Cavernous malformations of the central nervous system: An international consensus statement.

Introduction: Cavernous malformations (CM) of the central nervous system constitute rare vascular lesions. They are usually asymptomatic, which has allowed their management to become quite debatable. Even when they become symptomatic their optimal mode and timing of treatment remains controversial. Research question: A consensus may navigate neurosurgeons through the decision-making process of selecting the optimal treatment for asymptomatic and symptomatic CMs. Material and methods: A 17-item questionnaire was developed to address controversial issues in relation to aspects of the treatment, surgical planning, optimal surgical strategy for specific age groups, the role of stereotactic radiosurgery, as well as a follow-up pattern. Consequently, a three-stage Delphi process was ran through 19 invited experts with the goal of reaching a consensus. The agreement rate for reaching a consensus was set at 70%. Results: A consensus for surgical intervention was reached on the importance of the patient's age, symptomatology, and hemorrhagic recurrence; and the CM's location and size. The employment of advanced MRI techniques is considered of value for surgical planning. Observation for asymptomatic eloquent or deep-seated CMs represents the commonest practice among our panel. Surgical resection is considered when a deep-seated CM becomes symptomatic or after a second bleeding episode. Asymptomatic, image-proven hemorrhages constituted no indication for surgical resection for our panelists. Consensus was also reached on not resecting any developmental venous anomalies, and on resecting the associated hemosiderin rim only in epilepsy cases. Discussion and conclusion: Our Delphi consensus provides an expert common practice for specific controversial issues of CM patient management.

Two-step treatment of a giant skull vault hemangioma: A rare case report and literature review / Tratamiento en dos pasos de un hemangioma de la bóveda craneal gigante: informe de un caso poco frecuente y revisión de la literatura

kull vault hemangiomas are benign vascular tumours of the calvaria that are usually asymptomatic or present as firm, painless lumps. We present a case of a 59-year-old female with a giant intraosseous calvarial hemangioma that was admitted in our department with a palpable mass over the left frontoparietal region, personality changes and impaired emotional and cognitive functions. The patient was treated with a two-step approach involving endovascular and surgical treatment, and suffered two rare, but recognized complications, a contrecoup intracerebral haemorrhage and valproate-induced stupor and parkinsonism. At the 6-month follow-up, the patient had complete recovery with a good neurological outcome (AU)

Los hemangiomas de la bóveda craneal son tumores vasculares benignos de la calota que suelen ser asintomáticos o aparecen como bultos firmes e indoloros. Presentamos el caso de una mujer de 59 años con un hemangioma de calota intraóseo gigante que ingresó en nuestra unidad con una masa palpable en la región frontoparietal izquierda, con cambios de personalidad y con la alteración de las funciones emocional y cognitiva. La paciente recibió tratamiento con un método de dos pasos que incluía terapia endovascular y quirúrgica, y experimentó dos complicaciones poco frecuentes, pero reconocidas: hemorragia cerebral por contragolpe, así como estupor y parkinsonismo inducidos por valproato. A los seis meses de seguimiento, la mujer se recuperó por completo con un buen desenlace neurológico (AU)

Two-step treatment of a giant skull vault hemangioma: A rare case report and literature review.

Skull vault hemangiomas are benign vascular tumours of the calvaria that are usually asymptomatic or present as firm, painless lumps. We present a case of a 59-year-old female with a giant intraosseous calvarial hemangioma that was admitted in our department with a palpable mass over the left frontoparietal region, personality changes and impaired emotional and cognitive functions. The patient was treated with a two-step approach involving endovascular and surgical treatment, and suffered two rare, but recognized complications, a contrecoup intracerebral haemorrhage and valproate-induced stupor and parkinsonism. At the 6-month follow-up, the patient had complete recovery with a good neurological outcome.

Treatment of carotid cavernous sinus fistulas with flow diverters. A case report and systematic review.

INTRODUCTION: Carotid cavernous fistulas (CCFs) are rare, usually follow head trauma or aneurysmal rupture. Recent treatment options include endovascular techniques such as flow diversion devices (FDDs). OBJECTIVE: To present our case treated with FDD application with transarterial cavernous-sinus coiling and present a systematic review on the use and effectiveness of FDDs in CCF treatment. MATERIALS AND METHODS: We present our case of CCF treatment with FDD. A search was also conducted in PubMed, EMBASE and Cochrane until November 2020. Reference lists were also cross-checked. RESULTS: Including our case, thirty-eight patients were identified with a CCF that was treated with FDDs in sixteen studies. Twenty-two patients were females, nine were males and the rest unidentified. The mean age was 52,6 years (range 17-86, SD± 19.28). Thirty-six patients suffered from direct and two from indirect CCFs. Single FDD was used in four cases, single FDD with embolic materials in eleven cases, multiple overlapping FDDs were used in six cases and multiple overlapping FDDs with embolic materials were used in seventeen cases. Thirty-five patients (92,1%) had clinical improvement, immediate angiographic occlusion was seen in 44,7% of the cases, while long-term occlusion rate was 100% but with variable follow-up periods. One patient (2,6%) presented with a neurological deficit related to FDD deployment. CONCLUSION: Targeted treatment of CCFs with single or overlapping FDDs with or without adjunct embolic agents offers a high success rate, both clinically and long-term angiographically compared to other endovascular methods alone. However, further research with multi-center prospective trials is warranted.

Two-step treatment of a giant skull vault hemangioma: A rare case report and literature review.

Skull vault hemangiomas are benign vascular tumours of the calvaria that are usually asymptomatic or present as firm, painless lumps. We present a case of a 59-year-old female with a giant intraosseous calvarial hemangioma that was admitted in our department with a palpable mass over the left frontoparietal region, personality changes and impaired emotional and cognitive functions. The patient was treated with a two-step approach involving endovascular and surgical treatment, and suffered two rare, but recognized complications, a contrecoup intracerebral haemorrhage and valproate-induced stupor and parkinsonism. At the 6-month follow-up, the patient had complete recovery with a good neurological outcome.

Central vascular catheters versus peripherally inserted central catheters in nurse anesthesia. A perspective within the Greek health system.

PURPOSE: We present a study comparing the insertion of central vascular catheter (CVC) and peripherally inserted central catheter (PICC) by an anesthesia nurse at 2 Greek University Hospitals. METHODS: Eighty patients, aged 20-80 years, were enrolled in the study. Patients were divided into 2 groups. In group A (41 patients), a CVC was inserted in the internal jugular vein. In group B (39 patients), a pressure-injectable PICC was inserted in the basilica vein. RESULTS: Correlations between the methods applied, the patients' characteristics, the procedures' characteristics and the overall satisfaction scores for each procedure were examined. The final results show that the patients of group B (PICC method) were more satisfied with the procedure than the patients of group A (CVC method), at the statistical significance level of a=0.01. Also, according to the results of the analysis, the PICC method offers significantly more comfort and relative satisfaction than the CVC method, at the statistical significance level of a=0.01. The satisfaction scores of "physicians" were statistically more significant, at a=0.01, for the patients of group A (classic CVCs) mainly because of the insufficient flow rate of the PICCs when compared with the CVCs and especially if one considers the fact that the physicians did not have any experience with the PICC method at all. CONCLUSIONS: PICCs under ultrasound guidance constitute the solution of choice for patients and they definitely surpass the CVCs focusing mainly on the improvement of the quality of life and the satisfaction of patients.

A randomized double-blind trial of anesthesia provided for colonoscopy by university-degreed anesthesia nurses in Greece: safety and efficacy.

There are numerous studies in the literature of anesthesia administered during colonoscopy including various methods, drugs, and monitoring systems; however, none of them has studied whether a university-degreed nurse anesthesia provider (known as a certified registered nurse anesthetist in the United States) is skillful enough to provide safe anesthesia in patients undergoing endoscopic procedures. The aim of our study was to determine whether anesthesia provided by a university-degreed nurse anesthesia provider during an endoscopic procedure is comparable in terms of safety and efficacy with routine sedation practice. This randomized, double-blind study included 100 adult patients who underwent colonoscopy conducted in the Evgenidion University Hospital during a single year. Subjects were divided into 2 groups: the first group received the usual scheme of intravenous sedation with midazolam and fentanyl administered by a member of the endoscopic team that was blind to Bispectral Index (BIS) values recordings (Group 0). The second group received intravenous bolus injection of propofol bolus by a university-degreed anesthesia registered nurse based on the BIS values (Group 1). The average of the mean BIS values of Group 0 was 85.07 (SD = 8.01) and for Group 1 was 76.1 (SD = 10.88; p = .04). The parameters of "patient memory during procedure" and the satisfaction scores (as self-assessed by the patients as well as 2 gastroenterologists) were also significantly different between the patients of the 2 groups (p = .000). Comparison between the 2 groups showed that the sedation offered by a university-degreed nurse anesthesia provider was absolutely safe and effective, offering particular comfort to the patient during the intervention and contributing significantly to its successful results.

Greece reports prototype intervention with first peripherally inserted central catheter: case report and literature review.

Placement of peripherally inserted central catheters (PICCs), definitely offers a clear advantage over any other method regarding central venous catheterization. Its ultrasonographic orientation enhances significantly its accuracy, safety and efficacy, making this method extremely comfortable for the patient who can continue his or her therapy even in an outpatient basis. We present the first reported case of a PICCS insertion in Greece, which has been performed by a university-degree nurse. The aim of this review of literature was to present the evolution in nursing practice in Greece. A PICC was inserted in a 77-year-old male patient suffering from a recent chemical pneumonia with a history of Alzheimer's disease. A description of all the technical details of this insertion is reported, focusing on the pros and cons of the method and a thorough review of the history and advances in central venous catheterization throughout the years is also presented. PICCs provide long-term intravenous access and facilitate the delivery of extended antibiotic therapy, chemotherapy and total parenteral nutrition. We strongly believe that PICCs are the safest and most effective method of peripherally inserted central venous catheterization. Larger series are necessary to prove the above hypothesis, and they are under construction by our team.

CNS tuberculosis: a review and illustration from an autopsy case.

An estimated one-third of the world's population (2 billion people) is infected with the tubercle bacilli (TB), which is estimated to cause 6% of all deaths worldwide. Despite there being a decline in the incidence of tuberculosis seen in Europe, there are still some countries in the rest of the world where the estimated number of new cases is very high. When a person presents with persistent fever with or without neurological symptoms, the diagnosis of TB cannot be excluded. We present a case report of a 26-year-old male patient, who died of CNS tuberculosis. Such case studies will help keep neuroscience nurses alert to potential medical issues in multiethnic patient populations.

Intraoperative use of cell saver on patients undergoing open abdominal aortic aneurysm surgical repair: a Greek hospital experience.

Perioperative use of a cell saver device can serve as a cost-beneficial alternative to the transfusion method, especially in countries where the cost of a single unit of blood is high. The purpose of this study, conducted in a Greek hospital, was to calculate the cost benefit of using a cell saver device to salvage intraoperative blood during open surgical abdominal aortic aneurysm repair or open aortofemoral bypass for occlusive disease. This retrospective study measured the amounts of salvaged blood and reinfused blood encountered during the procedure and then calculated the cost benefit of cell saver use. With the cost of a unit of blood purchased in Greece about €450 ($585), the blood units salvaged and reinfused were calculated at a mean cost benefit of €754 ($980) per case.

Preventive thyroidectomy in patients with hereditary medullary thyroid carcinoma found heterozygote for mutant RET proto-oncogene.

The currently available genetic tests for identification of the RET proto-oncogene mutation offer the possibility of prospective successful therapy before the hyperplasia of C-cells evolve to Medullary Thyroid Carcinoma. We present our experience regarding the preventive thyroidectomy of family members with history of Medullary Thyroid Carcinoma, who were found to be heterozygote for mutant RET proto-oncogene. We have retrospectively reviewed 19 members of 6 families with history of Medullary Thyroid Carcinoma, who were heterozygote for mutant RET protooncogene and underwent prophylactic thyroidectomy. All patients included in this series were below twenty years of age. The Medullary Thyroid Carcinoma was asymptomatic and the mutation of RET protooncogene has been also documented pre-operatively in all of them. All patients had undergone total thyroidectomy, while 1 with pheochromocytoma had undergone also left epinephridectomy. Fourteen patients (73.68%) had undergone lymph-nodes resection (in 10 of them the resection was central, in 3 unilateral and in 1 bilateral). Although none of our patients suffered from hyperparathyroidism, 7 parathyroid glands have been also resected from 3 patients, while auto-transfusion has been performed in one. In all patients, preoperative measurement of the calcitonin blood levels before and after stimulation with pentagastrin has been performed.

Incidental catheterization of a radical arterial branch during vascular cannulation: A case report.

This articles presents a rare case of accidental insertion of an intravascular catheter into an artery by an experienced nurse (RN). Due to the patient's hypotension, this faulty positioning was misdiagnosed and a potential peripheral ischemic necrosis was, fortunately, avoided only because the anesthesia drug injection was performed through another vein. Clinical signs were also present but were also underestimated. After intra-arterial confirmation of the incorrect position, the catheter was subsequently removed. No further complications were observed.

Right procedure, wrong organ, an unusual case report of aortic trauma in a multiple injured patient.

Blunt traumatic injury and acute dissection of thoracic aorta is increasing in incidence in seriously multi-trauma patients, remaining highly lethal. Early identification and repair is the key to a successful outcome. We report an unusual case of a 62-year-old man involved in a motor vehicle accident after subarachnoid hemorrhage due to an intracranial artery aneurysm rupture. The post-traumatic aorta dissection was overlooked during the initial evaluation and was found incidentally later during an attempt for endovascular treatment of the intracranial aneurysm. The pitfalls in the diagnostic approach of this patient are discussed and the paramount importance of the correct interpretation of all the available clinical and investigational findings in multiple injured patients are highlighted.

Solitary internal jugular vein invasion by thyroid carcinoma: resection and reconstruction.

Thyroid carcinoma usually presents as asymptomatic thyroid nodule. Thyroid cancer may show microscopic vascular invasion; however, internal jugular vein (IJV) invasion is a rare complication of thyroid cancer. We present a case of unilateral invasion of IJV caused by local nodal recurrence of the primary thyroid carcinoma. The patient had undergone a near total thyroidectomy, followed by modified left lymph node resection with left IJV resection. In this case, the infiltrated part of the right IJV was resected, and the vessel was reconstructed using saphenous vein autograft. In locally advanced, well-differentiated thyroid cancers, only the radical resection relieves symptoms and increases survival.

Sphenoid wing meningioma and glioblastoma multiforme in collision - case report and review of the literature.

The coexistence of two histologically different primary tumours in the same brain region is relatively rare. The situation where these tumours in collision appear in an area of a previously excised meningioma is even more rare and only two cases have been reported so far. We present the third case of a 73-year-old woman who underwent an uneventful excision of a right sphenoid wing meningioma. She was re-admitted 3 years later due to reappearance of a tumour in the area adjacent to the previously excised meningioma. Histological diagnosis revealed a collision tumour of a glioblastoma multiforme and a fibrillary meningioma. The coincidence of these two different neoplasms in the same location at the same time 3 years after surgical removal of a meningioma leads us to speculate on the pathogenesis, and to review the literature regarding this particular issue.

Delayed visual deficits and monocular blindness after endovascular treatment of large and giant paraophthalmic aneurysms.

OBJECTIVE: Paraophthalmic aneurysms may exert mass effect on the optic apparatus. Although surgical clipping and endovascular coiling of these aneurysms can be complicated by immediate postoperative visual deterioration, endovascular coil embolization has the unique risk of visual complications later (>24 h) in the perioperative period. METHODS: Six patients with a delayed onset of vision loss after technically successful coil embolization of paraophthalmic region aneurysms were identified. All available clinical, angiographic, and cross sectional imaging for these patients, in addition to histopathological data, were reviewed. RESULTS: Six patients who underwent endovascular treatment of paraclinoid aneurysms at our institutions developed delayed postoperative visual decline. Four were treated with combination hydrogel-coated and bare platinum coils, one with hydrogel-coated coils, and one with bare platinum coils. Three patients presented with some degree of visual impairment caused by their aneurysms. Catheter angiography performed after the visual decline revealed no etiology in any of the cases. Magnetic resonance imaging was performed in all patients and was unremarkable in two. At follow-up, two had improved, three remained unchanged, and one patient died before any follow-up assessment of her vision. CONCLUSION: Both acute and delayed visual disturbances can present after the endovascular treatment of carotid artery paraophthalmic aneurysms. Delayed visual deterioration can be observed up to 35 days after embolization. Although the cause is still undefined, it is likely that the more delayed visual deterioration can be attributed to progression of mass effect and/or perianeurysmal inflammatory change. Our case series raises the possibility that this phenomenon may be more likely with HydroCoil (HydroCoil Embolic System; MicroVention, Aliso Viejo, CA). This possibility should be taken into account by neurointerventionists when selecting a coil type to treat large paraophthalmic aneurysms.

The haemodynamics of endovascular aneurysm treatment: a computational modelling approach for estimating the influence of multiple coil deployment.

This paper proposes a novel computational methodology for modelling the haemodynamic effects of endovascular coil embolization for cerebral aneurysms. We employ high-resolution 3-D angiographic data to reconstruct the intracranial geometry and we model the coiled part of the aneurysm as a porous medium, with porosity decreasing as coils are inserted. The actual dimensions of the coils employed are used to determine the characteristics of the porous medium. Simulation results for saccular aneurysms from the anterior communicating and middle cerebral arteries show that insertion of coils rapidly changes intraaneurysmal blood flow and causes reduction in mural pressure and blood velocity up to stagnation, providing favorable conditions for thrombus formation and obliteration of the aneurysm.

The "hanging technique" of vascular transposition in microvascular decompression for trigeminal neuralgia: technical report of four cases.

The successful long-term outcome of microvascular decompression for trigeminal neuralgia is largely dependent on the maintenance of the isolation between the trigeminal nerve and the offending vessel, avoiding also the development of scar tissue around the nerve. We propose an alternative technique to achieve this target by "hanging" the offending vessel from the overlying tentorium using a strip of autologous tissue without interposing any foreign material.

Haemodynamic simulation of aneurysm coiling in an anatomically accurate computational fluid dynamics model: technical note.

INTRODUCTION: Computational fluid dynamics (CFD) is a numerical technique that is used for studying haemodynamic parameters in cerebral aneurysms. As it is now possible to represent an anatomically accurate intracranial aneurysm in a computational model, we have attempted to simulate its endosaccular occlusion with coils and demonstrate the haemodynamic changes induced. This is the first attempt to use this particular porous medium-based method for coiling simulation in a CFD model, to our knowledge. METHODS: Datasets from a rotational 3-D digital subtraction angiogram of a recently ruptured anterior communicating aneurysm were converted into a 3-D geometric model and the discretized data were processed using the computational technique developed. Coiling embolisation simulation was achieved by impediment of flow through a porous medium with characteristics following a series of embolisation coils. Haemodynamic parameters studied were: pressure distribution on the vessel wall, blood velocity and blood flow patterns. RESULTS: Significant haemodynamic changes were detected after deployment of the first coil. Similar, but less dramatic changes occurred during subsequent stages of coiling. The blood flow patterns became less vortical in the aneurysm sac as velocity decreased to stagnation and the wall pressure at the fundus was gradually reduced. Furthermore, the haemodynamic characteristics developed at the area of the neck remnant could form the basis for assessing the likelihood of delayed coil compaction and aneurysm regrowth. CONCLUSION: Appropriate computational techniques show great promise in simulating the haemodynamic behaviour of the various stages in coil embolisation and may be a potentially valuable tool in interventional planning and procedural decision-making.

Embolization of spinal intramedullary arteriovenous malformations using the liquid embolic agent, Onyx: a single-center experience in a series of 17 patients.

OBJECT: The aim of this study was to analyze the endovascular treatment results of using the Onyx liquid embolic system for spinal intramedullary arteriovenous malformations (AVMs). METHODS: The clinical and radiological records of 17 patients with symptomatic spinal intramedullary AVMs treated exclusively by embolization with Onyx between 1999 and 2003 were retrospectively reviewed. There were 12 females and five males in the patient series (mean age 29 years). Four of these AVMs were located in the cervical spine, eight in the thoracic spine, and five in the lumbar spine. The clinical presentation of these AVMs included upper motor neuron signs and symptoms, and hemorrhage was the initial presentation in 12 patients. Neurological and functional evaluation was performed before and after treatment with Onyx in all patients. RESULTS: Thirteen patients underwent a single endovascular treatment and four patients underwent two endovascular treatments (average 1.23 sessions per patient). Intraprocedural complications occurred on two occasions without neurological consequences. The mean follow-up duration was 24.3 months. Angiographic outcomes included total AVM obliteration in six patients (37.5%), subtotal obliteration in five patients (31.25%), and partial obliteration in five patients (31.25%). Improvement in neurological and/or functional status was noted in 14 patients, resulting in an 82% rate of overall good clinical outcome. CONCLUSIONS: Embolization using the Onyx system is a promising treatment method for spinal vascular malformations, even for challenging intramedullary AVMs. Larger studies with longer follow-up durations will further enhance our knowledge on the safety and efficacy of this relatively new liquid embolic agent.