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Indocyanine green video angiography (ICG-VA) is a non-invasive, easy to use and very useful tool for various neurosurgical procedures. The first application was in neurovascular surgery, because it was born as an intravascular tracer for vessels visualization; this has been really useful in aneurysms, atero-venous malformations (AVMs) and dural fistulas surgery where identification, obliteration or patency of vessels is essential. introduced in vascular neurosurgery since 2003, icg-Va applications have broadened over time, both in vascular and in other neurosurgical fields. In 2003 Raabe et al. have been the first to describe the use of ICG-VA for intraoperative assessment of cerebral vascular flow, enabling visualization of vessel patency and aneurysm occlusion during aneurysm surgery. ICG-VA applications in vascular neurosurgery have significantly increased over time including complex aneurysms, bypass, atero-venous malformations (AVM) artero-venous fistulas (AVF), evaluation of cortical perfusion. The procedure can be easily repeated after 5-10 minutes. adverse reactions are comparable to those of other types of contrast media, with frequencies of 0.05% (hypotension, arrhythmia, or, more rarely, anaphylactic shock) to 0.2% (nausea, pruritus, syncope, or skin eruptions. The aim of the present study was to systematically analyze ICG-VA applications in vascular neurosurgery, highlighting the reported advantages and disadvantages, and discussing future perspectives.

Objectives: 3D anatomical models are becoming a new frontier in surgery for planning and simulation on an individualized patient specific basis. Since 1999, 3D cerebral aneurysms models for neurosurgery have been proposed. The possibility of reproducing in a realistic 3D fashion the malformation with the surrounding vascular structures, provides important preoperative information for the treatment strategy. The same models can be used for training and teaching. Unfortunately stereolitography is often burdened by high costs and long times of production. These factors limit the possibility to use 3D models to plan surgeries in an easy daily fashion. Patients and methods: Our study enrolled 5 patients harboring cerebral aneurysms. DICOM data of each aneurysm were elaborated by an open source freeware to obtain CAD molds. Afterwards, the 3D models were produced using a fused deposition or a stereolitography printer. Results: Models were evaluated by Neurosurgeons in terms of quality and usefulness for surgical planning. Costs and times of production were recorded. Conclusions: Models were reliable, economically affordable and quick to produce.

Background In spite of the advent of neurointerventional treatment, different clinical and anatomical features are still strong indications for clipping of posterior communicating artery (PComA) aneurysms. But the experience of young neurosurgeons is increasingly limited, and therefore providing technical operative guidelines is a fundamental prerequisite to achieve the best aneurysm exclusion and avoid perioperative complications. Study Objective We describe a technical algorithm we use to teach young neurosurgeons how to approach carotid aneurysms that may help them develop a procedural memory and thus perform an efficient and safe surgery. Material and Methods We reviewed our last 10 years of institutional experience of > 150 cases of clipping ruptured and unruptured PComA aneurysms, analyzing our technical refinements and the difficulties in teaching residents and young neurosurgeons how to establish fundamental key points and design a didactic algorithm that includes operative instructions and safety rules. Results We recognized seven pragmatic technical key points regarding craniotomy, cisternostomy, proximal and distal control, aneurysm neck dissection, preservation of neurovascular structures, and clipping to use in a didactic algorithm for teaching residents and as operative instructions for inexperienced neurosurgeons. Conclusion In the setting of clipping PComA aneurysms, respect for surgical rules is of paramount importance to perform an efficacious and safe procedure and ensure the best aneurysm exclusion and preservation of neurovascular structures.

Background The far-lateral is a standardised approach to clip aneurysms of the posterior inferior cerebellar artery (PICA). Different variants can be adopted to manage aneurysms that differ in morphology, topography, ruptured status, cerebellar swelling and surgeon preference.Method We distinguished five paradigmatic approaches aimed to manage aneurysms that are: proximal unruptured; proximal ruptured requiring posterior fossa decompression (PFD); proximal ruptured not requiring PFD; distal unruptured; distal ruptured.Conclusions Preoperative planning in the setting of PICA aneurysm surgery is of paramount importance to perform an effective and safe procedure, to ensure an adequate PFD and optimal proximal control before aneurysm manipulation.

Background: Recently, the lateral supraorbital (LSO) keyhole variant of the standard pterional (PT) approach has been popularized for anterior skull base surgery, because it provides good anatomic exposition, reduced complications, and better aesthetic and functional results. However, these aspects have been formally compared only by a limited number of studies. We reviewed our experience with 50 consecutive anterior communicating artery (AComA) and A1/A2 aneurysms. Of these 50 patients, 25 had undergone the standard PT approach and 25, the LSO variant. We report the results in terms of exclusion of the aneurysm, postoperative complications, functional/masticatory outcomes, and aesthetic and patient satisfaction. Methods: From January 2014 to December 2015, 25 patients with unruptured AComA and A1/A2 aneurysms underwent the standard PT craniotomy. From January 2016 to March 2017, another 25 patients underwent the LSO technique. Results: No statistically significant differences were observed in the aneurysmal exclusion rate at angiographic follow-up or major complications. A statistically significant difference in the clinical outcome (Glasgow Outcome Scale) was evident only for the immediate postoperative time and was not significant during the follow-up period. The hospital stay was shorter in the LSO group. Minor complications, patient satisfaction, aesthetics, and functional and masticatory outcomes were significantly better statistically in the LSO group. Conclusions: The LSO approach demonstrated a lower rate of early clinical minor complications, with a reduction in hospitalization. The LSO approach provides better results for patient satisfaction, masticatory comfort, and cosmetic results. In our experience, the LSO approach is a safe and effective substitute to the standard PT craniotomy to treat unruptured AComA and A1/A2 aneurysms.

The authors evaluated the usefulness of three-dimensional rotational angiography (3DRA) in surgical planning and postoperative evaluation of cerebral aneurysms.

Although several descriptions of the angioarchitectural features of brain arteriovenous malformations (AVMs) associated with higher hemorrhagic risk have been reported, the prognostic value of the different bleeding patterns still needs to be elucidated. This study evaluated the influence on clinical appearance and outcome of the parenchymal and non-parenchymal (subarachnoid hemorrhage-SAH-and intraventricular hemorrhage-IVH) bleedings associated with ruptured AVMs. Clinical records and neuroradiological examinations of 30 patients with hemorrhagic AVMs were reviewed in order to identify their angioarchitectural features and the associated bleeding pattern. These data along with demographic characteristics and treatment modality were dichotomized and their relationship with clinical status at admission and follow-up was tested. IVH as well as parenchymal hematomas larger than 20 cm(3) appeared associated with a severe clinical status at admission, whereas SAH involving basal cisterns was significantly associated with unfavorable outcome. Age, sex and angioarchitectural features did not show significant association with the severity of the prognosis. However, none of these bleeding patterns appeared as an independent risk factor of poor outcome at multivariate analysis. In conclusion, our data emphasized the possibility that non-parenchymal bleeding may worsen the outcome of patients with hemorrhagic AVMs.

Brain arteriovenous malformations are characterized by a tangle of abnormal vessels directly shunting blood from the arterial to venous circulation. They are known to occur either sporadically or in the context of well-defined genetic disorders. Haemorrhage represents the most severe clinical manifestation, whereas other common symptoms include headache, seizures and neurological deficits. Although sporadic forms do not recognize a specific genetic cause, in recent years, it has been hypothesized that genes involved in angiogenesis and inflammation or coding for proteins, such as fibronectins, laminins and integrins, may play a role in the pathophysiology of brain arteriovenous malformations. More recently, a new trend of genetic studies has investigated the association between sporadic arteriovenous malformations and single nucleotide polymorphisms, single base variations between genomes within members of a biological species or between paired chromosomes in an individual, which may determine the susceptibility to develop complex diseases and influence their natural history. Several polymorphisms in two different families of genes have been associated with disease susceptibly and increased haemorrhagic risk. These genes are mainly involved in the inflammatory cascade and in the regulation of angiogenesis. However, most of the investigated polymorphisms have been selected on the basis of candidate genes because of their potential functional role in the pathogenesis of brain arteriovenous malformations or in other cerebrovascular diseases. Only one hypothesis-free genome-wide association study in a small number of patients has been performed so far, but it was unable to identify significant associations between brain arteriovenous malformations and specific genetic loci. In this article, we review and analyse the polymorphisms investigated to date in association with sporadic brain arteriovenous malformations in the medical literature. We discuss the biological, path

We tried to identify molecular markers in peripheral blood to predict high risk of aneurysm rupture. Extraction of the total population of peripheral blood mononuclear cell (PBMC) from total blood volume, total RNA extraction from PBMC and Agilent One Color Gene-expression Oligo-Microarray were performed on peripheral venous blood samples from 45 patients with ruptured, unruptured cerebral aneurysms and control group (15). Mean foreground/ background signal intensities and A (log2(R*G)/2) values were calculated for each spot. Genes with absolute fold change (FC) greater than or equal to plus or minus 1.5 and p-value less than 0.05 were considered differentially expressed in the 3 groups (Student T-test). Genes coding for MMPs were strongly underexpressed in ruptured aneurysms group, suggesting a possible role in aneurysms development more than their rupture. Genes coding for adhesine proteins of the extracellular matrix (ICAM1) and cytoskeleton (WIPF1,TUBA4A) were underexpressed in ruptured aneurysms. Genes coding proteins involved in the regulation of apoptotic processes may be important in aneurysm development and rupture, resulting into an increased rate of remodeling processes in the arterial wall. Fas coding gene, SUMO1, ZFAT, BCL2, CCR5 genes were all over-represented in unruptured aneurysms. The coexisting over-representation of pro-apoptotic genes and the underexpression of cytoskeleton and extracellular matrix genes confirms that aneurysms development and evolution are part of a degenerative process of the arterial wall not involved in aneurysms rupture. MMPs may be involved in repairing chronic damages to the arterial walls and preventing SAH. Unexpectedly, Heat Shock Proteins (HSP90AA1, HSPA1A, HSPB1), G and RAS proteins, generally activated by stress situations were under-represented in aneurysmal walls. Further PCR and Western Blotting studies are needed to confirm such findings and to identify diagnostic and prognostic markers in order to define screen

Single nucleotide polymorphisms (SNPs) on chromosome 9p21 have been recently associated with intracranial aneurysms and stroke. In this study, we tested the association between the rs1333040C>T polymorphism on the 9p21 locus and sporadic brain arteriovenous malformations (BAVMs).

Epileptic seizures account for 24-40% of all clinical onsets in patients with brain arteriovenous malformations (AVMs).

Brain arteriovenous malformations are characterized by a tangle of abnormal vessels directly shunting blood from the arterial to venous circulation. They are known to occur either sporadically or in the context of well-defined genetic disorders. Haemorrhage represents the most severe clinical manifestation, whereas other common symptoms include headache, seizures and neurological deficits. Although sporadic forms do not recognize a specific genetic cause, in recent years, it has been hypothesized that genes involved in angiogenesis and inflammation or coding for proteins, such as fibronectins, laminins and integrins, may play a role in the pathophysiology of brain arteriovenous malformations. More recently, a new trend of genetic studies has investigated the association between sporadic arteriovenous malformations and single nucleotide polymorphisms, single base variations between genomes within members of a biological species or between paired chromosomes in an individual, which may determine the susceptibility to develop complex diseases and influence their natural history. Several polymorphisms in two different families of genes have been associated with disease susceptibly and increased haemorrhagic risk. These genes are mainly involved in the inflammatory cascade and in the regulation of angiogenesis. However, most of the investigated polymorphisms have been selected on the basis of candidate genes because of their potential functional role in the pathogenesis of brain arteriovenous malformations or in other cerebrovascular diseases. Only one hypothesis-free genome-wide association study in a small number of patients has been performed so far, but it was unable to identify significant associations between brain arteriovenous malformations and specific genetic loci. In this article, we review and analyse the polymorphisms investigated to date in association with sporadic brain arteriovenous malformations in the medical literature. We discuss the biological, path

We explored the feasibility of concurrent palliative chemotherapy and low-dose fractionated radiotherapy (LD-FRT) in glioblastoma multiforme (GBM). Patients with recurrent/progressive GBM at least 3 months after the end of primary radiotherapy received 0.3 Gy twice daily with cisplatin and fotemustine if progressing on temozolomide, or 0.4 Gy twice daily with temozolomide if recurrent 4-6 months later (retreatment group). Newly diagnosed GBM with gross residual mass received 30 Gy with concomitant and adjuvant temozolomide and 0.4 Gy twice daily from the second adjuvant cycle (naive group) for 2-4 cycles. Twenty-six patients were enrolled. In the retreatment group (n = 17; median LD-FRT total dose 7.2 Gy [range 2.4-11.6]), grade 3 or 4 hematological toxicity was observed in 5.9% of patients. Median follow-up time was 20 months (range 4-35). Median progression-free survival (PFS) and overall survival (OS) from the time of recurrence or progression were 4 and 8 months, respectively (OS at 6 months, 69%; at 12 months, 16.7%). In the naive group (n = 9; median LD-FRT total dose 8 Gy [range 3.2-16]), grade 3 or 4 hematological toxicity was observed in 11.1% of patients. Median follow-up time was 17 months (range 8-20)-median PFS was 9 months, with PFS at 6 months and at 1 year of 66.7% and 26.7%, respectively; and median OS was 12 months, with OS at 6 months and at 1 year of 77.8% and 34.6%, respectively. LD-FRT with concurrent chemotherapy was well tolerated.

A comment on impaired peri-nidal cerebrovascular reserve in seizure patients with brain arteriovenous malformations

The laser welding of biological tissues is a particular use of lasers in surgery. The technique has been proposed since the 1970s for surgical applications, such as repairing blood vessels, nerves, tendons, bronchial fistulae, skin and ocular tissues. In vascular surgery, two procedures have been tested and optimized in animal models, both ex vivo and in vivo, in order to design different approaches for blood vessels anastomoses and for the repair of vascular lesions: the laser-assisted vascular anastomosis (LAVA) and the laser-assisted vessel repair (LAVR). Sealing tissues by laser may overcome the problems related to the use of conventional closuring methods that are generally associated with various degrees of vascular wall damage that can ultimately predispose to vessel thrombosis and occlusion. In fact, the use of a laser welding technique provides several advantages such as simplification of the surgical procedure, reduction of the operative time, suppression of bleeding, and may guarantee an optimal healing process of vascular structures, very similar to restitutio ad integrum. Despite the numerous preclinical studies performed by several research groups, the clinical applications of laser-assisted anastomosis or vessel repair are still far off. Substantial breakthrough in the laser welding of biological tissues may come from the advent of nanotechnologies. Herein we describe the present status and the future perspectives in laser welding of vascular structures.

OBJECTIVE: To verify whether the treatment of brain oligometastases with whole-brain radiotherapy (WBRT) plus stereotactic radiotherapy (SRT) or surgical resection results in different outcomes. METHODS: Files of patients affected by brain metastases submitted to surgical resection followed by WBRT (group A) or WBRT + SRT (group B) were retrospectively selected for this study. The two treatment groups were matched for the following potential prognostic factors: WBRT schedule, age, gender, performance status, tumor type, number of brain metastases, extra-cerebral metastases, and recursive partitioning analysis class (RPA). The outcomes of patients in both groups were evaluated in terms of toxicity, local control, and overall survival. RESULTS: Total of 97 patients were selected (56 male; 42 female) who were respectively submitted to surgical resection followed by WBRT (group A, n = 50 patients) or WBRT + SRT (Group B, n = 47 patients). Median follow-up was 95 months (range, 8-171 months). The 1-year local control rates were 46.0% and 69.0% respectively. No significant difference in local tumor control was observed between group A and B (p = 0.10). Median overall survival was 15 and 19 months in group A and B, respectively. One-year survival was 56.0% and 62%, respectively. No difference was observed in the two groups (p = 0.40). CONCLUSION: Surgery remains the main therapeutic approach in symptomatic patients; nevertheless, our data support the use of WBRT plus SRT in one or two brain metastases smaller than 3 cm.

Dissection of intracranial arteries is a rare cause of cerebrovascular diseases commonly presenting as an ischemic stroke. We report a patient with middle cerebral artery dissection who developed a large middle cerebral artery dissecting aneurysm mimicking a hemorrhagic stroke.

It is a prevalent myth that a postoperative infection may actually confer a survival advantage in patients with malignant glioma. This contention is based largely on anecdotal reports. Recently, a single-center study showed there was no survival advantage in those patients who had glioblastoma with postoperative infection.

Springer-Verlag 2011 Sir, We report a case of 40-year-old sportsman admitted to our department for a generalized seizure associated with bladder and bowel incontinence occurred during exercise. The patient quickly regained consciousness without postcritical deficits. Neurological examination appeared completely normal. A head computer tomography (CT) scan showed a midline arteriovenous malformation (AVM) without the evidence of bleeding (Fig. 1a, b). A digital subtraction angiography revealed a dysplastic nidus fed by branches of bilateral internal–external carotid and vertebrobasilar arteries, and draining both in the superficial and deep venous system, which showed varicose dilatation with Galen’s vein stenosis (Fig. 1c–g). Cerebral varix is defined as an ectasia which doubles vein diameter. It can be due to an arteriovenous shunt and appears more common in patients with direct fistulas, than in cerebral AVM with dysplastic nidi [1]. Differently from those associated with Galen’s vein fistulae, huge intracranial varix associated with cerebral AVMs were seldom reported. Headache, bruit, focal mass effect and hydrocephalus are common presentation symptoms [2]. Intracranial haemorrhage has been instead less often reported at clinical onset [3]. In the most of the cases of giant varix, direct arteriovenous communications in the context of nidus were observed, especially between feeding arteries and the varicose veins [4]. This discrete angiographic finding separate these vascular malformations from the classical and more common AVMs in which an abnormal vascular network is identified between the arterial feeders and draining veins [4]. Venous hypertension with retrograde drainage often results in focal neurological deficits and seizures [1]. Although it is commonly assumed that venous ectasia increases the bleeding risk, varix haemorrhagic presentation has been rarely reported [4]. It is may be due to the progressive thickening of the arterialized veins wall, with int

Few studies have evaluated the over or the underexpression of genes directly in samples of aneurysmal wall and extracranial pericranial vascular tissue to investigate the genetic influence in formation and rupture of intracranial aneurysms. We present the results obtained using the DNA microarray technique analysis on sample tissues collected during surgery. We collected and analyzed 12 aneurismal and 9 peripheral arteries (superficial temporal (STA) and middle meningeal artery (MMA) specimens from ruptured aneurysm group patients (13 cases), 10 aneurismal and 12 STA and MMA samples from unruptured aneurysm group patients (14 cases) and 5 STA and MMA artery specimens from control group patients (4 cases). Total RNA was isolated from samples and subjected to cDNA microarray analysis with the use of the human genome U133A GeneChip oligonucleotide microarray (Affymetrix, Santa Clara, CA), which allows to analyze a total number of 14,500 genes in the same time. For genes of interest, real-time RT-PCR was performed to confirm their expression level. Total RNA was isolated from samples and subjected to DNA microarray analysis with the use of the human genome U133A GeneChip oligonucleotide microarray, which allows to analyze a total number of 14,500 genes at the same time. For genes of interest, real-time RT-PCR was performed to confirm their expression level. Regarding ruptured aneurysms, genes were identified showing differential expressions (overexpressed or downregulated) pertaining to specific pathways, particularly those for the structural proteins of the extracellular matrix, members of matrix metalloproteinase (MMP) family (which resulted as being overexpressed) and genes involved in apoptotic phenomena. Particularly, real-time RT-PCR analysis confirmed the upregulation of MMP-2, MMP-9 and pro-apoptotic genes, such as Fas, Bax and Bid, and the downregulation of anti-apoptotic genes, such as Bcl-X(L) and Bcl-2. In a compared analyses of ruptured vs unruptured aneury

Objective. To report about a case of complicated late postpartum eclampsia where neonatal low birth weight could be considered a predictive factor of placental sufferance. Methods. A 25-year-old woman, without medical or familiar history for hypertension or cerebrovascular diseases, underwent a normal spontaneous delivery with neonatal birth weight of 2340 g (9th percentile). Eight days later the patient presented sudden headache and generalized tonic-clonic seizures. Results. Blood hypertension and alterations in laboratory studies were detected; a diagnosis of late postpartum eclampsia was made. A CT scan showed subarachnoid hemorrhage (Hunt and hess grade I, Fisher grade III). Serial cerebral angiograms did not show any intracranial vascular malformations; epilepsy and hypertension were successfully medically treated; and a repeat CT examination showed the gradual resolution of subarachnoid hemorrhage. Headache progressively disappeared. Conclusions. Low neonatal birth weight could be linked to placental dysfunction and considered as a predictive factor for the onset of postpartum preeclampsia/eclampsia. We recommend a careful clinical and laboratory management of puerperium up to the first month postpartum, in particular in cases of "sine causa" neonatal low birth weight.

International guidelines suggest that a high prevalence of meticillin-resistant Staphylococcus aureus (MRSA) infections should influence the use of vancomycin for surgical prophylaxis. In order to compare the efficacy and adverse effects of vancomycin versus cefazolin as antimicrobial prophylaxis for insertion of cerebrospinal fluid (CSF) shunts, a randomised prospective clinical trial was performed. Over a 16-month period, all consecutive adult patients who underwent CSF shunt insertion at a university hospital with a high prevalence of MRSA infections were included. Patients were randomly allocated to receive either vancomycin or cefazolin before surgery and followed-up for four weeks for the development of infections. Of the 176 patients included in the study, 88 received vancomycin and 88 cefazolin. Shunt infections were significantly less likely to be observed in patients who were on vancomycin prophylaxis (4% vs 14%; P=0.03). All isolated staphylococci were resistant to meticillin. Mortality of patients with post-surgical infections was higher in the cefazolin group (P=0.02). Our data suggest that use of vancomycin as prophylactic agent for cerebrospinal shunt placement reduces the rate of shunt infections in the context of high prevalence of MRSA.

Leuconostoc species are emerging pathogens that can cause severe infections, particularly in immunocompromised patients. Using molecular methods, we identified Leuconostoc mesenteroides as the cause of a brain abscess which was successfully treated by surgery and antimicrobial treatment. This is the first report of brain abscess caused by this species

Leuconostoc species are emerging pathogens that can cause severe infections, particularly in immunocompromised patients. Using molecular methods, we identified Leuconostoc mesenteroides as the cause of a brain abscess which was successfully treated by surgery and antimicrobial treatment. This is the first report of brain abscess caused by this species.

We report on a symptomatic case in which the whole intracranial blood supply was provided by a single vertebral artery as both internal carotid arteries were occluded and the contralateral vertebral artery was severely hypoplasic. The patient was treated by a flow-augmentation extracranial-intracranial bypass. Preoperative perfusion studies were essential in tailoring surgical strategy. Keypoints of the paper are contralateral perfusion changes after unilateral bypass surgery. The patient experienced a total recovery from symptoms and a bilateral improvement in brain perfusion, probably as consequence of post-operative hemodynamic rearrangement.

Objectives Dural arteriovenous fistulas (DAVFs) are a challenging condition in vascular neurosurgery. Disease natural history and its management is still debated. In the present paper we report our center series on DAVFs over a period of 10 years. Our data were compared with relevant literature. Patient and methods Our series includes 45 cases: 14 cavernous sinus, 11 transverse-sigmoid, 8 patients tentorial, 6 anterior cranial fossa, 5 patients spinal, 1 patient foramen magnum. Results and conclusions DVAFs distribution, clinical presentation and hemorrhagic risk are discussed. Cavernous sinus DAVFs are the most common site in our series. Other locations in order of frequency are transverse-sigmoid sinus, tentorial, anterior cranial fossa, spinal and foramen magnum. The majority of patients presented with non-aggressive symptoms. 18% presented with intracranial hemorrhage: all the hemorrhages occurred in high-grade DAVFs. For most patients, endovascular treatment, transarterial or transvenous, was the first option. Surgery was performed for the anterior cranial fossa DAVFs and other complex lesions draining mostly transverse-sigmoid sinus and tentorium. In 7% of cases a combination of endovascular + surgical treatment was used. Our series has been carefully analyzed in comparison 'side by side' with most relevant literature on DVAFs, focusing particularly on management strategies, therapeutic options and risks related to treatment.

We report on a symptomatic case in which the whole intracranial blood supply was provided by a single vertebral artery as both internal carotid arteries were occluded and the contralateral vertebral artery was severely hypoplasic. The patient was treated by a flow-augmentation extracranial-intracranial bypass. Preoperative perfusion studies were essential in tailoring surgical strategy. Keypoints of the paper are contralateral perfusion changes after unilateral bypass surgery. The patient experienced a total recovery from symptoms and a bilateral improvement in brain perfusion, probably as consequence of post-operative hemodynamic rearrangement.