Management of Complex Cerebral Aneurysms.

BACKGROUND: Complex intracranial aneurysms (CIAs) are challenging pathologies to treat. Characteristics making an aneurysm complex include dimension, history of previous treatment, location, absence of collateral circulation, intraluminal thrombosis, and calcification of the wall. The goal of the therapeutic process is to exclude the malformation from the cerebral circulation and both endovascular and surgical treatments are valid procedures. METHODS: Between 1990 and 2020, 170 CIAs were treated at our institution (33 ruptured, 137 unruptured). They were 3 prepetrous segment of the internal carotid artery (ICA), 14 purely intracavernous sinus, 27 intracavernous with subarachnoid extension, 60 paraclinoid, 4 ICA bifurcation, 15 anterior communicating artery, 24 middle cerebral artery, and 23 in the posterior circulation. All the patients underwent neuroradiologic examinations and images were evaluated by the neurosurgical and interventional radiologist team. Endovascular treatment was considered as the treatment of choice. Alternative treatment was surgical clipping; revascularization procedures were performed when neither endovascular treatment nor direct clipping were possible. RESULTS: Of 170 patients, 45 underwent endovascular treatment, 77 surgical clipping, and 55 revascularization procedures. In the unruptured group, 12 patients died, 22 reported major complications, 3 had minor complications, and 101 had an uneventful postoperative course. In the ruptured group, 9 patients died, 10 had minor complications, 1 minor complication, and 13 had a complete recovery. CONCLUSIONS: Endovascular treatment should represent the treatment of choice for CIAs. Alternative treatments include direct surgical clipping and revascularization. Overall, the correct identification of the therapeutic process guarantees a good clinical outcome.

The Role of Arachnoid Veils in Chiari Malformation Associated with Syringomyelia.

Chiari malformation type I (CM-I), or hindbrain herniation syndrome, has traditionally been defined as a dislocation of the cerebellar tonsils 5 mm or more below the foramen magnum on sagittal magnetic resonance imaging (MRI) [1, 2]. An association of this anomaly with syringomyelia is observed in 45-68% of patients [3, 4].

The Extreme Lateral Approach to the Craniovertebral Junction: An Anatomical Study.

BACKGROUND: The extreme lateral approach is a direct lateral approach which allows a good control of the entire length of the vertebral artery (VA), the jugular foramen, the lowest cranial nerves, and the jugular-sigmoid complex. Herein we try to exploit the variants of the approach and we identify indications, advantages, and disadvantages. METHODS: All phases of the study were conducted at the Institute of Public Health Section of Legal Medicine and Insurance of the University. We performed the extreme lateral approach in four subjects, who died between 24 and 48 h before in non-traumatic circumstances (three men and one woman). RESULTS: The great auricular nerve, the spinal accessory, the branches of the first ventral spinal nerves, the jugular vein, and the vertebral artery were identified in all the cadavers. In all cases the right VA exited from the transverse foramen of C1. The site of SCM piercing the accessory nerve was at a distance from the tip of the mastoid between 3 and 4 cm (3.3 in one case, 3.4 in 2 cases, and 3.7 in one case). No vessels and nerves have been damaged after being identified and isolated. CONCLUSIONS: Extradural lesions at the ventro-lateral aspect of the CVJ may require an extreme lateral approach, a procedure more aggressive comparing with far lateral approach, which represents a reasonable option for large anterior and anterolateral lesions when greater exposure is required.

Transoral Versus Transnasal Approach for Craniovertebral Junction Pathologies: Which Route Is Better?

BACKGROUND: Several pathologies that affect the craniovertebral junction (CVJ) can be treated by means of a microsurgical transoral approach (TOA) or, alternatively, with an endoscopic endonasal approach (EEA), which is potentially able to overcome some complications associated with the former approach. In this paper, after discussing updates in the recent literature, to which we add our own surgical experience, we critically analyse these procedures with the aim of demonstrating that the TOA still deserves to be considered a viable alternative and that, in selected cases, it can even be considered superior to the EEA. METHODS: Our experience involves 25 anterior procedures in 24 paediatric and adult patients (18 TOA and seven EEA). The TOA group (13 male and five female patients) encompassed three tumours, three rheumatoid arthritis cases, one condylus tertius, three basilar invaginations, four impressio basilaris cases, one developmental anomaly of C0-C1, one os odontoideum, one posttraumatic C1-C2 compression and one C2 fracture. The EEA group (three male and four female patients, median age 39 years, operated on over a 7-year period) comprised four tumours, two impressio basilaris cases and one case of impressio basilaris with platybasia. RESULTS: In the TOA group, all but one patient were discharged after posterior procedures within 2 weeks and improved or remained unchanged after surgery and during the follow-up period. No major complications occurred in the TOA group. In the EEA group, two patients who developed a cerebrospinal fluid (CSF) infection died, one from disease progression and the other from myocardial infarction. CONCLUSION: Our data, in agreement with those from previous reports on other series, suggest that no clear superiority of the EEA over the endoscopic TOA can be postulated so far; in fact, the EEA can produce complications similar to those observed with the TOA in CVJ surgery.

Endoscope-Assisted Far Lateral Approach to the Craniovertebral Junction with Neuronavigation: A Cadaver Laboratory Experience.

The far lateral approach (FLA) is a technique performed nowadays to gain access to and remove intradural lesions located ventrolaterally to the brainstem and to the craniovertebral junction (CVJ).

The Decision-Making Process in Traumatic Lesions of the Craniovertebral Junction: An Evidence-Based Approach? Part II.

This paper is Part II of a two-part report. Part I of the report covered atlanto-occipital dislocation or dissociation, and isolated condylar fractures. This part of the report covers isolated and combination fractures of the atlas and axis.

Posttraumatic Anatomical Injuries of the Craniovertebral Junction and Treatment Implications: Part I.

Please check the hierarchy of the section headings and correct if necessary.

The Decision-Making Process in Traumatic Lesions of the Craniovertebral Junction: An Evidence-Based Approach? Part I.

Evidence-based medicine is a rather young concept, which entered the scientific literature in the early 1990s.

Posttraumatic Anatomical Injuries of the Craniovertebral Junction and Treatment Implications: Part II.

This paper is Part II of a two-part report. In Part I of the report, injuries of the occipital bone, atlanto-occipital dissociation and the atlanto-occipital joint space were discussed. This part of the report discusses atlantoaxial dislocation and fractures of the atlas and axis.

Jugular tubercle and vertebral artery/posterior inferior cerebellar artery anatomic relationship: a 3-dimensional angiography computed tomography anthropometric study.

OBJECTIVE: To evaluate structural variations of the jugular tubercles (JTs) and their relationships with the vertebral artery, the posterior inferior cerebellar artery (PICA), and the vertebrobasilar junction (VBJ). METHODS: The depth, height, and width of the JTs were measured using 30 cadaveric basicranial specimens and 50 three-dimensional angiography computed tomographic (angio-CT) scans evaluating morphological variations between the 2 sides. Angio-CT analysis evaluated the relationships of the JTs with the vertebral arteries and the PICAs. The location of the VBJ with respect to the JT level in the coronal plane was evaluated. RESULTS: In the cadaveric specimens, the mean JT depth ranged from 0.9 to 3.1 cm, the mean height ranged from 0.6 to 1.5 cm, and the mean width ranged from 0.4 to 1.2 cm. According to the 3-dimensional angio-CT scans, JT measurements ranged as follows: depth, 0.7 to 2.6 cm; height, 0.6 to 1.4 cm; and width, 0.3 to 1.2 cm. The vertebral artery was in close contact with the JT on the left side in 30% of cases and on the right side in 24% of the cases. On axial scans, the PICA origin was classified as anterior to the JT in 20.5% of patients on the left side and 17.4% on the right, at the JT level in 50% of patients on the left side and 45.7% on the right, and posterior to the JT in 29.5% of patients on the left side and 36.9% on the right. On coronal scans, the PICA origin was classified as superior to the JT in 13.6% of patients on the left side and 8.7% on the right, at the JT level in 54.6% of patients on the left side and 50% on the right, and inferior to the JT in 31.8% of patients on the left side and 41.3% on the right. In the coronal plane, the VBJ was located above the tubercles in 16 patients (32%), at the JT level in 28 patients (56%), and below the tubercles in 6 patients (12%). CONCLUSION: A precise morphometric analysis of the JTs on 3-dimensional CT scans was quick and safe and showed significant variations in their size and shape. The relationship of the JT with vertebral artery and the PICA varied significantly, as well as with the VBJ location. Knowledge of these morphological variations can contribute to optimal preoperative surgical planning, minimizing retraction and reducing morbidity during extreme lateral infrajugular-transtubercular exposure surgery.

Combined intra-extracanal approach to lumbosacral disc herniations with bi-radicular involvement. Technical considerations from a surgical series of 15 cases.

Large lumbosacral disc herniations effacing both the paramedian and the foraminal area often cause double radicular compression. Surgical management of these lesions may be difficult. A traditional interlaminar approach usually brings into view only the paramedian portion of the intervertebral disc, unless the lateral bone removal is considerably increased. Conversely, the numerous far-lateral approaches proposed for removing foraminal or extraforaminal disc herniations would decompress the exiting nerve root only. Overall, these approaches share the drawback of controlling the neuroforamen on one side alone. A combined intra-extraforaminal exposure is a useful yet rarely reported approach. Over a 3-year period, 15 patients with bi-radicular symptoms due to large disc herniations of the lumbar spine underwent surgery through a combined intra-extracanal approach. A standard medial exposure with an almost complete hemilaminectomy of the upper vertebra was combined with an extraforaminal exposure, achieved by minimal drilling of the inferior facet joint, the lateral border of the pars interarticularis and the inferior margin of the superior transverse process. The herniated discs were removed using key maneuvers made feasible by working simultaneously on both operative windows. In all cases the disc herniation could be completely removed, thus decompressing both nerve roots. Radicular pain was fully relieved without procedure-related morbidity. The intra-extraforaminal exposure was particularly useful in identifying the extraforaminal nerve root early. Early identification was especially advantageous when periradicular scar tissue hid the nerve root from view, as it did in patients who had undergone previous surgery at the same site or had long-standing radicular symptoms. Controlling the foramen on both sides also reduced the risk of leaving residual disc fragments. A curved probe was used to push the disc material outside the foramen. In conclusion, specific surgical maneuvers made feasible by a simultaneous extraspinal and intraspinal exposure allow quick, safe and complete removal of lumbosacral disc herniations with paramedian and foraminal extension.

Foraminal deposition of calcium pyrophosphate dihydrate crystals in the thoracic spine: possible relationship with disc herniation and implications for surgical planning. Report of two cases.

The authors report two cases of nodular calcium pyrophosphate dihydrate (CPPD) crystal deposition close to the thoracic neural foramen, which caused chronic radiculopathy. Preoperatively, the lesions were interpreted as calcified disc herniations. Both patients underwent surgery in which an extended transfacet pedicle-sparing approach was used. Incision of the posterior longitudinal ligament released soft degenerated material. In both cases, histological examination showed abundant degenerative debris along with CPPD crystals. Spinal CPPD deposition is a comparatively rare disease that almost invariably involves the posterior aspect of the spinal canal, typically the ligamentum flavum. The exceptional foraminal location of the lesions reported here, combined with the surgical findings, indicated that the CPPD crystals were deposited on a laterally herniated disc fragment. A distinctive feature in both cases was the soft consistency of the resected tissue. The consistency of the disc material and the location of the lesion in the axial plane (that is, median compared with lateral) are key factors in determining the optimal surgical approach to thoracic disc herniations. In describing consistency, terms such as "calcified" and "hard" have been used interchangeably in the literature. In the cases reported here, what appeared on computerized tomography and magnetic resonance imaging studies to be densely calcified lesions were shown intraoperatively to be soft herniations. The authors' experience underscores that not all densely calcified herniated discs are hard. Although detection of this discrepancy would have left surgical planning for the lateral disc herniations unchanged, it could have altered planning for centrally or centrolaterally located disc herniations.

Henoch-Schönlein syndrome and cerebellar hemorrhage: report of an adolescent case and literature review.

BACKGROUND: Henoch-Schönlein syndrome (HSS) is a systemic necrotizing vasculitis predominantly affecting children. Symptoms are usually self-limited and only rarely do they involve the central nervous system. Only five published reports describe cases of radiologically proven intracranial hemorrhages complicating HSS. CASE DESCRIPTION: In this 17-year-old boy, a cerebellar hemorrhage developed after aspecific symptoms of upper respiratory tract infection. His past medical history and emerging evidence of systemic bleeding yielded a diagnosis of recurrent HSS. This was the fourth time the disease had recurred since the age of 4. The patient underwent surgical treatment and returned to his normal activities. CONCLUSIONS: Intracerebral hemorrhages during HSS share a favorable prognosis and a posterior lobar localization, typically involving the parieto-occipital region. The case described here is unusual because the patient did not have the typical purpuric rash and unlike published cases, the intracranial hemorrhage marked the onset of HSS rather than complicating a typical HSS presentation.

Intraspinous postlaminectomy pseudomeningocele.

Pseudomeningoceles are uncommon complications of lumbar surgery. They are encapsulated cerebrospinal fluid collections developing extradurally as a consequence of incidental dural tears. They are typically located in the paraspinal compartment and occasionally reach the subcutaneous space. We describe the case of a patient in whom a postlaminectomy pseudomeningocele developed over a 10-year period within the L5 spinous process and remained completely encircled within its bony boundaries. The surgical implications of this finding are discussed.

Intramedullary neurenteric cyst with a false mural nodule: case report.

OBJECTIVE AND IMPORTANCE: Spinal neurenteric cysts are rare congenital lesions that may occur either alone or in the context of a complex malformative disorder including typical vertebral and cutaneous abnormalities. The interest of the case of a spinal neurenteric cyst described here lies in its rare intramedullary location and in the false mural nodule image on the preoperative magnetic resonance imaging scan. A further distinctive feature is the association with a cleft spinal cord. CLINICAL PRESENTATION: A 28-year-old woman presented with a 2-year history of progressive paraparesis and urinary retention. A magnetic resonance imaging study disclosed a T8-T9 intramedullary cystic lesion with a mural nodulelike formation on the posterior face. INTERVENTION: A posterior midline myelotomy exposed a cystic lesion that had translucent walls and contained a milky fluid. No mural nodules were found. Once the cyst had been emptied, a collateral finding was a cleft that was clearly observed in the anterior spinal cord. The histological diagnosis was a neurenteric cyst. Retrospectively, the nodular lesion found on the preoperative scan was attributed to mucinous clots deposited at the bottom of the cyst. CONCLUSION: This case report demonstrates that neurenteric cysts can vary widely in radiological appearance, depending on the contents of the cyst. These differences become especially important if the associated stigmata are lacking and the preoperative diagnosis rests on magnetic resonance imaging scan appearance alone.

Gas-containing otogenic brain abscess.

BACKGROUND: Gas-containing brain abscesses are very rare. Two mechanisms may be responsible for the presence of intracavitary gas: bacterial fermentation or penetration through an abnormal communication between the exterior and the intracranium. The need to search for this potential communication is considered an indication for open surgery. We report the case of a surgically treated gas-containing brain abscess originating from an undiagnosed chronic otitis media. CASE DESCRIPTION: A 54-year-old man developed acute neurologic deterioration, becoming comatose within 24 hours. A contrast-enhanced computed tomography (CT) scan disclosed a gas-containing cystic mass in the right temporal lobe. Urgent surgical decompression revealed the presence of an abscess, which was excised. During the same surgery, we performed a radical mastoidectomy, removing a previously undiagnosed attic cholesteatoma. Neither procedure revealed a discontinuity of the floor of the middle cranial fossa. Cultures grew a mixed flora. Antibiotics were administered for 6 weeks. The patient made a complete neurologic recovery. CONCLUSION: This report demonstrates that otogenic brain abscesses may contain gas due to fermentation of nonclostridial bacteria.

Rapid, symptomatic enlargement of a lumbar juxtafacet cyst: case report.

STUDY DESIGN: A case is reported in which a 45-year-old man developed cauda equina syndrome caused by enlargement of an L4-L5 juxtafacet cyst diagnosed 4 months earlier. OBJECTIVES: To highlight the short interval that can elapse between the discovery of a juxtafacet cyst and its remarkable progression. SUMMARY OF BACKGROUND DATA: Although juxtafacet cysts are acquired lesions, how long they take to develop remains unclear. Hemorrhage is a well-known cause of rapid or even dramatic cyst enlargement. This is the first report providing magnetic resonance imaging evidence of rapid, remarkable enlargement of a nonhemorrhagic juxtafacet cyst. METHODS: The patient underwent conservative treatment for an L4-L5 right juxtafacet cyst diagnosed by magnetic resonance imaging during evaluation of posttraumatic lower back pain. Four months later, the patient presented with severe pain radiating down the right lateral leg, urinary retention, and impaired dorsal flexion of the right foot. Repeat magnetic resonance imaging showed the cyst now markedly enlarged and occupying almost the entire width of the canal. RESULTS: The cyst was removed, and the patient's symptoms abated. At 15 months after surgery, he is symptom-free. CONCLUSIONS: Juxtafacet cyst may occasionally enlarge and cause severe symptoms within months.