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Posterior fossa dural arteriovenous fistulas are rare vascular malformations. If associated with cortical venous reflux, they present a significant risk of hemorrhage. We present a 54-year-old male who presented with progressive hearing loss without other neurologic symptoms. Further workup revealed tentorial incisura dural arteriovenous fistula with cortical venous reflux and aneurysmal dilation of venous drainage (type IV Cognard), fed from the right internal carotid artery and external carotid artery. After multidisciplinary discussion, we decided on surgical disconnection of the fistula as we felt this approach would have the highest chance of immediate and durable cure. We performed a right retrosigmoid craniotomy with (Video 1) disconnection of the arterialized veins and thus achieved completed obliteration. Follow-up angiography 8 months later showed no evidence of residual/recurrent fistula. The patient's hearing improved. There were no adverse effects during the perioperative period., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Dural arteriovenous fistulas (dAVFs) are rare vascular malformations of uncertain pathophysiology. If associated with cortical venous reflux, they present a significant risk of hemorrhage. We present a 69-year-old patient who presented with spontaneous right-sided symptomatic chronic subdural hematoma, which was evacuated via burr hole. Due to lack of history of prior trauma, computer tomography angiography was performed, which showed dilated convoluted vessels in the right occipital region and an enlarged right posterior cerebral artery, suspected to be an arteriovenous malformation or dAVF. Subsequent angiography demonstrated occipital tentorial dAVF with primary cortical venous reflux (Cognard III) and reflux into the transverse sinus, fed primarily from the petrosquamous branch of the middle meningeal artery and neuromeningeal trunk. The fistula was initially treated by transarterial endovascular embolization of the occipital artery and neuromeningeal trunk with Onyx, achieving complete obliteration. However, follow-up angiography demonstrated recurrence of the lesion fed from the contralateral middle meningeal artery and pial branches of the enlarged right posterior cerebral artery. Given the recruitment of the contralateral supply from the left middle meningeal artery and ipsilateral posterior cerebral artery, we felt that surgical disconnection of the fistula was the best option for the patient. An occipital craniotomy with disconnection of the fistula without isolation of the transverse sinus was performed (Video 1), as published literature demonstrated lower intraoperative risk with disconnection only. The perioperative course was uneventful. Immediate postoperative and follow-up angiography demonstrated complete occlusion of the fistula., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Objective: Awake craniotomy for removal of intra-axial lesions is a well-established procedure. Few studies, however, have investigated the usefulness of this approach for resection of arteriovenous malformations adjacent to eloquent language areas. We demonstrate our experience by using cortical stimulation mapping and report for the first time on the usefulness of subcortical stimulation with interrogation of language function during resection of arteriovenous malformations (AVMs) located near language zones., Methods: Patients undergoing awake craniotomy for AVMs located in language zones and at least 5 mm away from the closest functional magnetic resonance imaging activation were analyzed. During surgery, cortical bipolar stimulation at 50 Hz, with an intensity of 2 mA, increased to a maximum of 10 mA was performed in the region around the AVM before claiming it negative for language function. In positive language site, the area was restimulated 3 times to confirm the functional deficit. The AVM resection was started based on cortical mapping findings. Further subcortical stimulation performed in concert with speech interrogation by the neuropsychologist continued at key points throughout the resection as feasible. The usefulness of cortical and subcortical stimulation in addition to patient outcomes was analyzed., Results: Between March 2009 and September 2014, 42 brain AVM resections were performed. Four patients with left-sided language zone AVMs underwent awake craniotomy. The AVM locations were fronto-opercular in 2 patients and posterior temporal in 2. The AVM Spetzler-Martin grades were II (2 patients) and III (2 patients). In 1 patient, complete speech arrest was noticed during mapping of the peri-malformation zone, which was not breached during resection. In a second patient who initially demonstrated negative cortical mapping, a speech deficit was noticed during resection and subcortical stimulation. This guided the approach to protect and avoid the sensitive zone. This patient experienced mild postoperative expressive dysphasia that improved to normal within 6 weeks. Complete resection was achieved in all 4 patients. There were no other complications and no permanent neurological morbidity, resulting in good outcome in all 4 patients., Conclusions: Language mapping, both cortical and subcortical during AVM resection, may be valuable in a very select group of AVMs in language zones. Defining safe margins and feedback to the surgeon may provide the highest chances of a surgical cure while minimizing the risk of incurring a language deficit., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Ruptured aneurysms with intraparenchymal hematoma and mass effect are primarily treated by surgical clipping. In this video presentation, a 68 year old male with a large ruptured right ICA bifurcation aneurysm is presented. Patient's neurological exam was rapidly deteriorating, therefore the patient was transferred to the operating theater after initial evaluation by CT and CT angiogram. A pterional craniotomy was performed, the frontal hematoma was partially removed and the aneurysm was clipped. Residual hematoma was removed after securing the aneurysm and the aneurysm dome was punctured(detail of surgical clipping in the video). Patient made a good recovery at 2 weeks post-op with complete recovery of left sided weakness, and some remaining cognitive deficit. The video can be found here: http://youtu.be/dKFWptdgC4M .

Proximally located posterior communicating artery (PCoA) aneurysms, projecting postero-laterally in proximity to the tentorium, may pose a technical challenge for microsurgical clipping due to obscuration of the proximal aneurysmal neck by the anterior petroclinoid fold. We describe an efficacious technique utilizing fenestration of the anterior petroclinoid fold to facilitate visualization and clipping of PCoA aneurysms abutting this aspect of the tentorium. Of 86 cases of PCoA aneurysms treated between 2003 and 2013, the technique was used in nine (10.5 %) patients to allow for adequate clipping. A 3 mm fenestration in the anterior petroclinoid ligament is created adjacent and lateral to the anterior clinoid process. This fenestration is then widened into a small wedge corridor by bipolar coagulation. In all cases, the proximal aneurysm neck was visualized after the wedge fenestration. Additionally, an adequate corridor for placement of the proximal clip blade was uniformly established. All cases were adequately clipped, with complete occlusion of the aneurysm neck and fundus with preservation of the PCoA. There were two intraoperative ruptures not related to creation of the wedge fenestration. One patient experienced post-operative partial third nerve palsy, which resolved during follow-up. We describe a technique of fenestration of the anterior petroclinoid fold to establish a critical and safe corridor for both visualization and clipping of PCoA aneurysms.

Background: Cerebral vasospasm is the most common cause of morbidity and mortality after aneurysmal subarachnoid hemorrhage (SAH). This study is designed to determine whether the incidence of symptomatic vasospasm and the overall clinical outcome differ between patients treated with surgical clipping compared with endovascular obliteration of aneurysms., Methods: In this prospective study, 98 patients with aneurysmal SAH were treated. Seventy-two patients underwent surgery and clipping and 26 had coil embolization. The incidence of symptomatic vasospasm, permanent neurologic deficit due to vasospasm and clinical outcome were analyzed. Patients with better clinical and radiological grades (World Federation of Neurological Surgeons grades I-III and Fisher grades I-III) were analyzed separately., Results: Symptomatic vasospasm occurred in 22% of the patients; 25% in the surgical group and 15% in the endovascular group. Nine percent of the patients in the surgical group and 7% in the endovascular group suffered ischemic infarction with permanent neurological deficit. These differences did not reach statistical significance (p = 0.42). For patients with better clinical and radiological grades, no significant difference was found for the rate of symptomatic vasospasm; 23% in the surgical and 12% in the endovascular group (p = 0.49). The overall clinical outcome was comparable in both groups, with no difference in the likelihood of a Glasgow Outcome Scale score of 3 or less (15% in the surgical and 16% in the endovascular group; p = 0.87). The same results for outcome were obtained for the subgroup of patients with better clinical grades on admission., Conclusion: Symptomatic vasospasm and ischemic infarction rate seem comparable in both groups, even for patients with better clinical and radiological admission grades. There is no significant difference in the overall clinical outcome at the long-term follow-up between both groups., (Copyright 2004 S. Karger AG, Basel)

Tuberculum sella meningioma can be approached by either open or endoscopic approaches. The aim of this video case presentation is to highlight the nuances of the lateral supraorbital craniotomy for tuberculum sella meningioma resection. The authors present a 34-year-old female patient who presented with decreased right eye visual acuity (20/60), afferent pupillary defect, and nasal field cut due to a tuberculum sella meningioma. The tumor was partially encasing the left A1 artery, severely displacing the optic apparatus, and minimally invading the right optic canal. The lateral supraorbital craniotomy was considered the most suitable approach to this tumor. The operative nuances and pitfalls of this approach are detailed in the video. Gross total resection of the tumor was achieved and confirmed with postoperativeMRI. The patient's vision gradually improved and she was discharged on the fourth postoperative day. The minimally invasive lateral supraorbital craniotomy for tuberculum sella meningioma is a suitable approach in selected cases. [ABSTRACT FROM AUTHOR]

A 79-year-old woman presented to the emergency department following multiple falls in the previous week. Her past medical history was unremarkable except for chronic obstructive pulmonary disease. She was neurologically intact on arrival with normal laboratory data. Brain imaging revealed a right-sided sphenoid wing meningioma with considerable edema around it. Owing to her cognitive decline and recent symptoms, it was decided to proceed with surgical resection of the lesion. Considering her age and underlying disease, we planned to avoid probable complications of an aggressive resection. She underwent preoperative transarterial embolization with particles. In the supine position, a right pterional craniotomy with orbital extension was performed followed by tumor resection under microscopic magnification. One of the branches of the middle cerebral artery was engulfed by the tumor and could not be separated; therefore, the artery was cut to resect the tumor and then mobilized and reanastomosed under microscope. Doppler probe confirmed patency of the anastomosis. The patient recovered well from the surgery, experienced an uneventful hospital stay, and was discharged on postoperative day 10 after completely controlling her chronic obstructive pulmonary disease. Postoperative imaging did not show any signs of infarction, and the revascularized artery was patent on postoperative computed tomography angiography (Video 1). [ABSTRACT FROM AUTHOR]