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Background: Cerebrospinal fluid (CSF) leakage is a frequent and challenging complication in neurosurgery, especially in the posterior fossa, with a prevalence of 8%. It is associated with substantial morbidity and increased healthcare costs. A novel dural sealant patch (LIQOSEAL) was developed for watertight dural closure. The objective of this study is to clinically assess the safety and effectiveness of LIQOSEAL as a means of reducing intra- as well as postoperative CSF leakage in patients undergoing elective posterior fossa intradural surgery with a dural closure procedure compared to the best currently available dural sealants.Methods: We will conduct a two-arm, randomized controlled, multicenter study with a 90-day follow-up. A total of 228 patients will be enrolled in 19 sites, of which 114 will receive LIQOSEAL and 114 an FDA-approved PEG sealant. The composite primary endpoint is defined as intraoperative CSF leakage at PEEP 20 cm H2O, percutaneous CSF leakage within 90 days of, wound infection within 90 days of or pseudomeningocele of more than 20cc on MRI or requiring intervention. We hypothesize that the primary endpoint will not be reached by more than 10 patients (9%) in the investigational arm, which will demonstrate non-inferiority of LIQOSEAL compared to control.Discussion: This trial will evaluate whether LIQOSEAL is non-inferior to control as a means of reducing CSF leakage and safety TRIAL REGISTRATION: ClinicalTrials.gov NCT04086550 . Registered on 11 September 2019. [ABSTRACT FROM AUTHOR]

In this case report, a 49-year-old woman developed subarachnoid hemorrhage in the right cerebellopontine angle cistern and blood into the fourth ventricle from a ruptured peripheral aneurysm of the anterior inferior cerebellar artery (AICA) located at the meatal loop. Concomitantly, a contralateral peripheral aneurysm was found in the posterior inferior cerebellar artery (PICA). A second peripheral aneurysm, not identified by previous angiography, was found in the caudomedial branch of AICA. We describe this diagnostic dilemma, management, and review the clinical presentation and location of 84 other peripheral AICA aneurysms reported in the literature. [ABSTRACT FROM AUTHOR]

With the rise of endovascular treatments for the management of unruptured intracranial aneurysms (UIAs), advances in microsurgical techniques are underrepresented in modern surgical series, which largely consist of patients with aneurysms unfit for coiling. We report a modern series of microsurgical treatment for UIAs performed by a single surgeon as the preferred treatment modality. We retrospectively reviewed the charts of all patients with UIAs treated by the senior author with microsurgical clipping over an 11-year period. Procedure-related mortality, major neurologic morbidity (modified Rankin Score 3–5), complications, and persistent neurologic deficits were recorded. Risk factors for persistent neurologic deficits and major morbidity or mortality were analyzed using multivariate logistic regression analysis. We identified 329 patients with 400 UIAs treated in 353 surgeries. The average age was 52 years, 80% of patients were women, and 13% had a previous subarachnoid hemorrhage. The average aneurysm size was 7 mm and 92% were in the anterior circulation. The mean follow-up was 15 months (range 0.5–125). There was one procedure-related death (0.3%), and two patients suffered major morbidity (0.6%). Twenty procedures (5.6%) resulted in a persistent neurologic deficit. Risk factors for death and major morbidity were increasing age and posterior circulation, while risk factors for persistent neurologic deficits were increasing aneurysm size and posterior circulation. We conclude that microsurgical clipping is safe, effective, and should be given strong consideration as the primary treatment modality for younger patients with small to medium sized UIAs in the anterior circulation. [ABSTRACT FROM AUTHOR]

Immune checkpoint inhibitors (ICI) are increasingly used to treat patients with brain metastases, while stereotactic radiosurgery (SRS, 1 fraction) and stereotactic radiotherapy (SRT, 3-5 fractions) are established modalities. Emerging data suggest that ICI and SRS/SRT may work synergistically, with reports of increased efficacy and toxicity. We characterized factors associated with intracranial control and radiation necrosis in patients receiving both ICI and SRS/SRT. We retrospectively identified patients treated with ICI and SRS/SRT for intact brain metastases at two institutions from 2013-2020. Patients had diagnoses of non-small cell lung cancer, renal cell carcinoma, or melanoma and were followed for a minimum of 2 months after receipt of both SRS/SRT and ICI with brain MRI. The analysis was completed on a per-metastasis basis. Local failure (LF) and radiation necrosis (determined radiographically with clinical impression or pathologically; included grade 2 (symptomatic) or higher) were analyzed by univariate and multivariate logistic regression which included tumor diameter, timing of ICI relative to SRS/SRT, PD-L1 (positive defined as ≥ 1%), and SRT vs. SRS. Progression-free survival (PFS) was defined as time from SRS/SRT to local or distant brain failure, death, or last follow up for those without progression. There were 179 patients with 549 metastases, 492 metastases treated with SRS, and 57 metastases treated with SRT. Median follow up from the time of SRS/SRT was 14.7 months. Median tumor size was 7mm (< 5mm: 253, ≥ 5 & < 10mm: 159, ≥ 10 and < 20mm: 91, and ≥ 20mm: 46). Rates of LF and grade 2+ radiation necrosis for the entire cohort were 5.8% (32/549) and 6.9% (38/549), respectively (15.6% (28/179) rate of grade 2+ radiation necrosis per-patient). LF rates for those who received ICI outside +/- 3 months from SRS/SRT vs. within +/- 3 months from SRS/SRT were 9.0% and 4.4%, respectively. Rates of grade 2+ radiation necrosis for those with positive vs. negative PD-L1 were 9.2% vs. 1.6%, respectively. Positive PD-L1 status was associated with improved intracranial PFS (HR 0.53, p = 0.03). Combination ICI and SRS/SRT is increasingly used to treat brain metastases. Our study showed improved local control when ICI is given within 3 months from time of SRS/SRT without an associated increase in radiation necrosis. Increasing tumor size was associated with LF and radiation necrosis. Positive PD-L1 was associated with improved intracranial PFS and increased radiation necrosis. We recommend further study, ideally prospectively, to better characterize this treatment combination. [ABSTRACT FROM AUTHOR]

Background and purpose: Little is known about calcifications associated with pediatric intracranial arterial aneurysms (IAA). We sought to characterize calcifications associated with pediatric IAA according to aneurysm pathogenetic subtype. Materials and methods: Patients with IAA less than 20 years of age were retrospectively identified. Three fellowship-trained neuroradiologists independently reviewed each patient's CT studies for calcifications of the parent artery or aneurysm. Aneurysmal calcification (ANC) was correlated with characteristics of the patient (age, sex) and aneurysm pathogenetic subtype, size, morphology, rupture status, and location. Results: Thirty-three patients (mean age 10 years) with 43 IAA were analyzed. There were no parent artery calcifications. Nine IAA were calcified. IAA in children with non-hemodynamic risk factors (arteriopathy, trauma, infection, tumor) were more commonly calcified than idiopathic IAA ( p = 0.029). More than one third of the pediatric IAAs in this group (arteriopathy, infection trauma, tumor) were calcified. IAA ≥ 10 mm were more likely to be calcified ( p = 0.03). IAA that were ruptured at presentation were less likely to be calcified ( p = 0.03). ANC was not significantly associated with patient age (≤10 years vs. >10 years), sex, morphology (fusiform vs. saccular) or location (anterior vs. posterior circulation). Conclusion: Aneurysmal but not parent artery calcifications are associated with a significant minority of pediatric IAA. Pediatric ANCs are associated with underlying non-hemodynamic vascular risk factors (arteriopathy, infection, trauma, and tumor), size ≥10 mm and non-hemorrhagic presentation. [ABSTRACT FROM AUTHOR]

Background: The Surgical Trial in Intracerebral Hemorrhage (STICH) showed no overall benefit from early surgery compared with initial conservative treatment for intracerebral hemorrhage (ICH). We hypothesized that the STICH trial findings would lead to a reduction in the rates of surgery for ICH in the United States. Using a national hospital database, we determined trends in surgery for ICH before and after publication of STICH. We also determined trends in ICH mortality during the study period.Methods: We queried the Premier database for all ICH-related admissions (denominator) using the ICD-9 codes 431 and 432.9, and craniotomy (numerator) with CPT procedure codes 01.2, 01.24, 01.25, 01.31, 01.39, or 01.59, for fiscal years (FY) 2000-FY2008. Trends in craniotomy and ICH mortality were determined. Change over time was tested using logistic regression.Results: During the study period, 107,590 ICH discharges were identified. A craniotomy procedure code was identified in 7,518 instances (7.0%). Surgical cases were younger and had lower mortality than non-surgical cases. Publication of the STICH trial did not significantly impact the rate of craniotomy for ICH in the United States (P = 0.15). Age-, race-, and gender-adjusted in-hospital ICH mortality decreased steadily during the study period (P < 0.001).Conclusions: The rate of surgery among ICH discharges in the United States has remained stable in the past decade. While in-hospital ICH mortality decreased, controlled clinical trials are needed to determine which ICH patients would benefit from surgery, and if decreasing in-hospital mortality is associated with decreased longer term mortality and improved functional outcomes. [ABSTRACT FROM AUTHOR]

Background. Although resection of the anterior clinoid process (ACP) is valuable in the surgical treatment of aneurysms of the ophthalmic (C6) segment of the internal carotid artery (ICA), quantitative assessment of this adjunct is incomplete. Our morphometric study assesses the effectiveness of the anterior clinoidectomy for exposure of the C6 segment of the ICA. Methods. Ten formalin-fixed adult cadaveric heads were dissected bilaterally and pterional craniotomies were performed bilaterally. Measurements before and after resection of the ACP included the length of C6 segment of the ICA on its lateral aspect; C6 segment length on its medial aspect; and medial length of the optic nerve from the optic chiasm to falciform ligament (before ACP resection) then to the annulus of Zinn (after ACP resection). Findings. Height and width of the intradural ACP were 8.67 ± 2.63 and 6.57 ± 1.68 mm, respectively. After clinoidectomy, mean length of the lateral C6 segment of the ICA increased 60% and mean exposure of the medial C6 segment of the ICA increased 113% ( p < 0.001). Exposure of the optic nerve increased 150% ( p < 0.001) after clinoidectomy and sectioning of the falciform ligament. No correlations were found between the lengths of the ACP and entire C6 segment, or the ACP size and amount of the C6 segment covered by the clinoid. Conclusions. Exposure of the C6 segment of the ICA is markedly increased by increase of the mobility of the optic nerve with clinoidectomy and section of the falciform ligament. [ABSTRACT FROM AUTHOR]

An abstract for the article "Durable occlusion of a ruptured venous aneurysm after partial transarterial embolization of the upstream pial arteriobvenous malformation," by M. Kemper, C. Farley, H. Kocaeli et al. is presented.