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Background Aneurysms of spinal arteries not associated with any known predisposing condition are referred to as isolated spinal aneurysms (SAs). In our series, an SA was found in 2 patients during the postpartum period. The goal of this study is to determine whether an occurrence of an SA may be related to puerperium. Methods In a retrospective analysis of our consecutive series of 10 cases of SAs from 2008 to 2020, we identified 2 cases of SAs during puerperium. Patients' charts and imaging were reviewed, for potential predisposing factors. Results In both cases, angiography showed fusiform aneurysms of the anterior SA with concomitant bilateral vertebral artery (VA) dissections. Serum vasculitis and inflammatory panel and genetic testing for collagen disorders were negative in both cases. Review of the literature showed that pregnancy is associated with an increased risk of arterial dissections in various locations and supports the hypothesis that hemodynamic and hormonal changes may play a role in the formation of SAs. Conclusions Pregnancy and peripartum state may be a distinct cause of the formation of SAs, possibly as a result of increased hemodynamic stress and hormonal changes that may alter the arterial wall. It would be appropriate to add pregnancy as a subgroup in the classification of SAs. In our series, both cases were associated with bilateral VA dissections; it is possible that the bilateral VA stenosis may have contributed to the formation of the SAs. It is important to recognize this possibility when considering the occlusion of a dissected VA.

BACKGROUND AND PURPOSE: Noninvasive angiography is commonly used to assess the outcome of surgical or endovascular treatment of intracranial aneurysms in clinical series or randomized trials. We sought to assess whether a standardized 3-grade classification system could be reliably used to compare the CTA and MRA results of both treatments. MATERIALS AND METHODS: An electronic portfolio composed of CTAs of 30 clipped and MRAs of 30 coiled aneurysms was independently evaluated by 24 raters of diverse experience and training backgrounds. Twenty raters performed a second evaluation 1 month later. Raters were asked which angiographic grade and management decision (retreatment; close or long-term follow-up) would be most appropriate for each case. Agreement was analyzed using the Krippendorff α (α(K)) statistic, and the relationship between angiographic grade and clinical management choice, using the Fisher exact and Cramer V tests. RESULTS: Interrater agreement was substantial (α(K) = 0.63; 95% CI, 0.55–0.70); results were slightly better for MRA results of coiling (α(K) = 0.69; 95% CI, 0.56–0.76) than for CTA results of clipping (α(K) = 0.58; 95% CI, 0.44–0.69). Intrarater agreement was substantial to almost perfect. Interrater agreement regarding clinical management was moderate for both clipped (α(K) = 0.49; 95% CI, 0.32–0.61) and coiled subgroups (α(K) = 0.47; 95% CI, 0.34–0.54). The choice of clinical management was strongly associated with the size of the residuum (mean Cramer V = 0.77 [SD, 0.14]), but complete occlusions (grade 1) were followed more closely after coiling than after clipping (P = .01). CONCLUSIONS: A standardized 3-grade scale was found to be a reliable and clinically meaningful tool to compare the results of clipping and coiling of aneurysms using CTA or MRA.

Background Rupture of spinal aneurysms is a rare cause of subarachnoid hemorrhage. These aneurysms are often associated with a variety of vascular malformations that increase blood flow in the spinal circulation or with disorders that compromise the vessel wall. However, spinal aneurysms may be isolated, not associated with any known predisposing condition. The objective of this study is to explore the possible mechanisms associated with the formation and rupture of isolated spinal aneurysms (ISAs). Methods We conducted a retrospective review of a series of consecutive patients admitted for a ruptured ISA. In all cases, spinal angiography confirmed the presence of a spinal aneurysm responsible for the bleeding. Particular attention was paid to medical history and symptoms before bleeding, for potential factors predisposing to their formation and rupture. Results Between 2008 and 2020, ten cases of spinal aneurysms were seen at our institution including 4 cases of ISA. All patients with ISA were female, and in 3 cases the aneurysm involved the territory of the posterior spinal artery. In 3 of these 4 (75%) ISA cases, there was a strikingly similar history of retching and vomiting preceding the thunderclap headache. In 1 patient, the aneurysm was surgically resected; pathologic analysis revealed a fusiform dissecting aneurysm. All 4 patients had a favorable outcome. Conclusions We suggest that the straining during prolonged retching and vomiting plays a role in the formation and rupture of some ISAs, possibly because of pressure spikes, increased transmural arterial pressure, and increased wall shear stress during straining.

Our knowledge of the vascularization of the precentral gyrus by branches of the anterior cerebral artery (ACA) relies mainly on anatomical cadaveric dissection. A distal branch of the ACA known as the posterior internal frontal artery (PIFA) is thought to vascularize the precentral gyrus responsible for proximal arm movement; however, no clinical correlation has yet been reported to confirm this relation. In this manuscript, we report a case of coil migration in the PIFA, causing proximal arm weakness in a 58-year-old woman treated for aneurysmal subarachnoid hemorrhage. The occurrence of clinical signs immediately following coil migration into the PIFA, combined with evidence of stroke in the cortical territory related to arm movement as seen on imaging, indicates that the PIFA indeed can vascularize this lateral portion of the precentral gyrus. This case confirms our current understanding of the vascularization of the precentral gyrus by distal ACA branches, in particular the PIFA.

P2-P3 junction aneurysms are challenging to treat surgically because of their frequent complex morphology and their location deep in close proximity to the midbrain. The sub-temporal route requires significant retraction of the temporal lobe in addition to potential injury to the vein of Labbe. We describe the technique for treating such aneurysms via a lateral supra-cerebellar infra-tentorial (LSCIT) approach, which eliminates manipulation of the temporal lobe. Cadaveric dissection provided comprehensive understanding of relevant anatomy. Intraoperative video shows clipping of the aneurysm using a LSCIT approach. LSCIT approach allows safe clipping of P2-P3 aneurysms with minimal brain manipulation.

Background Scleroderma, or systemic sclerosis, is an autoimmune disorder affecting connective tissues, including blood vessels. Although the exact mechanism is not understood, it results in the production of an abnormal amount of collagen. Cases have been reported in which patients with scleroderma also had intracranial aneurysms. We wish to gain insight into any potential association between the 2 diseases. Case Description We reviewed the literature of scleroderma cases with cerebral aneurysms and added our own case, focusing on patient and aneurysm characteristics. Including the present case, this paper pertains to 11 cases with 26 aneurysms. Fifty-five percent had multiple aneurysms, of which two thirds had >2. When data were available, 35% of aneurysms were ≥1 cm, 12% of which were giant. Four aneurysms were fusiform (15%). Patients presented with subarachnoid hemorrhage in 45% of cases. Conclusions Scleroderma may lead to the formation of an aneurysm, and the abnormal growth of collagen may protect it from early rupture, allowing it to reach a large size.

Background:Calcifying pseudoneoplasm of the neuraxis (CAPNON) is a rare tumor-like lesion with unknown pathogenesis. It is likely under-reported due to diagnostic challenges including the nonspecific radiographic features, lack of diagnostic markers, and often asymptomatic nature of the lesions.Methods:We performed detailed examination of 11 CAPNON specimens diagnosed by histopathology, with the help of electron microscopy and immunohistochemistry.Results:Electron microscopy revealed the presence of fibrillary materials consistent with neurofilaments. In addition to some entrapped axons at the periphery of CAPNONs, we discovered that all specimens stained positive for neurofilament-light (NF-L) within the granular amorphous cores, but not neurofilament-phosphorylated (NF-p). CAPNONs also showed variable infiltration of CD8+ T-cells and a decreased ratio of CD4/CD8+ T-cells, suggesting an immune-mediated process in the pathogenesis of CAPNON.Conclusion:NF-L and CD4/CD8 immunostains may serve as diagnostic markers for CAPNON and shed light on its pathogenesis.

Posterior fossa arteriovenous malformations (pfAVMs) can be challenging lesions to manage. AVMs in this location may have distinct features compared with supratentorial AVMs. Our aim was to systematically review the literature on the presenting characteristics of pfAVMs and compare clinical and angiographic outcomes after the various types of treatment employed. The review was conducted according to the Cochrane Collaboration guidelines. Electronic databases from 1900 to March 2018 were searched and complemented by hand-searching and cross-referencing. Articles were categorized into (i) AVM studies that included those in the posterior fossa, (ii) those that focused exclusively on pfAVM, and (iii) those that further specified a cerebellar or brainstem location of the AVM. Seventy-seven articles with 4512 pfAVM patients were retained for analyses. Compared with historical supratentorial controls, pfAVMs were reported to more frequently present with rupture, to more commonly have associated arterial aneurysms, and to more frequently lead to poor clinical and angiographic outcomes. The quality of the literature and lack of standardization of outcome reporting precluded performing a meta-analysis on the results of the various different treatment modalities. Posterior fossa AVMs may have some distinct features compared with supratentorial AVMs. The available reports on pfAVMs are not sufficiently standardized to provide reliable guidance for patient management decisions. This goal will require future studies to be multicentric and to focus on standardized, repeatable clinical and angiographic outcomes.

The ophthalmic artery (OA) has one of the most complex anatomy and the most fascinating embryological development. The complexity of the embryologic development of the OA resides in the implication of three different embryological systems: the carotid system, the stapedial system, and the ventral pharyngeal system. This explains very well the numerous variations in origin of the OA and the importance of vascular anastomoses developed with branches of the external carotid artery and with the middle meningeal artery. In this review, authors propose a comprehensive description of different hypotheses on the embryologic development of the OA and, in a second part, explain all anatomical variations and clinical implications of this artery.

Background:Calcifying pseudoneoplasm of the neuraxis (CAPNON) is a rare tumefactive lesion. CAPNONs can mimic calcified meningiomas at the skull base.Methods:Here, we report two cases of CAPNON and present a systematic review of the literature on skull base CAPNONs, to compare CAPNONs with calcified meningiomas.Results:Case 1: A 57-year-old man presented with right-sided lower cranial neuropathies and gait ataxia. He underwent a subtotal resection of a right cerebellopontine angle lesion, with significant improvement of his gait ataxia. However, his cranial neuropathies persisted. Pathological examination of the lesion was diagnostic of CAPNON, with the entrapped nerve fibers identified at the periphery of the lesion, correlating with the patient’s cranial neuropathy. Case 2: A 70-year-old man presented with progressive headache, gait difficulty, and cognitive impairment. He underwent a frontotemporal craniotomy for a near-total resection of his right basal frontal CAPNON. He remained neurologically stable 7 years after the initial resection without evidence of disease recurrence. We analyzed 24 reported CAPNONs at the skull base in our systematic review of the literature. Cranial neuropathies were present in 11 (45.8%) patients. Outcomes regarding cranial neuropathies were documented in six patients: two had sacrifice of the nerve function with surgical approaches and four had persistent cranial neuropathies.Conclusion:While CAPNON can radiologically and grossly mimic calcified meningiomas, they are two distinctly different pathologies. CAPNONs located at the skull base are commonly associated with cranial neuropathies, which may be difficult to reverse despite surgical intervention.

Background Aneurysmal subarachnoid hemorrhage (SAH) is a catastrophic disease with devastating consequences, including a high mortality rate and severe disabilities among survivors. Inflammation is induced following SAH, but the exact role and phenotype of innate immune cells remain poorly characterized. We investigated the inflammatory components of the early brain injury in an animal model and in SAH patients. Method SAH was induced through injection of blood in the subarachnoid space of C57Bl/6 J wild-type mice. Prospective blood collections were obtained at 12 h, days 1, 2, and 7 to evaluate the systemic inflammatory consequences of SAH by flow cytometry and enzyme-linked immunosorbent-assay (ELISA). Brains were collected, enzymatically digested, or fixed to characterize infiltrating inflammatory cells and neuronal death using flow cytometry and immunofluorescence. Phenotypic evaluation was performed at day 7 using the holding time and footprint tests. We then compared the identified inflammatory proteins to the profiles obtained from the plasma of 13 human SAH patients. Results Following SAH, systemic IL-6 levels increased rapidly, whereas IL-10 levels were reduced. Neutrophils were increased both in the brain and in the blood reflecting local and peripheral inflammation following SAH. More intracerebral pro-inflammatory monocytes were found at early time points. Astrocyte and microglia activation were also increased, and mice had severe motor deficits, which were associated with an increase in the percentage of caspase-3-positive apoptotic neurons. Similarly, we found that IL-6 levels in patients were rapidly increased following SAH. ICAM-1, bFGF, IL-7, IL-12p40, and MCP-4 variations over time were different between SAH patients with good versus bad outcomes. Moreover, high levels of Flt-1 and VEGF at admission were associated with worse outcomes. Conclusion SAH induces an early intracerebral infiltration and peripheral activation of innate immune cells. Furthermore, microglia and astrocytic activation are present at later time points. Our human and mouse data illustrate that SAH is a systemic inflammatory disease and that immune cells represent potential therapeutic targets to help this population of patients in need of new treatments.

Background and purpose Appropriate management of ruptured intracranial aneurysm (RIA) in patients eligible for surgical clipping but under-represented in or excluded from previous randomized trials remains undetermined. Methods The International Subarachnoid Aneurysm Trial-2 (ISAT-2) is a randomized care trial comparing surgical versus endovascular treatment (EVT) of RIA. All patients considered for surgical clipping but eligible for endovascular treatment can be included. The primary endpoint is death or dependency on modified Rankin score (mRS > 2) at 1 year. Secondary endpoints are 1 year angiographic results and length of hospital stay. Results An interim analysis was performed after 103 patients were treated from November 2012 to July 2017 in 4 active centers. Fifty-two of the 55 patients allocated to surgery were treated by clipping, and 45 of the 48 allocated to EVT were treated by coiling, with 3 crossovers in each arm. The main endpoint (1 year mRS > 2), available for 76 patients, was reached in 16/42 patients allocated to clipping (38%; 95%CI: 25%–53%), and 10/34 patients allocated to coiling (29%; 17%–46%). One year imaging results were available in 54 patients: complete aneurysm occlusion was found in 23/27 patients allocated to clipping (85%; 67%–94%), and 18/27 patients allocated to coiling (67%; 47%–81%). Hospital stay exceeding 20 days was more frequent in surgery (26/55 [47%; 34%–60%]) than EVT (9/48 [19%; 10%–31%]). Conclusion Ruptured aneurysm patients for whom surgical clipping may still be best can be managed in a randomized care trial, which is feasible in some centers. More participating centers are needed.

Ultrasound (US) examination of the eye can be used to detect and monitor elevated intracranial pressure (ICP) and its consequences. Elevated ICP is transmitted to the contiguous optic nerve and its sheath (dura mater), thus underlying the development of papilledema and a widened sheath diameter. The US measurement of the optic nerve sheath diameter (ONSD) has previously been validated to diagnose and monitor raised ICP. The occurrence of vitreous hemorrhage in association with subarachnoid hemorrhage (SAH)—i.e., Terson syndrome—can also be easily diagnosed using ophthalmic US. Because of its relevance in anesthesia and critical care, we describe how to perform the technique illustrated by two cases. A 72-yr-old man with hydrocephalus secondary to a SAH developed raised ICP following the removal of an external ventricular drainage (EVD) system. Daily ONSD measurements using handheld US allowed us to diagnose and monitor the progression and resolution of the intracranial hypertension following the placement of a second EVD system. We also describe the steps used to obtain ONSD measurements during the ophthalmic US examination of a 53-yr-old woman who presented with a stage IV SAH with concomitant bilateral vitreous hemorrhages or Terson syndrome. Ophthalmic US using a handheld device to measure and monitor ONSD at the bedside is useful in diagnosing and monitoring the progression of intracranial hypertension following EVD removal in a patient with hydrocephalus secondary to SAH. Ophthalmic US can also be used to identify concomitant vitreous hemorrhage that is associated with a worse prognosis.

Vertebro-PICA aneurysms may be challenging because of their relationship with the brainstem and the lower cranial nerves, especially when the vertebral artery is tortuous and the aneurysm is located in front of the brainstem, contralaterally to the parent vertebral artery. We describe the surgical technique for safe approach. Cadaveric dissection performed by the authors, provided comprehensive understanding of relevant anatomy. Intraoperative photos and videos show clipping of the aneurysm using a combined midline and far-lateral suboccipital craniotomy with a para-condylar extension. The literature reviews potential complications. This combined approach allows safe clipping of such PICA aneurysms.

Objective There are few randomized data comparing clipping and coiling for middle cerebral artery (MCA) aneurysms. We analyzed results from patients with MCA aneurysms enrolled in the CURES (Collaborative UnRuptured Endovascular vs. Surgery) and ISAT-2 (International Subarachnoid Aneurysm Trial II) randomized trials. Methods Both trials are investigator-led parallel-group 1:1 randomized studies. CURES includes patients with 3-mm to 25-mm unruptured intracranial aneurysms (UIAs), and ISAT-2 includes patients with ruptured aneurysms (RA) for whom uncertainty remains after ISAT. The primary outcome measure of CURES is treatment failure: 1) failure to treat the aneurysm, 2) intracranial hemorrhage during follow-up, or 3) residual aneurysm at 1 year. The primary outcome of ISAT-2 is death or dependency (modified Rankin Scale score >2) at 1 year. One-year angiographic outcomes are systematically recorded. Results There were 100 unruptured and 71 ruptured MCA aneurysms. In CURES, 90 patients with UIA have been treated and 10 await treatment. Surgical and endovascular management of unruptured MCA aneurysms led to treatment failure in 3/42 (7%; 95% confidence interval [CI], 0.02–0.19) for clipping and 13/48 (27%; 95% CI, 0.17–0.41) for coiling (P = 0.025). All 71 patients with RA have been treated. In ISAT-2, patients with ruptured MCA aneurysms managed surgically had died or were dependent (modified Rankin Scale score >2) in 7/38 (18%; 95% CI, 0.09–0.33) cases, and 8/33 (24%; 95% CI, 0.13–0.41) for endovascular. One-year imaging results were available in 80 patients with UIA and 62 with RA. Complete aneurysm occlusion was found in 30/40 (75%; 95% CI, 0.60–0.86) patients with UIA allocated clipping, and 14/40 (35%; 95% CI, 0.22–0.50) patients with UIA allocated coiling. Complete aneurysm occlusion was found in 24/34 (71%; 95% CI, 0.54–0.83) patients with RA allocated clipping, and 15/28 (54%; 95% CI, 0.36–0.70) patients with RA allocated coiling. Conclusions Randomized data from 2 trials show that better efficacy may be obtained with surgical management of patients with MCA aneurysms.

The persistent trigeminal artery is the most frequent of the persistent embryonic carotid-basilar artery anastomoses. In the literature, it has most often been described in relation to cerebrovascular pathologies such as aneurysms, vascular nerve compression, trigeminal cavernous fistulas, and thromboembolic ischemia. Its role as collateral circulation, thus supplying brain perfusion during main arterial trunk occlusion, has seldom been described. We describe the case of a patient who presented with a stroke due to a traumatic dissection of the internal carotid artery at the neck, in which the infarction may have been limited by a persistent trigeminal artery.

In the absence of randomized evidence, the optimal management of patients with unruptured intracranial aneurysms (UIA) remains uncertain.Comprehensive Aneurysm Management (CAM) is an all-inclusive care trial combined with a registry. Any patient with a UIA (no history of intracranial hemorrhage within the previous 30 days) can be recruited, and treatment allocation will follow an algorithm combining clinical judgment and randomization. Patients eligible for at least 2 management options will be randomly allocated 1:1 to conservative or curative treatment. Minimization will be used to balance risk factors, using aneurysm size (≥7 mm), location (anterior or posterior circulation), and age60 years.The CAM primary outcome is survival without neurologic dependency (modified Rankin Scale [mRS] score3) at 10 years. Secondary outcome measures include the incidence of subarachnoid hemorrhage during follow-up and related morbidity and mortality; morbidity and mortality related to endovascular treatment or surgical treatment of the UIA at 1 year; overall morbidity and mortality at 1, 5, and 10 years; when relevant, duration of hospitalization; and, when relevant, discharge to a location other than home. The primary hypothesis for patients randomly allocated to at least 2 options, 1 of which is conservative management, is that active UIA treatment will reduce the 10-year combined neurologic morbidity and mortality (mRS score2) from 24% to 16%. At least 961 patients recruited from at least 20 centers over 4 years will be needed for the randomized portion of the study.Patients with unruptured intracranial aneurysms can be comprehensively managed within the context of an all-inclusive care trial.

Objectives: With the current trend of aging of the population, neurosurgeons will be more and more confronted to surgical decision-making involving the elderly. Faced with this increasing demand and frailty of aged patients, a better understanding on the post-operative outcome of this growing population is warranted. The objective of the present study is to assess the post-operative outcome in regard of complications of elderly patients undergoing a craniotomy. Patients and methods: The files of consecutive patients aged 80 years old and more who underwent a craniotomy at a single institution were retrospectively reviewed. Data on demographics, surgical indication, length of surgery, operative blood loss, urgency of surgery, comorbidities using the Elixhauser comorbidity index and post-operative complications were gathered. We performed a multivariate analysis in search of risk factors for post-operative complications. Results: A total of 53 patients were included in the study. The mean age of all patients was 84 years old with the main indication for surgery being subdural hematoma. The overall complication rate was 62%, with 34% of patients suffering from a major complication and 47% from a minor complication. The mean Elixhauser comorbidity index, operative time and operative blood loss were similar to those reported in adult craniotomy series. None of the studied variables were statistically associated with the occurrence of complications in the multivariate analysis. Conclusion: Patients 80 years-old and more were found to harbour a high complication rate following craniotomy when compared to literature. Our study suggests increasing age itself remains an important risk factor for postoperative complications. Keywords: Comorbidity, Complication, Craniotomy, Elderly, Outcome

OBJECTIVEThe management of brain arteriovenous malformations (bAVMs) remains controversial. The Treatment of Brain AVMs Study (TOBAS) was designed to manage patients with bAVMs within a clinical research framework. The objective of this study was to study trial feasibility, recruitment rates, patient allocation to the various management groups, and compliance with treatment allocation.METHODSTOBAS combines two randomized care trials (RCTs) and a registry. Designed to be all-inclusive, the study offers randomized allocation of interventional versus conservative management to patients eligible for both options (first RCT), a second RCT testing the role of preembolization as an adjunct to surgery or radiotherapy, and a registry of patients managed using clinical judgment alone. The primary outcome of the first RCT is death from any cause or disabling stroke (modified Rankin Scale score > 2) at 10 years. A pilot phase was initiated at one center to test study feasibility, record the number and characteristics of patients enrolled in the RCTs, and estimate the frequency of crossovers.RESULTSAll patients discussed at the multidisciplinary bAVM committee between June 2014 and June 2016 (n = 107) were recruited into the study; 46 in the randomized trials (23 in the first RCT with 21 unruptured bAVMs, 40 in the second RCT with 17 unruptured bAVMs, and 17 in both RCTs), and 61 patients in the registry. Three patients crossed over from surgery to observation (first RCT).CONCLUSIONSClinical research was successfully integrated with normal practice using TOBAS. Recruitment rates in a single center are encouraging. Whether the trial will provide meaningful results depends on the recruitment of a sufficient number of participating centers.Clinical trial registration no.: NCT02098252 (clinicaltrials.gov)

Objective To our knowledge, there have not been any reported cases of a meningioma of the craniocervical region presenting solely with syncope as its initial symptom. Only 1 case of meningioma presenting with syncope has been published, but it was associated with hydrocephalus. We report 2 cases of syncope caused by a craniocervical junction meningioma, with syncope being the sole presenting symptom and without hydrocephalus. We discuss the possible pathophysiology, as well as the clinical relevance of this type of presentation. Methods We reviewed the charts, operative details, and imagery of 2 cases of meningioma in the region of the craniocervical junction, with syncope as their sole presenting feature. We also reviewed the literature. Results In 1 case the syncope occurred spontaneously. In the other, it occurred during a Valsalva maneuver. Both meningiomas were surgically removed via a retromastoid approach. There was no recurrence of syncope following surgery. Following a literature review, we found 1 case of posterior fossa meningioma presenting with syncope, but hydrocephalus was also present. Conclusion Syncope can be the sole manifestation of a meningioma of the craniocervical junction. Such syncopes are a consequence of transient dysfunction of the autonomous pathways in the medulla and/or of the medulla's output. In the absence of other causes of syncope, a meningioma in this region, even in the absence of hydrocephalus, should not be considered as fortuitous, but rather as the actual cause of syncope. Recognizing this possibility offers the potential for proper diagnosis and appropriate treatment of the syncope.

BACKGROUND AND PURPOSE: Moyamoya disease is a progressive neurovascular pathology defined by steno-occlusive disease of the distal internal carotid artery and associated with the development of compensatory vascular collaterals. The etiology and exact anatomy of vascular collaterals have not been extensively studied. The aim of this study was to describe the anatomy of collaterals developed between the ophthalmic artery and the anterior cerebral artery in a Moyamoya population. MATERIALS AND METHODS: All patients treated for Moyamoya disease from 2004 to 2016 in 4 neurosurgical centers with available cerebral digital subtraction angiography were included. Sixty-three cases were evaluated, and only 38 met the inclusion criteria. Two patients had a unilateral cervical internal carotid occlusion that limited analysis of ophthalmic artery collaterals to one hemisphere. This study is consequently based on the analysis of 74 cerebral hemispheres. RESULTS: Thirty-eight patients fulfilled the inclusion criteria. The most frequently encountered anastomosis between the ophthalmic artery and cerebral artery was a branch of the anterior ethmoidal artery (31.1%, 23 hemispheres). In case of proximal stenosis of the anterior cerebral artery, a collateral from the posterior ethmoidal artery could be visualized (16 hemispheres, 21.6%). One case (1.4%) of anastomosis between the lacrimal artery and the middle meningeal artery that permitted the vascularization of a middle cerebral artery territory was also noted. CONCLUSIONS: Collaterals from the ophthalmic artery are frequent in Moyamoya disease. Their development depends on the perfusion needs of the anterior cerebral artery territories. Three other systems of compensation could be present (callosal circle, leptomeningeal anastomosis, and duro-pial anastomoses).

BACKGROUND Treatment of thoracic spinal dural arteriovenous fistulas (DAVFs) by microsurgery has recently been approached using minimally invasive spine surgery (MISS). The advantages of such an approach are offset by difficult maneuverability within the tubular retractor and by the creation of "tunnel vision" with reduced luminosity to a remote surgical target. OBJECTIVE To demonstrate how the pitfalls of MISS can be addressed by applying 3-D endoscopy to the minimally invasive approach of spinal DAVFs. METHODS We present 2 cases of symptomatic thoracic DAVFs that were not amenable to endovascular treatment. The DAVFs were excluded solely via a minimally invasive approach using a 3-D endoscope. RESULTS Two patients underwent exclusion of a DAVF following laminotomy, one through a midline 5-cm incision and the other through a paramedian 3-cm incision using minimally invasive nonexpandable tubular retractors. The dura opening, intradural exploration, fistula exclusion, and closure were performed solely under endoscopic 3-D magnification. No incidents were recorded and the postoperative course was marked by clinical improvement. Postoperative imaging confirmed the exclusion of the DAVFs. Anatomical details are exposed using intraoperative videos. CONCLUSION When approaching DAVFs via MISS, replacing the microscope with the endoscope remedies the limitations related to the "tunnel vision" created by the tubular retractor, but at the expense of losing binocular vision. We show that the 3-D endoscope resolves this latter limitation and provides an interesting option for the exclusion of spinal DAVFs.

The best management of brain arteriovenous malformation (bAVM) patients remains unknown. Randomized allocation may be more readily accepted when there is uncertainty and disagreement regarding the management of potential participants. In planning for a trial, we aimed to assess variability and agreement among physicians managing bAVM patients.A portfolio composed of 35 patients was sent to 47 clinicians of various specialties managing bAVM patients. For each patient, physicians were asked their best management decision (surgery/embolization/radiosurgery/conservative), their confidence level, and whether they would include the patient in a randomized trial comparing conservative and curative management. Seven physicians, who had access to all images of each patient, independently responded twice, to assess inter and intra-rater agreement using kappa statistics.The inter-rater agreement (30 raters, including 16 neuroradiologists) for best management decision was only "fair" (κ [95%CI]=0.210[0.157; 0.295]). Agreement remained below 'substantial' (κ.6) between physicians of the same specialty, and when no distinctions were made between various treatments (when responses were dichotomized as conservative versus curative). With access to all images the inter-rater agreement remained fair. The intra-rater agreement reached "substantial" only for the dichotomized decisions. Responding clinicians were willing to include 54.4% of patients (mainly unruptured bAVMs) in a randomized trial.There is a lack of agreement among clinicians involved in the management of bAVM patients. In this study a substantial proportion of clinicians were willing to offer randomized allocation of management options to a substantial number of patients.

OBJECTIVE The ARUBA study (A Randomized Trial of Unruptured Brain Arteriovenous Malformations [AVMs]) on unruptured brain AVMs has been the object of comments and editorials. In the present study the authors aim to systematically review critiques, discuss design issues, and propose a framework for future trials. METHODS The authors performed a systematic review of the French and English literature on the ARUBA study published between January 2006 and February 2015. The electronic search, including the Cochrane Library, MEDLINE (PubMed and Ovid), CINAHL, and EMBASE databases, was complemented by hand searching and cross-referencing. The comments were categorized as items related to the design, the conduct, and the analysis and interpretation of the trial. RESULTS Thirty-one articles or letters were identified. The pragmatic design, with heterogeneity of patients and lack of standardization of the treatment arm, were frequently stated concerns. The choice of outcome measures was repeatedly criticized. During the trial, low enrollment rates, selection bias, and premature interruption of enrollment were frequent comments. The short follow-up period, the lack of subgroup analyses, the lack of details on the results of the various treatments, and a contentious interpretation of results were noted at the analysis stage. A fundamental problem was the primary hypothesis testing conservative management. The authors believe that other trials are needed. Future trials could be pragmatic, test interventions stratified at the time of randomization, and look for long-term, hard clinical outcomes in a large number of patients. CONCLUSIONS In the authors' view, the ARUBA trial is a turning point in the history of brain AVM management; future trials should aim at integrating trial methodology and clinical care in the presence of uncertainty.

The recurrent artery of Heubner (RAH) is a very fascinating artery for various reasons. The first one is its early development in the embryologic and phylogenic life. The second one is the discrepancy between its diameter and its functional importance and the last but not least reason is the many variations of origin and course of this artery. For more than a century, numerous studies furnished important information about variations in origin, course, and parenchymal territory of the RAH. The most important anomaly concerning the RAH is the accessory middle cerebral artery and well-illustrates the complexity of its embryologic development. For these reasons, authors provide a review of anatomical variations of this artery that could be encountered with a particular attention given to the history and embryological knowledge.

A 24-year-old woman was referred to us for an intracranial haemorrhage in the left temporal lobe caused by a ruptured cavernous malformation; the bleeding extended over the left Heschl’s gyrus and Wernicke area. On admission, the patient had global aphasia. A few days later, she spontaneously improved but remained with mild residual comprehensive dysphasia. She reported hearing, in her right ear, recently heard words, which is consistent with palinacousis. Auditory acuity testing was normal. EEG showed focal slowing in the left temporal region with no epileptiform activity. During awake surgery for resection of the cavernous malformation, stimulation of the superior temporal gyrus did not provoke palinacousis. The patient made good recovery with complete resolution of the aphasia and no recurrence of palinacousis. We aimed to review this phenomenon and to provide a systematic review of the current literature.

Objective The management of unruptured and ruptured brain arteriovenous malformations (AVMs) remains controversial. The Treatment of Brain AVM Study (TOBAS) was designed to assess curative treatments in the management of AVMs. The purpose of our study is to provide a care trial context to brain AVM patients. Methods TOBAS is a pragmatic, prospective study including 2 randomized controlled trials and a registry. All AVM patients can be recruited. The preferred management modality will be predetermined prior to randomization by the team based on clinical judgment. Patients eligible for both conservative and interventional management will be randomly allocated conservative or curative treatment. Randomization will be stratified by a treatment modality (surgery, radiosurgery or embolization) and minimized according to a history of previous rupture and Spetzler-Martin grade. A second randomization will allocate eligible patients to embolization/no embolization prior to surgery or radiosurgery. The primary outcome of the study is death (any cause) or disabling stroke (mRS > 2) at 10 years. All patients managed according to clinical judgment alone will be included in the registry. The study is registered under: wwwTrials.gov , ID: NCT02098252 . Expected results A minimum recruitment of 540 patients is required to show that treatment can reduce the primary outcome by 10 % (from 25 to 15 %); 440 patients will be needed to show a 10 % increase in angiographic occlusion for a good clinical outcome with pre-embolization. Conclusion The trial is designed to offer optimal and verifiable care to patients with brain AVMs in spite of the uncertainty. We are currently seeking the participation of multiple centers.

BACKGROUND The ascending pharyngeal artery (APA) may, in very rare cases, supply the posterior inferior cerebellar artery (PICA). In reported cases, when such is the case, the ipsilateral vertebral artery (VA) does not supply the PICA, and most of the time it is hypoplastic. OBJECTIVE To describe a unique cadaveric observation of a direct anastomosis between the posterior division (neuromeningeal) of the jugular branch of the APA and the PICA, where the PICA is also supplied by a normal-size VA. METHODS A direct connection between the APA and the PICA was examined in a cadaveric specimen using a 3-dimensional endoscope and a surgical microscope. RESULTS The enlarged jugular branch of the posterior division of the APA entered intracranially via the jugular foramen in its pars vascularis. It then connected directly with the lateral medullary segment of the PICA. The first segment of the PICA originated from a left vertebral artery of normal size and continued its normal course beyond the junction with the jugular branch of the APA. CONCLUSION Both the VA and the jugular branch of the APA may simultaneously supply the PICA territory. Recognition of this anatomic variant is relevant when planning surgical or endovascular treatments.

OBJECT Blister aneurysms of the supraclinoid part of the internal carotid artery (ICA) are known for their high morbidity and mortality rates related to treatment, regardless of whether the treatment is surgical or endovascular. However, this grim prognosis is based on results that indiscriminately group all blister aneurysms together without taking into account the heterogeneous appearance of these lesions. The goal of this study was 2-fold: to determine whether different blister aneurysm morphologies present different pitfalls, which would then require different surgical strategies, as well as to determine whether there are identifiable subgroups of these types of aneurysms based on morphology. METHODS The authors reviewed the charts, cerebral catheter angiograms, surgical reports, and intraoperative videos of all ICA blister aneurysms treated surgically at the Centre Hospitalier de l'Université de Montréal from 2005 to 2012 to investigate whether there was a relationship between morphology and pitfalls, and whether different surgical strategies had been used according to these pitfalls. During this review process the authors noted 4 distinct morphological aspects. These 4 aspects led to a review of the English and French literature on blister aneurysms in which imaging was available, to determine whether other cases could also be classified into the same 4 subgroups based on these morphological aspects. RESULTS The retrospective review of the authors’ series of 10 patients allowed a division into 4 distinct subtypes: Type I (classic), Type II (berry-like), Type III (longitudinal), and Type IV (circumferential). These subtypes may at times be progressive stages in the arterial anomaly, and could represent a continuum. Each subtype described in this paper presented its own pitfalls and required specific surgical adaptations. Upon reviewing the literature the authors retained 35 studies involving a total of 61 cases of blister aneurysms, and all cases were able to be classified into 1 of these 4 distinct subtypes. CONCLUSIONS Although they share some common characteristics, blister aneurysms may be divided into distinct subtypes, suggestive of a continuum. Such a classification with a detailed description of each type of blister aneurysm would allow for better recognition to anticipate complications during intervention and better assess the different treatment strategies according to the subtypes.

Dural metastasis from prostate cancer is rare and may mimic a subdural hematoma (SDH). Preoperatively diagnosis may be difficult and only reveal its presence during surgery. We present such a case and review the literature to identify common characteristics. A 65-year-old man presented with headache, confusion, and progressive right upper limb weakness. Past history included a prostate adenocarcinoma with bone metastasis 3 years earlier. Head computed tomography (CT) scan without contrast revealed a multinodular bilateral hyperdense extra-axial lesion interpreted as acute SDH. At surgery planned for SDH drainage no blood was found; instead there was an en plaque subdural yellowish tumor. Histopathologic examination was consistent with metastatic adenocarcinoma of the prostate. We found 11 cases reported as dural metastasis of prostate cancer mimicking SDH. Surgery was performed on nine cases with no suspicion of dural metastasis. On preoperative nonenhanced CT scan images, three types of image patterns can be described: a nodule in SDH, multinodular metastasis surrounded by SDH, and large en plaque subdural tumor. The latter group consists of those cases where no blood but rather an en plaque subdural tumor was found at surgery. Even though rare, dural metastasis should be considered among the differential diagnoses in a patient known for prostate cancer.

Background Meningiomas of the velum interpositum in the roof of the third ventricle are rare. Knowing from which leaflet the meningioma originates and thus its relationships with the internal cerebral and Galen veins, may help in choosing the surgical approach. Case description We report the case of a 40-year-old male with a meningioma arising from the superior leaflet of the velum interpositum. The tumor was resected successfully using the infratentorial-supracerebellar approach. Reviewing the literature, of the 22 reported cases of velum interpositum meningiomas, sufficient information regarding the precise location of the origin of the tumor was provided in 14 cases, all of which were from the inferior leaflet. Conclusion We report the first case of velum interpositum meningioma arising from the superior leaflet and give a potential explanation as to why meningiomas of the velum interpositum occur more commonly on the inferior leaflet. Distinguishing from which of the two leaflets the tumor originates may influence the surgical strategy.

a b s t r a c t Objective: Posterior fossa arteriovenous malformations (pAVMs) are rare and because of their location at or close to vital structures, their treatment remains challenging despite overall improvements in the management of cerebrovascular lesions. We reviewed our recent series of ruptured pfAVMs in search of guiding principles in the management of these complex lesions. Methods: This is a retrospective series of consecutive patients admitted for a ruptured pfAVM from 2002 to 2013. We analyzed clinical and radiological data, as well as initial and definitive management. Outcome was assessed using the modified Rankin Scale (mRS) at 6 months. Results: The study included 34 patients (19 women and 15 men). Upon admission, 79% of patients pre- sented with an intra-cerebellar hematoma, 42% of which required urgent drainage. Hydrocephaly was also present in 82% of patients, 56% of which required emergency ventriculostomy. There was an aneurysm associated with the AVM in 47% of cases. In 38% of the cases, the aneurysm was the source of the hemor- rhage. Only 68% of patients were amenable to undergo treatment of the AVM: 24% exclusively by surgery, 9% by embolization, 3% by radiosurgery, and 32% using combined means. Five patients died within the first week: one as a direct result of the severity of the hemorrhage, and the other four due to re-bleeding before treatment. Outcome was favorable (mRS 0-2) in 71% of patients. Conclusion: Patients with a ruptured pfAVM are often comatose upon admission, requiring emergency live-saving surgical treatment. An associated aneurysm is often the source of bleeding which if dealt with immediately, offers time to plan the most appropriate strategies to eliminate the AVM. Nevertheless, early re-bleeding is frequent, and a cause of concern as it often leads to death. Despite the gravity of the clinical condition upon admission, outcome is favorable for those amenable to treatment.

Background Development of hydrocephalus can occur after subarachnoid hemorrhage (SAH). Typically, it is diagnosed with computed tomography, CT, scan. However, transcranial sonography (TCS) can be used particularly in patients with craniotomy which removes the acoustic interference of the skull and allows a closer up visualization of brain structures through the skin. Case presentation We report a 73-year-old woman who was hospitalized for SAH and developed acute hydrocephalus requiring an external ventricular drain (EVD). In this patient, detection and monitoring of hydrocephalus was done and monitored with a small pocket-sized TCS device. Nine days after surgery, weaning of the EVD was attempted. Prior to EVD closure and removal, TCS showed a measurement of the 3rd ventricle at around 1.16 cm. On the third day, the patient deteriorated clinically and the TCS showed a dilated 3rd ventricle measuring 1.37 cm which correlated well with computed tomography and with clinical signs of active hydrocephalus as both her sensorium and communication were affected. Subsequently following EVD re-installation, on the next day, TCS showed that the 3rd ventricle dimension was reduced to 0.99 cm and the following day it went down to 0.69 cm. Conclusions Patients with SAH and in particular those with a craniotomy can be monitored easily at the bedside with hand-held TCS for the development and monitoring of hydrocephalus.

International audience; Background: Due to their important size and complex localization, the management of thoracic dumbbell tumors is challenging, frequently requiring the need for an anterior approach. Our study aims to first report the feasibility and safety of a single-stage posterior minimally invasive procedure in achieving complete resection of voluminous thoracic dumbbell tumors.Methods: We retrospectively reviewed the medical records of five consecutive patients, who underwent the minimally invasive resection of a type III thoracic dumbbell tumor in our institution between March 2007 and March 2012. There were two men and three women, with a mean age at diagnosis of 57 years (range 41-68 years). After the placement of a non-expandable tubular retractor under fluoroscopic control, a costotransversectomy was achieved. By moving the retractor in all directions, the tumor was largely exposed and resected with the cavitron ultrasonic surgical aspirator. Clinical and radiological monitoring was performed before discharge, at 6 months, 1 year and 2 years.Results: No major intraoperative complication was reported. Gross total resection was achieved in four patients. The mean operative time was 219 mins (range 75-540 mins) and the mean estimated blood loss was 230 ml (range 50-500 ml). No postoperative complication was reported. The mean length of hospital stay was 3.6 days (range 2-6 days) and all patients were discharged home. Histological analysis confirmed the diagnosis of grade 1 schwannoma in four patients and revealed a hemangiopericytoma in one patient. No tumor recurrence was noted with a mean follow up period of 46 months (range 32-54 months).Conclusion: Thoracic dumbbell tumors can be safely and completely resected using a single-stage minimally invasive procedure. The costotransversectomy can be performed through a non-expandable retractor allowing sufficient access to all parts of the tumor.

OBJECTIVE: To evaluate the quality of information available on the Internet to patients with a cervical pathology undergoing elective cervical spine surgery. METHODS: Six key words ("cervical discectomy," "cervical foraminotomy," "cervical fusion," "cervical disc replacement," "cervical arthroplasty," "cervical artificial disc") were entered into two different search engines (Google, Yahoo!). For each key word, the first 50 websites were evaluated for accessibility, comprehensibility, and website quality using the DISCERN tool, transparency and honesty criteria, and an accuracy and exhaustivity scale. RESULTS: Of 5,098,500 evaluable websites, 600 were visited; 97 (16%) of these websites were evaluated for quality and comprehensiveness. Overall, 3% of sites obtained an excellent global quality score, 7% obtained a good score, 25% obtained an above average score, 15% obtained an average score, 37% obtained a poor score, and 13% obtained a very poor score. High-quality websites were affiliated with a professional society (P = 0.021), had bibliographical references (P = 0.030), and had a recent update within 6 months (r = 0.277, P < 0.001). No correlation between global quality score and other variables was observed. CONCLUSIONS: This study shows that the search for medical information on the Internet is time-consuming and often disappointing. The Internet is a potentially misleading source of information. Surgeons and professional societies must use the Internet as an ally in providing optimal information to patients.

Object The management of unruptured intracranial aneurysms remains controversial. The goal of this study was to evaluate the clinical community agreement in decision making regarding unruptured intracranial aneurysms. Methods A portfolio of 41 cases of unruptured intracranial aneurysms with angiographic images, along with a short description of the patient presentation, was sent to 28 clinicians (16 radiologists and 12 surgeons) with varying years of experience in the management of unruptured intracranial aneurysms. Five senior clinicians responded twice at least 3 months apart. Nineteen cases (46%) were selected from patients recruited in the Canadian UnRuptured Endovascular versus Surgery trial, an ongoing randomized comparison of coil embolization and clip placement. For each case, the responder was to first choose between 3 treatment options (observation, surgical clip placement, or endovascular coil embolization) and then indicate their level of certainty on a quantitative 0–10 scale. Agreement in decision making was studied using κ statistics. Results Decisions to coil were more frequent (n = 612, 53%) than decisions to clip (n = 289, 25%) or to observe (n = 259, 22%). Interjudge agreement was only fair (κ = 0.31 ± 0.02) for all cases and all judges, despite substantial intrajudge agreement (range 0.44–0.83 ± 0.10), with high mean individual certainty levels for each case (range 6.5–9.4 ± 2.0 on a scale of 0–10). Agreement was no better within specialties (surgeons or radiologists), within capability groups (those able to perform endovascular coiling alone, surgical clipping alone, or both), or with more experience. There was no correlation between certainty levels and years of experience. Agreement was lower when the cases were taken from the randomized trial (κ = 0.19 ± 0.2) compared with nontrial cases (κ = 0.35 ± 0.2). Conclusions Individuals do not agree regarding the management of unruptured intracranial aneurysms, even when they share a background in the same specialty, similar capabilities in aneurysm management, or years of practice. If community equipoise is a necessary precondition for trial participation, this study has found sufficient uncertainty and disagreement among clinicians to justify randomized trials.

Cavernous malformations in the midbrain can be accessed via several safe entry zones. The accepted rule of thumb is to enter at the point where the lesion is visible at the surface of the brainstem to pass through as little normal brain tissue as possible. However, in some cases, in order to avoid critical neural structures, this rule may not apply. A different safe entry zone can be chosen. Our video presents a case of a ruptured cavernous malformation in the midbrain reaching its anterior surface which was successfully resected via a posterolateral route using the supracerebellar infratentorial approach.The video can be found here: https://youtu.be/7kt-OQuBmz0.

Thalamomesencephalic cavernous malformations are located high in the brainstem and may be difficult to reach. We present a case of such a lesion which was successfully approached via the supracerebellar transtentorial route. Our enclosed video provides elements to justify this posterior approach and illustrates the steps required for the cavernoma’s safe removal, which include opening of the tentorium and gentle retraction of the exposed temporal lobe.The video can be found here: https://youtu.be/Ex5OfLyBzPY.

Background Unruptured intracranial aneurysms (UIAs) are increasingly diagnosed and are commonly treated using endovascular treatment or microsurgical clipping. The safety and efficacy of treatments have not been compared in a randomised trial. How to treat patients with UIAs suitable for both options remains unknown. Methods We randomly allocated clipping or coiling to patients with one or more 3–25 mm UIAs judged treatable both ways. The primary outcome was treatment failure, defined as: initial failure of aneurysm treatment, intracranial haemorrhage or residual aneurysm on 1-year imaging. Secondary outcomes included neurological deficits following treatment, hospitalisation >5 days, overall morbidity and mortality and angiographic results at 1 year. Results The trial was designed to include 260 patients. An analysis was performed for slow accrual: 136 patients were enrolled from 2010 through 2016 and 134 patients were treated. The 1-year primary outcome, available for 104 patients, was reached in 5/48 (10.4% (4.5%–22.2%)) patients allocated surgical clipping, and 10/56 (17.9% (10.0%–29.8%)) patients allocated endovascular coiling (OR: 0.54 (0.13–1.90), p=0.40). Morbidity and mortality (modified Rankin Scale>2) at 1 year occurred in 2/48 (4.2% (1.2%–14.0%)) and 2/56 (3.6% (1.0%–12.1%)) patients allocated clipping and coiling, respectively. New neurological deficits (15/65 vs 6/69; OR: 3.12 (1.05–10.57), p=0.031), and hospitalisations beyond 5 days (30/65 vs 6/69; OR: 8.85 (3.22–28.59), p=0.0001) were more frequent after clipping. Conclusion Surgical clipping or endovascular coiling of UIAs did not show differences in morbidity at 1 year. Trial continuation and additional randomised evidence will be necessary to establish the supposed superior efficacy of clipping.

OBJECTIVE Surgical management of recurrent aneurysms following failed flow diversion may pose difficulties in securing vascular control with temporary clips. The authors tested the efficacy and impact of different types of aneurysm clips on flow-diverted arteries. METHODS Six wide-necked experimental aneurysms were created in canines and treated with Pipeline flow diverters. In 4 aneurysms, occlusion of the artery at the level of the proximal and distal landing zones (n = 2 per aneurysm) was attempted, using temporary, fenestrated, single, and double permanent aneurysm clips. Two aneurysms served as unclipped controls. Serial angiography was performed to investigate the efficacy of clip occlusion, flow diverter deformation, and thrombus formation. After the animals were killed, the flow-diverted aneurysm constructs were opened and photographed to determine neointimal or device damage as a result of clip placement. RESULTS Angiography-confirmed clip occlusion was only possible for 4 of 8 of the tested flow-diverted arterial segments. Clip application attempts led to filling defects consistent with thrombus formation in 2 of 4 flow-diverted constructs, and to minor damage of the flow diverter with neointimal fracture in 1 of 4 cases. CONCLUSIONS Aneurysm clips placed on canine parent arteries bearing a Pipeline flow diverter were unable to reliably stop blood flow. Application of aneurysm clips can cause mild damage to the device and neointima, which might translate into thromboembolic risks. If possible, vascular control should be sought beyond the terminal ends of the implanted device.

Retrochiasmatic craniopharyngiomas involving the anterior third ventricle are challenging to access. Although the pterional approach is a common route for suprasellar lesions, when the craniopharyngioma extends behind the chiasma into the third ventricle, access is even more difficult, and the lamina terminalis may offer a good working window. The translamina terminalis approach provides direct access to the retrochiasmatic portion of the tumor with minimal brain retraction and no manipulation of the visual nerves. In this video, we emphasize the utility of using the lamina terminalis corridor to resect the retrochiasmatic intraventricular portion of a craniopharyngioma.The video can be found here: https://youtu.be/hrLNC0hDKe4.

Rebleeding and symptomatic vasospasm (VS) are the major causes of subsequent morbidity and mortality in patients surviving a subarachnoid hemorrhage (SAH). Although most patients present rapidly after the bleed, some may seek medical attention in a delayed fashion due to non-resolving or worsening headaches or new neurological deficits, requiring treatment during the period at risk for VS. Such patients may either present asymptomatic radiological VS on their diagnostic angiogram or present symptomatic VS confirmed on angiogram. A similar situation may occur in patients presenting within the first 48 hours after SAH with very early angiographic VS. Deciding on the optimal timing and modality of treatment in such patients with SAH and symptomatic VS on presentation is controversial. Only six observational studies that specifically assessed aneurysm treatment in the presence of symptomatic VS have been published to date. We reviewed the published literature on the management of ruptured intracranial aneurysms in the presence of symptomatic VS and suggest avenues for future studies.

Subarachnoid hemorrhage (SAH) has been recognized as a risk factor for ventriculostomy-related infections (VRI). In addition to the hemorrhagic cerebrospinal fluid (CSF), the potential need for prolonged catheterization may contribute to the increased CSF infection rate in this population. The use of antibiotic-impregnated catheters (AIC) has effectively reduced the risk of VRI. Herein, we examined specifically the impact of systematic insertion of AIC on the timing of CSF infections in SAH patients. Retrospective review of patients admitted between April 2006 to March 2009 with a non-traumatic SAH who required an external ventriculostomy. Only patients with AIC were included. A meningitis or ventriculitis was diagnosed according to the published criteria of the Center for Disease Control and Prevention. This study includes 75 patients in which 97 drains were inserted. Seven infections (7/75 = 9.3%) occurred over 1,024 drainage days (DD), resulting in a rate of 6.8 infections/1,000 DD. The mean drainage time was 15.4 days in the infected AIC group compared with 10.2 days in the non-infected AIC group. No infection occurred before day 9 of drainage and 71% (5/7) occurred after more than 2 weeks of drainage. The observed timing of infections is delayed in comparison with that reported in series using non-AIC, which typically occur prior to the 10th day of drainage. In the high-risk population of non-traumatic SAH, the use of AIC delays the occurrence of infection compared with that reported with non-antibiotic-impregnated catheters. This may orient management strategies in SAH patients requiring a ventriculostomy.

Intraventricular hemorrhage is common after the rupture of anterior communicating artery (ACoA) aneurysms, although the anatomical pathway has not been described. Knowledge of the mechanism of hemorrhage may enhance understanding of its prognosis. Using CT angiography, the authors analyzed this pathway in 2 cases of ACoA aneurysm rupture associated with intraventricular hemorrhage. The initial hemorrhages created a hyperdense ventriculographic image on which the subsequent contrast medium ejection could be followed. The contrast medium entered the subarachnoid space of the anterior interhemispheric fissure and broke through the lamina rostralis into the septum pellucidum and into the frontal horns of the lateral ventricles. Thus, the authors provide an explanation for bleeding from ACoA aneurysms into the ventricular system in the presence of an intact lamina terminalis. The septum pellucidum may act as a buffer before extension of the bleeding into the ventricular system.