home) by surgeon volume categories and per 5-year increase of LSC. RESULTS: We found no significant differences in any preoperative characteristics between the surgeon volume categories. IM patients operated on by low-volume surgeons had the lowest risk of first-year mortality (OR, 0.15 [0.01-2.05]) and the highest likelihood of living at home 3 months after surgery (OR, 12.61 [1.21-131.03]). Increasing LSC was associated with 1-year mortality (OR, 1.34 [1.03-1.73]) and with lower likelihood to live at home 3 months after surgery (OR, 0.83 [0.69-1.00]), but these associations were slightly nonsignificant after adjusting for IM patients' age, sex, and preoperative independency. CONCLUSIONS: In a high-volume academic hospital, less experienced neurosurgeons seem to achieve similar results as the more experienced neurosurgeons, even when operating on selected highly fragile meningioma patients.Peer reviewe

Recurrence of endovascularly and microsurgically treated intracranial aneurysmsreview of the putative role of aneurysm wall biology

Although endovascular therapy has been proven safe and has become in many centers the primary method of treatment for intracranial aneurysms, the long-term durability of endovascular embolization remains a concern; at least for some aneurysms despite initial good result. While healing after clipping relies on mechanical occlusion, restoration after endovascular occlusion mainly requires the induction of a biological response. Healing after embolization depends on the growth of new tissue over the thrombus formed by the embolization material, or alternatively, on the organization of thrombus into fibrous tissue. This review highlights the fundamental importance of aneurysm wall biology on the healing process and long-term occlusion after intracranial aneurysm (IA) treatment. It seems likely that the effect of luminal thrombus on the IA wall, as well as the IA wall condition at the time of thrombosis, determine if thrombus organizes into scar tissue (neointima formation by infiltration of cells originating from the IA wall) or if the wall undergoes continuous remodeling, which is primarily destructive (loss of mural cells). In the latter, intraluminal thrombus organization fails and the impaired healing increases the chance of recurrence. Mechanisms underlying IA reopening, the influence of intraluminal thrombosis on the IA wall, and clinical implications of the IA wall condition are discussed in detail, along with how knowledge of IA wall biology can offer new solutions for IA treatment and affect the patient selection for and follow-up after endovascular treatment.Peer reviewe