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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.

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.

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.

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.

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.

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).

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.

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.

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.

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.

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.

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.

Objectif: Il a ete bien demontre que l'hemicraniectomie decompressive (HD) diminue la mortalite chez les patients qui ont subi un infarctus malin dans le territoire de l'artere cerebrale moyenne (ACM). Plusieurs des patients qui survivent presentent une invalidite de moderee a severe. Il existe une controverse a savoir ce qui devrait etre considere comme etant un bon resultat. Nous avons evalue la qualite de vie (QV) de patients apres une HD effectuee suite a un infarctus malin dans le territoire de l'ACM dans notre milieu. Methode: Nous avons evalue le resultat chez tous les patients ayant subi une HD suite a un infarctus malin dans le territoire de l'ACM entre 2001 et 2009 au moyen d'une analyse retrospective de dossier et un suivi telephonique chez les survivants. Nous avons determine le resultat fonctionnel au moyen de la Glasgow outcome scale, de la modified Rankin scale (mRS) et du Bartel index (BI) et la QV au moyen de la Stroke Impact Scale. Resultats: Nous avons identifie 14 patients, 6 hommes et 8 femmes, dont l'âge moyen etait de 44 ans (ecart de 27 a 57 ans). Tous les patients avaient un niveau de conscience diminue avant la chirurgie. Cinq avaient subi un accident vasculaire cerebral de l'hemisphere dominant. L'intervalle median entre l'evenement et la chirurgie etait de 45 heures (ecart de 1 a 96 heures). Deux patients sont decedes et 1 patient n'a pas pu etre rejoint pour le suivi. Parmi les 11 survivants, l'issue fonctionnelle a ete favorable chez 7 patients (63,6%), soit un score mRS < 4. Aucun patient n'etait dans un etat vegetatif persistant. La majorite des patients dont nous avons fait l'entrevue et des soignants (7 de 8), incluant ceux qui avaient subi un AVC a l'hemisphere dominant, etaient satisfaits apres un suivi median de 18 mois (ecart de 6 a 43 mois) malgre une QV alteree, particulierement dans les domaines physiques. Conclusion: La plupart des patients rapportent une QV satisfaisante malgre une invalidite significative, meme ceux qui presentent une invalidite de moderee a severe et un AVC de l'hemisphere dominant. Un infarctus malin de l'ACM de l'hemisphere dominant ne devrait pas etre considere comme une contre-indication a l'HD.

Objective To present a review of the literature and a case series of blood blister–like aneurysms (BBA) to show that an adapted direct surgical approach enables treatment of BBA with a low complication rate. Methods A retrospective review was performed of patients treated for a ruptured BBA of the internal carotid artery (ICA) at Hopital Notre-Dame from 2005–2009. Clinicoradiologic data and intraoperative videos were analyzed. Outcome was assessed using the modified Rankin scale (mRS). Results This series includes 7 patients (4 women and 3 men) with a mean age of 44.7 (range 30–61). All patients presented with subarachnoid hemorrhage (SAH). Four angiograms were initially negative. Diameter of BBA ranged from 1.1–8.2 mm. No intraoperative or postoperative aneurysm rupture occurred in this series. Although angiograms showed expected mild stenosis of the ICA after clipping, no clinical or radiologic cerebral infarctions were observed. The outcome was favorable in all patients. Conclusions Recognition of BBA is essential for proper management. An appropriate neurosurgical strategy has enabled a significant reduction in perioperative aneurysm rupture compared with previous reports and obtains excellent functional results.

CASE REPORT Case 1 A 31-year-old female consulted for polydipsia and polyuria ongoing since a few weeks. She reported weight gain over the last eight months and amenorhea with galactorhea for the last four months. Physical examination revealed no abnormalities other than a decreased visual acuity in the left eye already noticed by the patient over the past three months. Biochemical and hematological data were within normal range. Endocrine work-up showed slightly increased prolactine, decreased luteinizing hormone/follicle stimulating hormone (LH/FHS), decreased free T4 and compensated insipidus diabetes. Magnetic resonance imaging (MRI) demonstrated a sellar cystic lesion with suprasellar extension, displacing the optic chiasm upwardly. The lesion was iso-intense on T1WI and slightly hyperintense on T2WI (Figure 1). The lesion’s rim enhanced following gadolinium injection. The stalk did not enhance. The preoperative diagnosis was a non-secreting cystic macroadenoma. The lesion was approached by an endoscopic endonasal transsphenoidal route. After opening a thin capsule beneath the dura, a whitish viscous substance spontaneously leaked out of the sella (Figure 2). After the mucoid substance was completely aspirated, the angled endoscope enabled a view inside the cavity and removal of free floating fragments of the capsule, sparing the pituitary gland. Intra-operative pathological findings were suggestive of an inflammatory process. In light of this information, the cavity was irrigated and surgery terminated. Post-operatively, the patient fully recovered her visual field defect. Currently two years following surgery, the patient remains on replacement treatment. Her follow-up MRI showed no lesion recurrence. The definitive pathological assessment showed fragments of pituitary tissue, with residual acini among tissue infiltrated with T and B lymphocytes and plasmocytes. A few giant cells were identified in the specimen. One of the fragments was lined by squamous cells, suggestive of a ruptured RCC with secondary hypophysitis (Figure 3). Special stains for micro-organisms yielded negative findings. Hypophysitis Secondary to a Ruptured Rathke Cleft Cyst

OBJECTIVESphenoid wing meningiomas are a heterogeneous group of tumors with variable surgical risks and prognosis. Those that have grown to a very large size, encasing the major cerebral arteries, are associated with a high risk of stroke. In reviewing the authors’ series of giant sphenoid wing meningiomas, the goal was to evaluate how the extent of the tumor’s invasion of surrounding structures affected the ability to safely remove the tumor and restore function.METHODSThe authors conducted a retrospective study of a series of giant sphenoid wing meningiomas operated on between 1996 and 2016. Inclusion criteria were meningiomas with a globoid component ≥ 6 cm, encasing at least 1 major intradural cerebral artery. Extent of resection was measured according to Simpson grade.RESULTSThis series included 12 patients, with a mean age of 59 years. Visual symptoms were the most common clinical presentation. There was complete or partial encasement of all 3 major cerebral arteries except for 3 cases in which only the anterior cerebral artery was not involved. The lateral wall of the cavernous sinus was invaded in 8 cases (67%) and the optic canal in 6 (50%). Complete resection was achieved in 2 cases (Simpson grades 2 and 3). In the remaining 10 cases of partial resection (Simpson grade 4), radical removal (> 90%) was achieved in 7 cases (70%). In the immediate postoperative period, there were no deaths. Four of 9 patients with visual deficits improved, while the 5 others remained unchanged. Two patients experienced transient neurological deficits. Other than an asymptomatic lacuna of the internal capsule, there were no ischemic lesions following surgery. Tumor recurrence occurred in 5 patients, between 24 and 168 months (mean 61 months) following surgery.CONCLUSIONSAlthough these giant lesions encasing major cerebral arteries are particularly treacherous for surgery, this series demonstrates that it is possible to safely achieve radical removal and at times even gross-total resection. However, the risk of recurrence remains high and larger studies are needed to see if and how improvement can be achieved, whether in surgical technique or technological advances, and by determining the timing and modality of adjuvant radiation therapy.

Object Conventional imaging demonstrates intertwined fibers of the cerebral white matter as a homogeneous substrate. Recently, diffusion tensor imaging has allowed 3D reconstruction of these fiber bundles. The goal of this study was to analyze the modifications of the association fibers induced by an arteriovenous malformation (AVM) in the parietotemporooccipital (PTO) associative area and their clinical significance. Methods The authors analyzed the long association fibers in seven patients harboring an AVM in or near the PTO region in relation with the fibers' clinical manifestation. The fibers include the arcuate fasciculus (AF), the occipitofrontal fasciculus (OFF), and the inferior longitudinal fasciculus (ILF). These structures were compared with the contra-lateral bundles. Results The modification of the tracts could establish a pattern signature depending on the specific location of the vascular malformation. There was a positive correlation between the degree of modifications of OFF and ILF fiber tracts and visual deficits. Alteration of the AF correlated with a speech disorder and the risk of postoperative deficits. Conclusions Diffusion tensor imaging enables in vivo dissection of fiber tracts coursing through the PTO area. Depending on the location of the AVMs, long association fibers are variously modified. These findings correlate with clinical manifestations and may predict outcome after surgery.

✓ The authors report the case of a 34-year-old woman who presented with increasing headaches. Neuroimaging revealed bilateral anomalous vessels arising at the level of each ophthalmic artery, coursing rostromedially to join the anterior communicating artery (ACA), which harbored an aneurysm. Intraoperatively, the authors identified an abnormal gyral segmentation of the frontoorbital region, with a median gyrus separated from the olfactory tracts on each side by the gyrus rectus. No interhemispheric fissure was observed in the exposed area. This is the first report in the literature of an abnormal gyral segmentation in association with an infraoptic course of an ACA. Recognition of this possible gyral abnormality in association with this vascular anomaly is relevant for surgical exposure and treatment of aneurysms by clip placement.

Animal studies have shown that Listeria monocytogenes can probably access the brain through a peripheral intraneural route, and it has been suggested that a similar process may occur in humans. However, thus far, its spreading through the central nervous system (CNS) has not been completely elucidated. The authors present a case of multiple L. monocytogenes cerebral abscesses characterized by a pattern of distribution that suggested spread along white matter fiber tracts and reviewed the literature to identify other cases for analysis. They elected to include only those cases with 3 or more cerebral abscesses to make sure that the distribution was not random, but rather followed a pattern. In addition, they included those cases with abscesses in both the brainstem and the cerebral hemispheres, but excluded cases in which abscesses were located solely in the brainstem. Of 77 cases of L. monocytogenes CNS abscesses found in the literature, 17 involved multiple abscesses. Of those, 6 were excluded for lack of imaging and 3 because they involved only the brainstem. Of the 8 remaining cases from the literature, one was a case of bilateral abscesses that did not follow a fiber tract; another was also bilateral, but with lesions appearing to follow fiber tracts on one side; and in the remaining 6, to which the authors added their own case for a total of 7, all the abscesses were located exclusively in the same hemisphere and distributed along white matter fiber tracts. The findings suggest that after entering the CNS, L. monocytogenes travels within the axons, resulting in a characteristic pattern of distribution of multiple abscesses along the white matter fiber tracts in the brain. This report is the first description suggesting intraaxonal CNS spread of L. monocytogenes infection in humans following its entry into the brain. This distinct pattern is clearly seen on imaging and its recognition may be valuable in the diagnosis of listeriosis. This finding may allow for earlier diagnosis, which may improve outcome.

Introduction Inferolateral pontine infarcts are well-described lesions of the anterior inferior cerebellar artery territory with a wide variety of clinical presentations. We report the case of isolated unilateral hearing loss and contralateral sensation of coldness due to a dorsolateral lower pontine infarct. Case description We describe the case of a 48-year-old female patient who developed isolated selective high-frequency hearing loss on the left side, and contralateral hemibody sensation of coldness. MRI showed a left-sided dorsolateral lower pontine ischemic lesion. A subsequent angiogram revealed the lesion to result from the spontaneous dissection of a long circumferential branch of the basilar artery. Conclusion To our knowledge, this is the first reported case of a vascular alternating syndrome consisting of isolated ipsilateral hearing loss and contralateral thermal dysesthesia from a dorsolateral lower pontine infarct. Occlusion of a long perforating branch of the basilar artery and consequent posterolateral lower pontine infarct may result in an alternating syndrome with subtle clinical symptoms. Knowledge of this type of syndrome may direct physicians towards the diagnosis of a dorsolateral lower pontine infarct, despite vague clinical complaints.

Background:Pulmonary edema (PE) can occur in the early or late period following subarachnoid hemorrhage (SAH). The incidence of each type of PE is unknown and the association with ventricular dysfunction, both systolic and diastolic, has not been described.Methods:Retrospective chart review of 178 consecutive patients with SAH surgically treated over a three-year period. Patients with pulmonary edema diagnosed by a radiologist were included. Early onset SAH was defined as occurring within 12 hours. Cardiac function at the time of the PE was analyzed using hemodynamic and echocardiographic criteria of systolic and diastolic dysfunction. Pulmonary edema was observed in 42 patients (28.8%) and was more often delayed (89.4%). Evidence of cardiac involvement during PE varied between 40 to 100%.Results and conclusions:Pulmonary edema occurs in 28.8% of patients after SAH, and is most commonly delayed. Cardiac dysfunction, both systolic and diastolic, is commonly observed during SAH and could contribute to the genesis of PE after SAH.

Like systolic dysfunction (SD), diastolic dysfunction (DD) has recently been proposed as a contributing factor in haemodynamic instability and in the genesis of pulmonary oedema, but its occurrence in subarachnoid haemorrhage (SAH) patients has not been described. Following aneurysmal SAH, three patients arrived at our institution with haemodynamic instability requiring vasoactive drugs and with pulmonary oedema. Transoesophageal echocardiographic study during aneurysm surgery documented mild to severe left ventricular SD and DD. Right ventricular SD and DD were also present. Documented biventricular systolic and diastolic myocardial dysfunctions may contribute to haemodynamic instability and pulmonary oedema following SAH due to intracranial aneurysmal rupture.

Aneurysms rarely occur at the choroidal branch of the posterior inferior cerebellar artery (PICA) and their pathogenesis is not well understood. We report such a case and review the literature. A 69-year-old female was admitted for a sudden onset of severe headache with nausea and vomiting. Soon after arrival, she became less responsive. CT of the head revealed an intraventricular haemorrhage (IVH) predominantly in the fourth and third ventricles without subarachnoid hemorrhage and associated with hydrocephalus. Cerebral angiography demonstrated an aneurysm at the choroidal branch of the PICA. The aneurysm was resected through a bilateral suboccipital craniotomy. The patient made a remarkable recovery. The literature describes five other cases of aneurysms arising from a choroidal branch of the PICA. Hypertension was a common finding in this population. In summary, aneurysms arising from a choroidal branch of the PICA are rare. Hypertensive vessel damage might be a major factor in their pathogenesis. We propose that the rupture of a hypertensive aneurysm might account for some isolated spontaneous IVH.

Object. Most reports of series on ruptured intracranial aneurysms contain information on select intraoperative complications. An understanding of all surgical complications, however, may guide us toward improved surgical procedures and enrich discussions concerning alternative management strategies, such as endovascular treatment, which are not exempt from complications and aneurysm recurrence. Methods. The study consists of a retrospective review of the charts, images, and notes from follow-up visits of 143 consecutive patients with subarachnoid hemorrhage (SAH) who were surgically treated during a 3-year period by one neurosurgeon. A surgical complication was determined based on findings of a clinical and/or radiological study in the absence of confounding factors such as the initial SAH ictus, vasospasm, hydrocephalus, and septic status. Functional outcome was assessed between 2 and 3 months post-SAH by using the Glasgow Outcome Scale (GOS). A procedure-related surgical complication was diagnosed in 29 (20.3%) of 143 patients studied. A brain tissue injury, including cerebral edema and hemorrhagic contusions, was diagnosed in 6.3% of patients, an unpredicted residual aneurysm neck in 5.3% of patients, and a cranial nerve deficit in 2.8% of patients. Functional outcome was good in 22 (75.9%) of the 29 patients with surgical complications. Death due to a surgical complication occurred in one (0.7%) of 143 patients. Conclusions. Surgical complications are more prevalent than previously thought. They may have been overlooked previously because of the high percentage of good functional outcomes and low mortality rates in this group. The identification of surgical complications may encourage the search for solutions to improve surgical treatment of aneurysmal SAH.

Background: The increased synthesis of matrix metalloproteinases (MMPs) by aortic smooth muscle cells (SMCs) is thought to be involved in the etiopathogenesis of abdominal aortic aneurysms (AAAs), but the functional regulation and the activation states of these MMPs remain unclear. In this study, we assessed the expression levels and the functional regulation of several MMPs in the pathogenesis of AAAs. Methods: Human healthy aorta and AAA specimens were homogenized, and the proteolytic activities of MMP-2 and MMP-9 and of the macrophage metalloelastase (MMP-12) were assessed with zymography. Protein expression of MMP-1, MMP-12, membrane-type 1 MMP (MT1-MMP), tissue inhibitor of MMP 1 (TIMP-1), TIMP-2, TIMP-3, α-actin, and β-actin was analyzed with electrophoresis on sodium dodecyl sulfate gels and immunoblotting. Results: MMP-1, MMP-9, and MMP-12 zymogen levels and proteolytic activities were increased in AAAs when compared with healthy aorta. A severe reduction in α-actin–positive vascular SMCs was observed in all the AAA specimens and was correlated with an increase in TIMP-3 but not TIMP-1 or TIMP-2 potential activities. Although pro–MMP-2 activity was decreased, the extent of activated MMP-2 remained unaffected in the AAAs. In accordance with this result, a highly activated MT1-MMP form was also observed in AAAs. Conclusion: These data suggest that chronic aortic wall inflammation is mediated by macrophage infiltration, which may account for the destruction of medial elastin, as reflected by SMC down regulation, through increased levels of active MMP-1 and MMP-12. Moreover, altered MT1-MMP proteolytic turnover and differential regulation of TIMP expression in AAAs suggest that tight regulatory mechanisms are involved in the molecular regulation of MMP activation processes in the pathogenesis of AAAs. (J Vasc Surg 2002;35:539-46.)

BACKGROUND Although endoscopic third ventriculostomy (ETV) is the first-line treatment for obstructive hydrocephalus due to various pathologies, its role in hemorrhage-related obstructive hydrocephalus is poorly defined. We report our experience with ETV for hemorrhage-related obstructive hydrocephalus, demonstrate it feasibility, and discuss potential advantages over more conventional treatment modalities. METHODS We performed a retrospective analysis of 78 consecutive patients who underwent ETV in our institution between January 2003 and January 2011. We identified 17 consecutive patients who underwent ETV for obstructive hydrocephalus related to intraventricular hemorrhage (IVH). RESULTS ETV was performed in 9 men and 8 women (mean age: 58 years; range: 42-79). All patients had IVH (n = 17), either alone (n = 3) or with intracranial hemorrhage (n = 4) or subarachnoid hemorrhage (SAH) (n = 10). Endoscopic clot evacuation was performed in seven cases (41%). External ventricular drain (EVD) was avoided in two patients. 15 patients had external EVD, and EVD wean was performed on average 5 days post-ETV. Two patients died in the early postoperative period (< 1 month) from the initial cerebral insult. For the 15 surviving patients, the average modified Rankin Scale (mRS) at last follow-up (15 months; range: 1-48) was 2.4. Thus most surviving patients were independent (mRS

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.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.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).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.

Twenty percent mannitol is widely used to reduce brain bulk and facilitate the surgical approach in intracranial surgery. However, a dose-response relationship has not yet been established. In this study, we compared the effects of 0.7 and 1.4 g·kg(-1) mannitol on brain relaxation during elective supratentorial brain tumor surgery.In this prospective, randomized, double-blind study, we enrolled 80 patients undergoing supratentorial craniotomy for tumor resection. Patients were assigned to receive 0.7 g·kg(-1) (group L) or 1.4 g·kg(-1) (group H) of 20% mannitol at surgical incision. Brain relaxation was assessed immediately after opening of the dura on a scale ranging from 1 to 4 (1 = perfectly relaxed, 2 = satisfactorily relaxed, 3 = firm brain, 4 = bulging brain).There was no significant difference between the 2 groups regarding age, sex, body mass index, and brain tumor localization or size. In group L 52.5% of patients and in group H 77.5% of patients presented a midline shift (P = 0.03). The median scores of brain relaxation (interquantile range) were 2.0 (1.75-3) and 2.0 (1-3) (P = 0.16 for patients in group L and H, respectively). We then used a proportional odds model to adjust for this unbalanced distribution and to assess the group effect (low-dose versus high-dose mannitol) on brain relaxation scores. When adjusted for the presence of midline shift, the use of a higher dose of mannitol resulted in an odds ratio of 2.5 (P = 0.03). This indicates that, considering the effect of a midline shift, the odds of having a 1-level improvement in relaxation score in patients who received a higher dose of mannitol (group H) was 2.5 times as large as the odds for the low-dose group. The odds ratio of 0.29 (P = 0.007) for the midline shift indicates that its occurrence was associated with a higher probability of a lower relaxation score, on average.In this study, we show that 1.4 g·kg(-1) of 20% mannitol results in equivalent brain relaxation scores as 0.7 g·kg(-1) in patients undergoing craniotomy for supratentorial brain tumor. When corrected for the presence of midline shift, this study reveals that patients in the high-dose group had significantly more chances of obtaining a better relaxation score compared with the lower-dose group.

Endoscopic third ventriculostomy (ETV) is an effective treatment of obstructive hydrocephalus (OH). However, the presence of a large or giant basilar aneurysm is generally considered a contra-indication to ETV for treating hydrocephalus. We report the feasibility and efficacy of ETV for the treatment of hydrocephalus in the presence of such aneurysms.We performed a retrospective chart analysis of patients that underwent ETV for large or giant basilar aneurysm-associated hydrocephalus between January 2003 and January 2011.During this period, 78 patients were treated by ETV. Of these, three patients presented with symptomatic hydrocephalus associated with a large giant basilar aneurysm (n = 3). Two of those patients had a history of previous subarachnoid hemorrhage (SAH) with intraventricular hemorrhage (IVH) 11 years and 13 years before ETV. Both aneurysms were embolized preoperatively. The third patient presented with OH due to an unruptured basilar artery aneurysm. There was no operative complication and symptoms resolution was observed in all patients at last follow-up.ETV is a safe and effective alternative to ventriculo-peritoneal shunting in patients with hydrocephalus caused by large or giant basilar artery aneurysms. In addition, a history of SAH/IVH should not be considered a contra-indication to ETV.

The expanded endonasal approach of the cranio-cervical junction provides comfortable working space while avoiding some of the disadvantages of the transoral route. We report a purely endonasal endoscopic resection of the odontoid process for basilar invagination in a patient with a Chiari type I malformation, without posterior decompression or fusion. A 54-year-old female patient presented with cranial nerve and brainstem deficits. CT and MRI showed a Chiari type I malformation and compression of the medulla by basilar invagination of the odontoid process. The tip of the latter was displaced up to the bulbo-pontine sulcus. The odontoid process was resected via the expanded endoscopic endonasal approach, without additional posterior decompression or fusion. The post-operative course was uneventful, including the absence of velopharyngeal insufficiency. Neurological deficits regressed rapidly. The preoperative cervical pain virtually disappeared. At 9 months follow-up, the patient had normal activity with minimal residual neurological deficits. Post-op dynamic radiography and CT showed stability of the cranio-cervical junction. Decompression of the bulbomedullary junction by purely endoscopic transnasal resection of the odontoid process is well tolerated and efficient. Immediate stabilization is not mandatory in all cases of congenital causes of basilar invagination.

Although arteriovenous malformations (AVM)-related intracranial hemorrhage (ICH) is infrequently devastating, there is a subgroup of patients that present comatose requiring immediate surgical treatment. We sought to determine the outcome and prognostic factors in those patients with severe AVM-ICH. Between 2003 and 2009, medical records of 16 consecutive patients presented with severe AVM-ICH were retrospectively reviewed. Outcome was determined using 30-day survival and Glasgow outcome scale and modified Rankin scale scores at last follow-up. There were seven males and nine females with a mean age of 32 years (range 6–66). All had Glasgow coma score 8 or less and most exhibited motor posturing and/or dilated pupils. Fifteen patients had intraprenchymal, ten had intraventricular, and four had subarachnoid hemorrhage (SAH). Twelve patients underwent hematoma evacuation with concomitant decompressive craniectomy in 11 and external ventricular drainage (EVD) in six. EVD was the only treatment offered to four patients. AVM excision was not routinely attempted in the acute phase. Three patients died from extensive bihemispheric infarction and refractory intracranial pressure. All 13 survivors improved neurologically and 12 had an acceptable functional outcome (modified Rankin scale ≤ 4) after a mean follow-up of 10 months (range 1–49). Among all clinical, radiological, and operative variables, only cisternal SAH (P = 0.007) and early seizures (P = 0.018) were significantly associated with death. Despite their poor initial clinical condition, most survivors of severe AVM-ICH achieve an acceptable functional outcome. Therefore, patients with severe AVM-ICH, particularly those without aneurysmal-like SAH, should be managed aggressively given their remarkable potential for neurological recovery.

Background It was recently suggested that communicating hydrocephalus is an almost universal finding after hemicraniectomy and that early cranioplasty may prevent the need for permanent cerebrospinal fluid diversion in these patients. Objective To conduct a study in an attempt to verify these findings. Methods The medical records of all patients who underwent decompressive craniectomy for medically refractory elevated intracranial pressure between 2001 and 2009 were retrospectively reviewed. Patients with subarachnoid hemorrhage, intraventricular hemorrhage, or head trauma were excluded. Hydrocephalus was classified as internal or external and as clinically significant or asymptomatic. Results The patient population consisted of 17 patients, 8 men and 9 women, with a median age of 44 years (range, 27-53 years). Etiologies included malignant middle cerebral artery territory infarction in 12 patients, hemorrhagic transformation of ischemic cerebrovascular accident in 2 patients, dural sinus thrombosis in 2 patients, and hemorrhagic cerebrovascular accident in 1 patient. The extent of craniectomy ranged from a large bone flap in 4 patients to a standard hemicraniectomy in 13 patients. Two patients died and 1 was lost to follow-up during the acute stage. The remaining 14 patients underwent cranioplasty after a median interval of 21 days (range, 3-42 days). In none of these patients did clinically significant hydrocephalus develop requiring cerebrospinal fluid diversion. Asymptomatic extra-axial cerebrospinal fluid collections developed in 2 patients that resolved spontaneously after cranioplasty. Conclusion Our results suggest that, contrary to some beliefs, hydrocephalus does not frequently occur after decompressive craniectomy.

Distal choroidal artery aneurysms stemming from the lateral wall of the ventricles are rare and are mostly associated with moyamoya disease. The treatment of these aneurysms is difficult because of their deep location. The authors report the case of a 50-year-old woman followed for moyamoya disease presenting with 2 intraventricular hemorrhages. Cerebral angiography showed an aneurysm located on the left distal choroidal artery. Magnetic resonance imaging also demonstrated that the lesion protruded from the lateral wall of the trigone of the left lateral ventricle. Using MR imaging-guided stereotactic localization, the aneurysm was accurately reached endoscopically and successfully resected from the parent artery. The patient was discharged neurologically intact. To the best of the authors' knowledge, this is the first report of a successfully endoscopically treated distal anterior choroidal artery aneurysm. Endoscopic surgery may be added to the armamentarium of procedures used to treat intraventricular aneurysms.

Objective:To present a new semiological description of unruptured middle cerebral artery (MCA) aneurysms.Methods:We present a series of three MCA aneurysms presenting with progressive or paroxystic somatosensory symptoms in combination with visceral, motor, language or autonomic symptoms.Results:A surgical approach was proposed for two aneurysms, and both patients experienced complete resolution of their symptoms. The third aneurysm was successfully excluded by endovascular coiling but the symptoms persisted.Conclusions:To our knowledge this is the first description of unruptured aneurysms presenting with insular-related symptoms.

The natural history of external hydrocephalus (EH) in adults is often marked by conversion into internal hydrocephalus. We describe a complication of this conversion, the ICE (intracerebral CSF entrapment) phenomenon, and demonstrate that both EH and ICE represent a challenge to current theories on the pathophysiology of communicating hydrocephalus (CHC). We propose a new model for CHC where the pattern of CSF distribution is largely determined by the intrinsic compliance of each of the intracranial structures. In this model, failure of distal CSF absorption resulting in an excessive intracranial CSF volume is the common denominator and CSF diversion the common solution to all forms of CHC.

Complex spinal automatism in a patient who was declared brain dead is described. These movements tend to appear once cerebrospinal shock has abated. We postulate that these manifestations are a reflection of the physiological potential of the isolated spinal cord. These spinal movements should be included in the revised guidelines for the determination of cerebral death.

The timing of aneurysmal surgery for patients presenting within the period at risk for vasospasm (VS) is controversial. The goal of this study is to review our experience of surgically treated patients in the presence of angiographic VS.From 1990-2004, 894 consecutive patients presented with an aneurysmal subarachnoid hemorrhage (SAH) and were treated with a policy of early surgery. We retrospectively analyzed the patients that had pre-operative angiographic VS. In this study, symptomatic VS was diagnosed when a decreased level of consciousness and/or focal deficit occurred after SAH in the presence of angiographic VS without confounding factors. Functional outcome was assessed three months after SAH using the Glasgow Outcome Scale.Of the 40 patients studied, 62.5% were in good clinical grade HuntHess (HH 1-2) on admission; 25%, intermediate grade (HH 3); 12.5%, poor grade (HH 4-5). Surgery was performed 24 hours or less after initial angiography in 87.5% of patients and less than 48 hours in 97.5%. Pre-operative symptomatic VS was diagnosed in 25%. Post-operatively, angiographic VS was documented in 87.2%. Of the 30% of patients that presented post-operative symptomatic VS, 66.7% also demonstrated pre-operative symptomatic VS. The functional outcome was favorable in 92.5% of the studied patients. Two deaths occurred in patients presenting pre-operative early radiological and symptomatic VS.Aneurysmal surgery, especially between 3-12 days following SAH, in the presence of asymptomatic pre-operative angiographic VS can be associated with a good outcome. Early surgery is not contra-indicated and might enable optimal treatment of VS.

Up to 80% of patients report moderate to severe pain after craniotomy. In this study, we assessed the efficacy of scalp block for decreasing postoperative pain in brain surgery. Thirty patients scheduled for supratentorial craniotomy were enrolled. They were randomly divided into two groups: Ropivacaine (scalp block with 20 mL of ropivacaine 0.75%) and Saline (scalp block with 20 mL of saline 0.9%). Anesthesia was standardized. The scalp block was performed after skin closure and before awakening. Postoperative pain was assessed at 4, 8, 12, 16, 20, 24, and 48 h by using a 10-cm visual analog scale. Analgesia was provided with sub- cutaneous codeine as requested by the patient. Average visual analog scale scores were higher in the Saline group as compared with Ropivacaine (3.7 +/- 2.4 vs 2.0 +/- 1.6; P = 0.036). The total dose of codeine did not differ, nor did the duration of time before the first dose of codeine was required in the Ropivacaine (571 +/- 765 min) versus Saline (319 +/- 409 min; P = 0.17) group. In conclusion, we found that postoperative scalp block decreases the severity of pain after craniotomy and that this effect is long lasting, possibly through a preemptive mechanism.Up to 80% of patients report moderate to severe pain after craniotomy. This randomized double-blinded study demonstrated that ropivacaine scalp block decreases the severity of pain after supratentorial craniotomy.

Objective and importance Paradoxical transtentorial herniation is a rare but well-documented complication of cerebrospinal fluid (CSF) drainage in patients with large decompressive craniectomies. However, brain sagging in the absence of CSF hypovolemia has not been previously reported. Clinical presentation A 30-year-old woman suffered massive intracerebral hemorrhage from a small residual left frontal arteriovenous malformation 1 year following endovascular embolization and stereotactic radiosurgery. The patient initially presented in coma with left mydriasis and decorticate posturing and underwent emergent decompressive craniectomy, evacuation of the hematoma, and insertion of an intracranial pressure (ICP) monitor. Postoperatively, despite a depressed skin flap and low ICP readings, she continued to deteriorate neurologically, and CT revealed increasing midline shift, transtentorial herniation, and brainstem compression. INTERVENTION OR TECHNIQUE: Although there was no history of CSF drainage, the diagnosis of brain sag was suspected, because herniation seemed to occur in the setting of intracranial hypotension. The patient was placed in a 15 degrees Trendelenburg position and improved dramatically within hours. A few days later, she was fully awake and had purposeful movements with her left side, although she had persistent aphasia and right hemiplegia. Conclusion Although rare, paradoxical herniation in the setting of a large craniectomy defect may occur in the absence of CSF drainage. This entity should be suspected whenever transtentorial herniation occurs in conjunction with direct or indirect signs of intracranial hypotension. Placing the patient in the Trendelenburg position should be attempted, because this simple maneuver may turn out to be life-saving.

✓ The surgical treatment of basilar bifurcation aneurysms is difficult and the need for an alternative approach is frequently stated. To assess the efficacy and safety of endovascular treatment of aneurysms located at the basilar bifurcation, the authors prospectively studied angiographic results, clinical results, and complications in 31 patients treated with Guglielmi detachable coils (GDCs). Patients treated acutely after subarachnoid hemorrhage (SAH) were graded according to the Hunt and Hess classification and clinical outcome was determined at 1- and 6-month intervals according to the Glasgow Outcome Scale (GOS). There were 18 women and 13 men, ranging in age from 34 to 67 years (mean age 48 years). Twenty-three were treated acutely after SAH. Clinical Hunt and Hess grades at presentation were as follows: Grade I, six patients; Grade II, three; Grade III, 11; Grade IV, two; and Grade V, one. The GOS score for the group of patients treated acutely was: GOS I, 18 patients; GOS II, III, and IV, one patient each; and GOS V, two patients. There were seven technical complications in this group, most often asymptomatic, but one patient died after aneurysm rupture during treatment and one had residual diplopia at 4 months. Eight patients were treated for incidental basilar bifurcation aneurysms. One technical complication with no neurological deficit occurred in this group of patients with incidental aneurysms. Immediate angiographic results were considered to be satisfactory in 94% of patients, with complete obliteration in 42% and residual neck and dog ears in 52%. There was no bleeding episode after treatment during clinical follow-up periods ranging from 3 to 42 months (mean 15.5 months in 29 surviving patients). Angiographic results were available for 27 patients at 6 months and were as follows: 30% of the lesions were completely obliterated, 59% presented some residual neck, and 11% showed some opacification of the aneurysm sac. During the follow-up period of up to 42 months, a total of seven recurrences were noted, necessitating retreatment with GDCs in five patients. Endovascular treatment of basilar bifurcation aneurysms prevented rebleeding and could be performed without clinically significant complications in 94% of patients. Clinical results after SAH compared favorably with surgical series. Morphological results appear less satisfactory, and long-term angiographic follow-up review is mandatory to detect recurrences.