Multidisciplinary management of posterior fossa dural arteriovenous fistula: A single-center experience.

PURPOSE: The management of posterior fossa dural arteriovenous fistulas (pfDAVFs) is challenging. Here, we show how multidisciplinarity leads to their successful management, even in complex cases. METHODS: All pfDAVFs managed from 2010 to 2019 at our center were reviewed. The preoperative clinical and radiological characteristics, their management and the occlusion rate were retrieved. The radiological and functional outcomes were retrieved at discharge and last follow-up (FU). RESULTS: n=27 patients were included (6 females, mean age: 61-years-old, mean FU: 22.5 months). n=8 patients presented with cerebral hemorrhage. Among patients with ruptured pfDAVFs, n=7 had headache, n=4 had ataxia, and n=2 had impaired level of consciousness. In the unruptured group N (n=19), n=7 patients had headache, n=6 patients had focal neurological deficit, n=4 patients had tinnitus, n=3 (had ataxia, and one presented with seizure. n=24 patients were treated by endovascular therapy (EVT), n=2 patients were treated by microsurgery (MS) and n=1 patient was managed with a combined approach. Re-treatment was necessary in n=6 patients. n=24 patients showed total exclusion at last FU. n=2 patients died during the first 30 days; n=1 patient died during FU. CONCLUSIONS: While EVT should be advocated as the first line therapy whenever possible, MS should not be banned from the treatment armamentarium. Neurosurgeons must be able to achieve direct surgical occlusion when the angioarchitecture speaks against EVT.

Subependymal giant-cell astrocytoma: A surgical review in the modern era of mTOR inhibitors.

INTRODUCTION: Surgical removal has been the historical treatment for subependymal giant-cell astrocytoma (SEGA) in tuberous sclerosis complex (TSC) patients. In the past decade, mTOR inhibitors have shown efficacy in the treatment of SEGA, significantly reducing tumor size. The aim of this study was to assess the safety and efficacy of surgical treatment at a time when mTOR inhibitors have changed standard treatment. MATERIAL AND METHODS: We conducted a single-center retrospective study including all patients treated by surgery for SEGA from October 2003 to September 2019, with a review of all SEGA surgical case series, following PRISMA guidelines. Research focused on demographics, surgical indications, surgical approach, use of CSF shunt, morbidity and mortality, resection quality, recurrence rate and treatment of recurrence, follow-up and long-term clinical status. RESULTS: Eleven patients were included, with a median age at surgery of 16.0 years. Gross total resection was achieved in 8 patients (72%), with no permanent morbidity. One patient needed further surgery for tumor recurrence. Eighteen studies were reviewed, totaling 263 TSC patients affected by SEGA and 286 surgical procedures. Gross total resection was achieved in 81.1% of cases, mortality was 4.9% and permanent morbidity 6.1%. Tumor recurrence occurred in 11.5% of cases, and was secondary to partial tumor resection at first surgery in the majority of cases. CONCLUSION: Surgical treatment of SEGA is still a valid and effective option. Morbidity is low and complete disappearance of SEGA can be achieved in selected cases.