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Chronic subdural hematoma (CSDH) is a common condition necessitating surgery; however, recurrence occurs in 15-25% of cases despite surgical management. The HEMACORT trial was a prospective randomized, double-blind, placebo-controlled, multi-centric study (NCT01380028). The aim of this trial was to determine the effect of corticosteroids as an adjuvant treatment to surgery on CSDH recurrence at 6 months. After surgery, participants were assigned by block-randomization to receive either placebo or oral prednisone at a dose of 1 mg/kg/day followed by weekly stepwise tapering in steps of 10 mg/day. The primary outcome was CSDH recurrence, defined by the need for reoperation and/or radiological progression of CSDH. Secondary outcomes were one-year death, radiological changes, safety, neurological status, and quality of life. The trial was discontinued at midpoint of expected inclusions: 78 participants received prednisone and 77 received placebo controls. In an intention-to-treat analysis, CSDH clinicoradiological recurrence was not different between prednisone and placebo groups (21.8% vs. 35.1%, respectively; hazard ratio 0.56; 95% confidence interval 0.30-1.02; p  = 0.06), although post hoc analyses concluded to statistical significance ( p  = 0.02). Earlier radiological resolution was observed after prednisone administration, but reoperation rates (reaching 5.8% overall) and functional outcomes were not different at 6 months. Among adverse events, sleep disorders occurred more often in the prednisone group (26.1% vs. 9.1%, p  = 0.02). The HEMACORT trial data suggest that prednisone, as an adjuvant treatment to surgery, may reduce early radiological recurrence of CSDH, although clinical benefits are unclear. In view of these findings, the authors suggest that shorter treatment duration should be assessed for safety and efficacy in future trials.

Background: Intracranial aneurysms (IAs) can be treated through endovascular treatment (EVT) or microsurgery (MS). Treated IAs can recanalize, which can lead to rupture or retreatment., Objective: The aim of our study was to evaluate the natural history of previously treated IA, by evaluating the risk of rupture and the risk of retreatment., Methods: All patients treated for an IA between 2007 and 2017 in 4 hospitals were included. The rate of (recurrent) hemorrhage and the rate of prophylactic retreatment were retrospectively evaluated. Kaplan-Meier survival analysis with log-rank tests was used to compare the rates of rupture or retreatment. Patients with ruptured and unruptured aneurysms were separated, and we compared the risk of retreatment between EVT and the surgical treatment., Results: A total of 4997 IAs were included in the study, corresponding to 20,489 patient-years. Overall, 28 (0.6%) aneurysms that had been previously treated demonstrated hemorrhage. Moreover, 237 (4.7%) aneurysms were retreated for recanalization without hemorrhage. The rate of retreatment was higher in the EVT-treated IAs as compared with the MS-treated IAs (LogRank: P < 0.0001) and higher in the previously ruptured IAs versus unruptured IAs (LogRank: P < 0.0001). However, the rate of posttreatment hemorrhage/IA rupture was similar for both groups., Conclusions: The rate of IA retreatment is low; however, the rate of hemorrhage/rupture from treated IAs is even lower. A higher rate of retreatment was noted in EVT-treated IAs versus MS-treated IAs and in ruptured IAs versus unruptured IAs; however, the rate of hemorrhage or rerupture was comparable between the groups., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Background: Severe traumatic brain injury (TBI) is the most common cause of disability in children. Refractory increased intracranial pressure can be a therapeutic challenge. Decompressive craniectomy can be proposed when medical management is insufficient, but its place is not clearly defined in guidelines. The aim of this study was to identify prognostic factors in children with TBI., Methods: We performed a retrospective, multicenter study to analyze long-term outcomes of 150 children with severe TBI treated by decompressive craniectomy and to identify prognostic factors., Results: A satisfactory neurologic evolution (represented by a King's Outcome Scale for Childhood Head Injury score >3) was observed in 62% of children with a mean follow-up of 3.5 years. Mortality rate was 17%. Prognostic factors associated with outcome were age, initial Glasgow Coma Scale score, presence of mydriasis, neuromonitoring values (maximal intracranial pressure >30 mm Hg), and radiologic findings (Rotterdam score ≥4)., Conclusions: This study in a large population confirms that children with severe TBI treated by decompressive craniectomy can achieve a good neurologic outcome. Further studies are needed to clarify the use of this surgery in the management of children with severe TBI., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Introduction: Meningiomas with orbital extension are the most frequent benign orbital tumors. The few studies available on the postoperative complications of their excision focus on the postoperative evolution of proptosis, visual acuity and visual field deficits. The goal of our study was to highlight the oculoplastic complications secondary to their excision., Material and Method: We identified all cases of meningiomas with orbital extension undergoing excision either neurosurgically or via an orbital approach in the ophthalmology and neurosurgery departments of Pasteur university medical center in Nice between February 2011 and January 2017. The data collection included the postoperative presence of proptosis, oculomotor disturbance, lid disorders, dry eye and trigeminal nerve damage., Results: Twenty-nine patients were included; 89.7 % were women. The mean age was 55 years. Postoperative complications included 25 % residual proptosis; 40.7 % oculomotor disturbance, 75 % of which regressed at least partially; 50 % ptosis, 21 % of which did not regress; 40 % dry eye; and in 21.4 % the trigeminal nerve was involved., Conclusion: The management of meningiomas with orbital extension is difficult due to their anatomical location and requires joint neurosurgical and oculoplastic management. Sufficient follow-up is required before recommending surgery for oculomotor disturbances. The frequency of occurrence of ptosis with potential recommendation for surgery requires caution given the occurrence of trigeminal nerve involvement and dry eye syndrome., (Copyright © 2018 Elsevier Masson SAS. All rights reserved.)

Purpose: Coiling associated with placement of a self-expandable intracranial stent has improved the treatment of intracranial wide-necked aneurysms. Little is known, however, about the durability of this treatment. The purpose of this report is to present our experience with the LEO stent and to evaluate the complications, effectiveness, and long-term results of this technique., Methods: We analyzed the records of 155 intracranial unruptured aneurysms that were treated by stent-assisted coiling with a LEO stent between 2008 and 2012. Procedural, early post-procedural, and delayed complications were recorded. Clinical and angiographic follow-up of patients was conducted over a period of at least 36 months., Results: No procedural mortality was observed. One-month morbidity was observed in 14 out of 153 patients (9,15%). One hundred thirty-eight patients (with 140 aneurysms) had clinical and angiographic follow-up for more than 36 months. No aneurysm rupture was observed during follow-up. Four patients presented an intra-stent stenosis at 8 months, and 6 patients who had an early recurrence were retreated. Final results showed 85% complete occlusion, 13% neck remnants, and 2% stable incomplete occlusion., Conclusion: Stent-assisted coiling with the LEO stent is a safe and effective treatment for unruptured intracranial aneurysms. The long-term clinical outcomes with the LEO stent are excellent with a high rate of complete occlusion that is stable over time.

Objectives: Intramedullary gliomas are rare tumors accounting for less than 4% of all primary central nervous system tumors. The aims of this retrospective multicenter study were to assess their natural outcome as well as management., Methods and Materials: We studied 332 patients from 1984 to 2011. Histopathological examination revealed 72% ependymomas (94% were low grade tumors), 24% astrocytomas (29% were high grade tumors), 2.4% mixed gliomas and 1.7% oligodendrogliomas., Results: The mean age at diagnosis was 42.4 years for ependymomas, with male predominance, versus 39.6 years for astrocytomas. Pain was the most common initial presentation. In 20% of cases, astrocytomas were biopsied alone, but more than 80% of ependymomas had surgical resection. Radiotherapy and chemotherapy were reserved for malignant tumors, especially if they were ependymomas. The 5-year survival rate was 76.8% for astrocytomas and 94.5% for ependymomas. Histology, functional status prior to surgery, and tumor grade are among the prognostic factors., Conclusion: Our study showed that surgical treatment of gliomas is well codified, at least for ependymomas, but adjuvant treatment continues to play a marginal role in the management even in astrocytomas, which are infiltrative tumors., (Copyright © 2017. Published by Elsevier Masson SAS.)

Background Thromboembolic complications are the main problem in stent-assisted coil embolization of unruptured intracranial aneurysms. The combination of aspirin and clopidogrel is generally used to decrease these complications, but some patients do not respond to clopidogrel and have a higher risk of stent thrombosis. In cardiology, clinical trials have shown that prasugrel reduced the incidence of ischaemic events in patients with acute coronary syndrome compared with clopidogrel but, according to several authors, prasugrel would produce an increased risk of cerebral haemorrhagic complications. Objective The purpose of this study was to determine whether prasugrel would be more effective than clopidogrel in reducing procedural events in patients with an unruptured aneurysm treated endovascularly with coils and stent. Materials and methods Two hundred consecutive patients with intracranial aneurysms were treated using coiling and stenting procedures. The first 100 patients were administered a dual antiplatelet of aspirin and clopidogrel, while the remaining 100 patients were administered a dual antiplatelet of aspirin and prasugrel. In each group data were collected on procedural and periprocedural haemorrhagic and ischaemic complications. Results Aneurysmal occlusion and haemorrhagic complications rates were identical in both groups. The number of thromboembolic events observed in the two groups of our study did not differ significantly, but the prasugrel group included more wide-neck aneurysms and more flow-diverted stents. Moreover, complications in the prasugrel group were more benign, explaining the significant difference in clinical outcomes between the two groups on Day 30. Conclusions Prasugrel reduces the clinical consequences of thromboembolic complications of endovascular treatment with stenting and coiling of unruptured intracranial aneurysms.

Compressive hematoma associated with deep arterio-venous malformation is a difficult surgery. Arterial presurgical embolization is often indicated but rarely effective. Endovascular occlusion via a venous approach is a technique that has recently been undertaken successfully to treat certain types of sub-pial vascular malformation. The venous endovascular approach has succeeded in a 20-year-old man of who presented with a compressive hematoma due to rupture of a deep arteriovenous malformation. By fully endovascular occlusion, the surgery consisted of surgical removal of the hematoma, with reduced cortical damage., (© The Author(s) 2016.)

Introduction: Thromboembolic complications are the most frequent complications of endovascular treatment of ruptured intracranial aneurysms. The optimal protocol to prevent thromboembolic complications during coil embolization does not yet exist. The aim of this study was to investigate the effectiveness and safety of eptifibatide for the prevention of thromboembolic complications during elective coil embolization of ruptured cerebral aneurysms., Methods: A consecutive series of 100 patients (group 1) with ruptured intracranial aneurysm were treated using endovascular coil embolization. At the beginning of the procedure, all patients received an intra-arterial bolus (0.2 mg/kg) of eptifibatide. The following data were collected: degree of aneurysmal occlusion after treatment, thromboembolic and hemorrhagic complications and other intraoperative adverse events. The results were compared with those from a control group (group 2) which were analyzed retrospectively. Group 2 consisted of 100 previous patients with ruptured aneurysm managed with coil embolization who had received heparin and/or aspirin at the beginning of the procedure., Results: (1) Patient populations in groups 1 and 2 were considered statistically comparable, except that group 1 (eptifibatide) included more wide-necked aneurysms (p = 0.011). (2) There were less thromboembolic complications in group 1 (p = 0.011): seven intraoperative complications in group 1 versus 20 in group 2. (3) Intraoperative hemorrhagic complications were statistically comparable in both groups (p = 1)., Conclusion: Eptifibatide was effective in lowering the intraoperative thromboembolic complication rate in ruptured aneurysms treated with coil embolization and did not increase the hemorrhagic risk.