Aneurysms of the intracranial segment of the ophthalmic artery trunk. case report and systematic literature review

Aneurysms arising from the ophthalmic artery trunk (OAT) are very rare, particularly in the artery's intracranial course. The onset of a subarachnoid hemorrhage (SAH) from a ruptured OAT aneurysm in this segment is extremely rare. We present a case and discuss the anatomy, clinical significance, and therapeutic options for an aneurysm at this site. We also retrospectively analyzed the record of a patient with a ruptured aneurysm of the intracranial segment of the OAT and conducted a comprehensive and systematic review of the PubMed and Scopus databases for literature on this pathology. Only one case report of SAH from an aneurysm of the intracranial segment of the OAT was published in the literature. Only in our case was the intracranial OAT segment aneurysm discovered in the acute phase of SAH. Conventional angiography with three-dimensional acquisition may help detect aneurysms at this level. Detailed knowledge of the anatomy of the OAT is of paramount importance for both surgical and endovascular approaches. Surgical treatment is complex because of difficulties in accessing the orbital region and the risk of optic nerve and vascular injuries. Endovascular treatment, when feasible, could be a good alternative to reduce the risk of loss of vision related to surgical manipulation

High Grade Glioma Treatment in Elderly People: Is It Different Than in Younger Patients? Analysis of Surgical Management Guided by an Intraoperative Multimodal Approach and Its Impact on Clinical Outcome

Objective: Age is considered a negative prognostic factor for High Grade Gliomas (HGGs) and many neurosurgeons remain skeptical about the benefits of aggressive treatment. New surgical and technological improvements may allow extended safe resection, with lower level of post-operative complications. This opportunity opens the unsolved question about the most appropriate HGG treatment in elderly patients. The aim of this study is to analyze if HGG maximal safe resection guided by an intraoperative multimodal imaging protocol coupled with neuromonitoring is associated with differences in outcome in elderly patients versus younger ones. Methods: We reviewed 100 patients, 53 (53%) males and 47 (47%) females, with median (IQR) age of 64 (57; 72) years. Eight patients were diagnosed with Anaplastic Astrocytoma (AA), 92 with Glioblastoma (GBM). Surgery was aimed to achieve safe maximal resection. An intraoperative multimodal imaging protocol, including neuronavigation, neurophysiological monitoring, 5-ALA fluorescence, 11C MET-PET, navigated i-US system and i-CT, was used, and its impact on EOTR and clinical outcome in elderly patients was analyzed. We divided patients in two groups according to their age: 65 years, and surgical and clinical results (EOTR, post-operative KPS, OS and PFS) were compared. Yet, to better understand age-related differences, the same patient cohort was also divided into 70 years and all the above data reanalyzed. Results: In the first cohort division, we did not found KPS difference over time and survival analysis did not show significant difference between the two groups (p = 0.36 for OS and p = 0.49 for PFS). Same results were obtained increasing the age cut-off for age up to 70 years (p = 0.52 for OS and p = 0.92 for PFS). Conclusions: Our data demonstrate that there is not statistically significant difference in post-operative EOTR, KPS, OS, and PFS between younger and elderly patients treated with extensive tumor resection aided by a intraoperative multimodal protocol

European Stroke Organisation (ESO) Guidelines on Management of Unruptured Intracranial Aneurysms

Unruptured intracranial aneurysms (UIA) occur in around 3% of the population. Important management questions concern if and how to perform preventive UIA occlusion; if, how and when to perform follow up imaging and non-interventional means to reduce the risk of rupture. Using the Standard Operational Procedure of ESO we prepared guidelines according to GRADE methodology. Since no completed randomised trials exist, we used interim analyses of trials, and meta-analyses of observational and case-control studies to provide recommendations to guide UIA management. All recommendations were based on very low evidence. We suggest preventive occlusion if the estimated 5-year rupture risk exceeds the risk of preventive treatment. In general, we cannot recommend endovascular over microsurgical treatment, but suggest flow diverting stents as option only when there are no other low-risk options for UIA repair. To detect UIA recurrence we suggest radiological follow up after occlusion. In patients who are initially observed, we suggest radiological monitoring to detect future UIA growth, smoking cessation, treatment of hypertension, but not treatment with statins or acetylsalicylic acid with the indication to reduce the risk of aneurysm rupture. Additionally, we formulated 15 expert-consensus statements. All experts suggest to assess UIA patients within a multidisciplinary setting (neurosurgery, neuroradiology and neurology) at centres consulting >100 UIA patients per year, to use a shared decision-making process based on the team recommendation and patient preferences, and to repair UIA only in centres performing the proposed treatment in >30 patients with (ruptured or unruptured) aneurysms per year per neurosurgeon or neurointerventionalist. These UIA guidelines provide contemporary recommendations and consensus statement on important aspects of UIA management until more robust data come available.info:eu-repo/semantics/publishedVersio

Brain AVMs: An Endovascular, Surgical, and Radiosurgical Update

Brain arteriovenous malformations (bAVMs) are complex vascular lesions. Despite multiple studies, several classifications, and a great interest of the scientific community, case selection in AVM patients remains challenging. During the last few years, tremendous advancements widened therapeutic options and improved outcomes spreading indications for patients harboring lesions deemed inoperable in the past. Anatomical and biological case specific features, and natural history with a focus on presenting symptoms should be evaluated case by case and always kept in mind while planning a therapeutic management for a bAVMs. A multidisciplinary approach is strongly recommended when dealing with bAVMs and should involve physicians expertise in this kind of challenging lesions. The goal of this paper is to provide a focused review of the most recent acquisitions and therapeutic strategies regarding surgical, endovascular, and radiosurgical treatment

In reply to "Ways to improve outcome of decompressive craniectomy: judicious utilization of microneurosurgical technique adjuncts"

We read with interest the article “Measurement of bone flap surface area and midline shift to predict overall survival after decompressive craniectomy ”. 1 Decompressive craniectomy is associated with multitude of therapeutic effects including enlargement of the intracranial volume , re-opening up of perimesencephalic cisterns, improvement of cerebral compliance, increase in cerebral blood flow and cerebral perfusion, improvement of cerebrovascular regulation and reduction in midline shift, and intracranial pressure . However, outcome of decompressive craniectomy depends on various factors i.e. age of patient, primary intracranial pathology, size of decompressive craniectomy, preoperative midline shift, preoperative rise in intracranial pressure level, co-morbid illness, neurological status, mass effect and still controversy exists regarding size of decompressive craniectomy, optimal patient group, timings and surgical technique

The central cord syndrome in patients with cervical spinal cord tumorsA XIX century vignette from (Karl) Julius Vogel (1814-1880)

Between 1830 and 1850, (Karl) Julius Vogel was one of the most important German pathologists. He received his doctorate in medicine in 1838 from the University of Munich and habilitation in pathology in 1840. In 1846, he moved to the University of Giessen as a full professor of pathology. From 1855, he taught special pathology and therapy at the University of Halle and became director of the internal clinic. Vogel and Heinrich Adolph Karl Dittmar were the first clinicians to describe the symptoms and pathological findings of central cord syndrome in a cervical spine tumor

Intracerebral hemorrhage after cranioplasty: an unpredictable treacherous complication due to reperfusion or possible systemic inflammatory response syndrome

Introduction: In case of malignant cerebral infarction and progressive neurological worsening, decompressive craniectomy is the surgical option that is recommended when medical therapies fail. The occurrence of an intracerebral hemorrhage after reconstruction of the bone defect is extremely rare. This is an extremely rare complication, with only four cases reported thus far in the literature. Case Report: A 54-year-old male suffered a malignant cerebral infarction and progressive neurological worsening requiring decompressive hemicraniectomy. Three months later, an autologous cranioplasty was performed. Postoperatively, the patient experienced a generalized epileptic seizure and a hemorrhage in the left cerebellar hemisphere on control CT scan. After surgical removal the patient did not improve, and CT revealed the occurrence of further cerebellar, mesencephalic, and intraventricular hemorrhages. Systemic inflammatory response syndrome was suspected, but death occurred 72 hours after cranioplasty. Conclusions: The reperfusion-hyperperfusion mechanism after cranioplasty might favor intracerebral hemorrhages limited to the ischemic tissue, which is unable to support the cerebral blood perfusion pressure. When diffuse atypical hemorrhages far from the surgical site occur after cranioplasty, a systemic inflammatory response syndrome is supposed

Intracerebral hemorrhage after cranioplasty: an unpredictable treacherous complication due to reperfusion or possible systemic inflammatory response syndrome

Introduction: In case of malignant cerebral infarction and progressive neurological worsening, decompressive craniectomy is the surgical option that is recommended when medical therapies fail. The occurrence of an intracerebral hemorrhage after reconstruction of the bone defect is extremely rare. This is an extremely rare complication, with only four cases reported thus far in the literature. Case Report: A 54-year-old male suffered a malignant cerebral infarction and progressive neurological worsening requiring decompressive hemicraniectomy. Three months later, an autologous cranioplasty was performed. Postoperatively, the patient experienced a generalized epileptic seizure and a hemorrhage in the left cerebellar hemisphere on control CT scan. After surgical removal the patient did not improve, and CT revealed the occurrence of further cerebellar, mesencephalic, and intraventricular hemorrhages. Systemic inflammatory response syndrome was suspected, but death occurred 72 hours after cranioplasty. Conclusions: The reperfusion-hyperperfusion mechanism after cranioplasty might favor intracerebral hemorrhages limited to the ischemic tissue, which is unable to support the cerebral blood perfusion pressure. When diffuse atypical hemorrhages far from the surgical site occur after cranioplasty, a systemic inflammatory response syndrome is supposed