Dural venous sinus stenting technique for idiopathic intracranial hypertension in patients with tortuous venous anatomy.

Venous sinus stenting (VSS) for medically refractory idiopathic intracranial hypertension (IIH) is emerging as a safe and effective alternative to shunting. However, stent navigation past the jugular bulb with commonly used carotid stenting systems via femoral access in cases with tortuous venous anatomy can present a challenge, leading to procedural failure. We present a technical refinement using a cervical access and peripheral vascular stent with a more stable 0.035-in. delivery platform as an alternative to the traditional approach to simplify the procedure and overcome the technical difficulties in cases with tortuous venous anatomy. Our institutional database for patients who had IIH and undergone VSS using the peripheral vascular stent between 2013 and 2023 was retrospectively reviewed. Data on 36 patients (33 women, 3 men, mean age 32 years) was collected. VSS was technically successful in all patients (100%) without major complications or thrombosis. There was one case of minor neck cellulitis treated with oral antibiotics. Three patients underwent repeat stenting, and 2 patients had ventriculoperitoneal shunt placement after stenting due to persistent or recurrent symptoms. All patients (100%) had improvement or resolution of papilledema; however, six patients had evidence of optic atrophy and persistent vision loss. Headache was resolved or improved in 91% of patients. In the presence of tortuous venous anatomy, VSS using cervical access and a peripheral vascular stent with a more stable 0.035-in. delivery platform can be considered as a safe and effective alternative approach with shorter procedure time. This approach is particularly advantageous in situations where the procedure is prolonged or high dose of contrast has been administered due to the technical challenges associated with the traditional use of carotid systems via femoral access for stent delivery.

Covered stent delivery in tortuous internal carotid artery for treatment of direct carotid cavernous fistula / Colocación de un stent cubierto en una arteria carótida interna tortuosa para el tratamiento de la fístula carótida cavernosa directa

Direct carotid cavernous fistulas (dCCF) are high-flow shunts between the internal carotid artery (ICA) and cavernous sinus and are commonly caused by traumatic injuries. Endovascular intervention using detachable coils, with or without stenting, is often the treatment of choice; however, migration or compaction of the coils can occur due to high-flow nature of dCCFs. Alternatively, deployment of a covered stent in ICA can be considered for treatment of dCCFs. We report a case of dCCF with tortuous intracranial ICA successfully treated by placement of a covered stent graft and we will illustrate the technical aspects of the procedure. In the presence of a tortuous ICA navigation and deployment of covered stents is technically complicated and requires modified maneuvers (AU)

Las fístulas carótidas cavernosas directas (dCCF) son derivaciones de alto flujo entre la arteria carótida interna (ACI) y el seno cavernoso y suelen ser causadas por lesiones traumáticas. La intervención intravascular con espirales desmontables, con o sin stent, suele ser el tratamiento de elección; sin embargo, la migración o compactación de las bobinas puede ocurrir debido a la naturaleza de alto flujo de los dCCF. Alternativamente, se puede considerar el despliegue de un stent cubierto en la ACI para el tratamiento de dCCF. Presentamos un caso de dCCF con ACI intracraneal tortuosa tratada con éxito mediante la colocación de una endoprótesis cubierta e ilustraremos los aspectos técnicos del procedimiento. En presencia de una ACI tortuosa, la navegación y el despliegue de los stents cubiertos es técnicamente complicado y requiere maniobras modificadas (AU)

Covered stent delivery in tortuous internal carotid artery for treatment of direct carotid cavernous fistula.

Direct carotid cavernous fistulas (dCCF) are high-flow shunts between the internal carotid artery (ICA) and cavernous sinus and are commonly caused by traumatic injuries. Endovascular intervention using detachable coils, with or without stenting, is often the treatment of choice; however, migration or compaction of the coils can occur due to high-flow nature of dCCFs. Alternatively, deployment of a covered stent in ICA can be considered for treatment of dCCFs. We report a case of dCCF with tortuous intracranial ICA successfully treated by placement of a covered stent graft and we will illustrate the technical aspects of the procedure. In the presence of a tortuous ICA navigation and deployment of covered stents is technically complicated and requires modified maneuvers.

Late Onset Symptomatic Enlargement of Treated Spinal Intradural Neurocysticercosis Cyst.

Cyst enlargement with progressive symptoms in spinal intradural Neurocysticercosis (NCC) is an uncommon finding after effective treatment of NCC. Neither imaging nor clinical presentation is sufficient to differentiate a sterile arachnoid cyst from recurrence of NCC. We present a case of symptomatic spinal intradural cyst enlargement 16 years after successful treatment of intracranial and spinal NCC with anti-helminthics.

Microsurgical and endoscopic anatomy of the extended retrosigmoid inframeatal infratemporal approach.

BACKGROUND: Different and often complex routes are available to deal with jugular foramen tumors with extracranial extension. OBJECTIVE: To describe a novel extension of the retrosigmoid approach useful to expose the extracranial area abutting the posterior fossa skull base. METHODS: A navigation-guided, endoscope-assisted retrosigmoid inframeatal approach was performed on 6 cadaveric heads in the semisitting position, displaying an area from the internal acoustic meatus to the lower cranial nerves and exposing the intrapetrous internal carotid artery. We then continued removing the temporal bone located between the sigmoid sinus and the hearing apparatus, reaching the infratemporal area just lateral to the jugular fossa. This drilling, which we refer to as posterolateral inframeatal drilling, has not previously been described. Drilling of the horizontal segment of the occipital squama allowed good visualization of the uppermost cervical internal carotid artery, internal jugular vein, and lower extracranial cranial nerves. RESULTS: We were able to provide excellent exposure of the inframeatal area and of the posterior infratemporal fossa from different operative angles, preserving the neurovascular structures and the labyrinth in all specimens. The intradural operative window on the extracranial compartment was limited by the venous sinuses and the hearing apparatus and presented a mean width of 8.52 mm. Sigmoid sinus transection led to better visualization of the lateral half of the jugular foramen and of the uppermost cervical internal carotid artery. CONCLUSION: The navigation-guided endoscope-assisted extended retrosigmoid inframeatal infratemporal approach provides an efficient and versatile route for resection of jugular foramen tumors with extracranial extension.

Anatomical variations and neurosurgical significance of Liliequist's membrane.

INTRODUCTION: Liliequist's membrane is an arachnoid membrane that forms a barrier within the basilar cisternal complex. This structure is an important landmark in approaches to the sellar and parasellar regions. The importance of this membrane was largely recognized after the advance of neuroendoscopic techniques. Many studies were, thereafter, published reporting different anatomic findings. METHOD: A detailed search for studies reporting anatomic and surgical findings of Liliequist's membrane was performed using "PubMed," and included all the available literature. Manual search for manuscripts was also conducted on references of papers reporting reviews. RESULTS: Liliequist's membrane has received more attention recently. The studies have reported widely variable results, which were systematically organized in this paper to address the controversy. CONCLUSION: Regardless of its clinical and surgical significance, the anatomy of Liliequist's membrane is still a matter of debate.

Primary diffuse large B cell lymphoma of the cranial vault.

Primary non-Hodgkin's lymphoma of the cranial vault is extremely rare. This case report presents a 42-year-old man with a painless subcutaneous scalp mass which extended intracranially associated with recent mild headache. Initial computed tomography and magnetic resonance imaging revealed two lesions emanating from the skull. Biopsy revealed a diagnosis of diffuse large B cell lymphoma (DLBCL). A thorough work-up revealed no other point of involvement. This case is concerned about considering lymphoma in the differential diagnosis of calvarial lesions with both intra- and extra cranial extensions but without obvious intervening bony destruction.