Embolic Stroke of Undetermined Source (ESUS) and Stroke in Atrial Fibrillation Patients: not so Different after all?

Abstract Background: Stroke related to atrial fibrillation (AF) is associated with high recurrence and mortality rates. Embolic Stroke of Undetermined Source (ESUS) is associated with fewer vascular risk factors, less disability, and a high recurrence rate. Objective: To compare risk factors, functional outcomes and the occurrence of primary endpoint (a composite of recurrent stroke, cardiovascular death, and myocardial infarction) between AF stroke and ESUS patients. Method: A retrospective analysis was conducted including all consecutive patients with first-ever ischemic stroke admitted to the Hospital de Clinicas (Clinical Hospital) of the Federal University of Paraná from October 2012 to January 2017 (n=554). There were 61 patients with stroke due to AF and 43 due to ESUS. Both groups were compared for demographic characteristics and vascular risk factors. Logistic regression models were performed to assess the impact of each variable on the primary endpoint in a 12-month follow-up. Statistical significance was considered for p-values < 0.05. Results: ESUS patients, as compared to AF patients, were younger and more likely to be smokers. ESUS patients presented a mean CHADS2VASc score of 4, while the AF group presented a score of 5 (p <0.001). The primary endpoint was observed in 9 (20.9%) ESUS and 11 (18.0%) AF patients over a 12-month period (p=0.802). Higher glucose levels upon hospital admission (p=0.020) and a higher modified Rankin Scale upon hospital discharge (p=0.020) were predictors of the primary endpoint occurrence. Conclusion: AF and ESUS stroke patients presented very similar independence rates upon hospital discharge and outcomes after 12 months, despite some baseline differences, including stroke recurrence, vascular death, and myocardial infarction.

Posterior petrosal approach for microsurgical resection of petroclival meningioma: 3-Dimensional operative video.

BACKGROUND: Petroclival meningiomas are challenging lesions considering their deep location and close relationship with many vital neurovascular structures.[1-8]. CASE DESCRIPTION: We present the case of a 54-year-old male presenting a history of headache, dizziness, and tinnitus on the left side, associated with left facial hypoesthesia. Preoperative imaging depicted a lesion highly suggestive of a petroclival meningioma with important compression of the brainstem. Considering worsening of symptoms, size, and location of this lesion, microsurgical resection was indicated. A left posterior petrosal approach was employed with aid of neurophysiological monitoring. The patient was placed in a true lateral position and an arciform incision was done. First, the mastoidectomy was performed and then the craniotomy around encompassing both posterior and middle cranial fossae. Middle and posterior fossa dural incisions were connected through coagulation of the superior petrosal sinus. Then tentorium was all the way cut to the incisura. After that, sigmoid sinus can be mobilized posteriorly, increasing exposure of presigmoid space. The area since jugular foramen up to the supratentorial region was fully exposed, allowing safe total resection of the lesion. Postoperative imaging demonstrated complete tumor removal. Patient presented improvement of symptoms, with no new neurological deficits on follow-up. CONCLUSION: The posterior petrosal approach provided a shorter pathway and direct angle of attack to the tumor attachment, allowing successful resection.[1,6] Extensive laboratory training is essential to get familiarized with the complex anatomical relationships in that area. Informed consent was obtained from the patient for the procedure and publication of this operative video.

Microsurgical Resection of Trigeminal Schwannomas: 3-Dimensional Operative Video.

Trigeminal schwannomas are benign lesions arising from the Schwann cells of the trigeminal nerve. This is an unusual tumor that accounts for less than 0.4% of intracranial pathologies, even though they are the second most frequent schwannoma after the vestibular schwannoma. The tumor spreads along the natural course of the V nerve at its cisternal portion, along the ganglion inside Meckel's cave or through its peripheral division. Even though the tumor can reach great size and become multicompartmental. We present a 51-yr-old woman, with an history of 3 mo of incapacitating facial pain, that was found on examination to be on the territory of the third division of the trigeminal nerve on the right side. The MRI depicted a large homogeneous enhancing lesion at the base of the right middle fossa with extension through the petrous apex to the most superior and medial part of the posterior fossa. The patient was operated by the senior author, through a middle fossa approach, dissecting between the two layers of the middle fossa dura (the apparent inner and the true outer layer of the cavernous sinus), the so called middle fossa "peeling". We achieved total resection of the tumor, but the patient presented after surgery with facial nerve paresis. This is thought to be related to geniculate ganglion manipulation, as it was unprotect by bone at the middle fossa and the patient maintained lacrimal function (post-geniculate alteration). It resolved completely after 6 mo. The patient consented to publication of her images.