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The transcallosal retroforniceal transchoroidal approach represents an advanced neurosurgical technique that allows access to lesions located within the posterior third ventricle and mesencephalon. It relies on a comprehensive understanding of microsurgical anatomy and embryology, integrating modern neurosurgical operative techniques to minimize retraction and injury to the normal neuronal structures. We report the cases of 2 patients undergoing treatment via this approach, one presenting with a thalamic cavernoma and the other with cystic low-grade glioma of the midbrain. In these 2 cases, the decision to use the transcallosal approach was mainly due to improved trajectory, gravitational retraction of the hemisphere, and improved delivery of the lesion into the operative field by gravity alone. Through a detailed description of the surgical approach and anatomy, we illustrate the feasibility of the transcallosal retroforniceal transchoroidal approach for accessing lesions located deeply in the brain. [ABSTRACT FROM AUTHOR]

Background: The Covid-19 pandemic imposed numerous constraints on medical practice and exacerbated preexisting vulnerabilities in Lebanon’s healthcare system, which was already grappling with instability due to concurrent political and economic crises. This situation had a complex impact on the doctor-patient relationship (DPR), with both negative and positive repercussions. Methods: We conducted semistructured interviews with physicians from various specialties practicing at a tertiary-care center in Lebanon. Our study aimed to 1) explore the impact of the Covid-19 pandemic on the DPR in Lebanon, and 2) provide recommendations for improving the DPR, healthcare policy, and education. Results: Thematic analysis of the data revealed that the pandemic had varying effects on the DPR. While both physicians and patients seemed to have developed a more favourable perception of the medical profession, communication between them appeared to be challenged by the use of personal protective equipment and patients’ concerns about close contact with physicians. The media played a vital role in educating and raising awareness during the pandemic but lacked organization and ethical standards, leading to anticipated fear and confusion among the society. Telemedicine emerged as an alternative means for communication and remote care but faced several obstacles including inadequate internet infrastructure and disruptions to physicians’ personal lives. Conclusion: Our qualitative study unveiled the multifaceted impact of the Covid-19 pandemic on perceiving the healthcare system, doctor-patient interactions, and the role of telemedicine in Lebanon, among others. These findings underscore the importance of effective communication in enhancing the DPR, the need to address misinformation on social media, and the imperative for systemic improvements to strengthen the resilience of Lebanon’s healthcare system. [ABSTRACT FROM AUTHOR]

The widespread use of magnetic resonance imaging (MRI) has led to an increase in incidental findings in the central nervous system. Radiologically isolated syndrome (RIS) is a condition where imaging reveals lesions suggestive of demyelinating disease without any clinical episodes consistent with multiple sclerosis (MS). The prognosis for RIS patients is uncertain, with some remaining asymptomatic while others progress to MS. Several risk factors for disease progression have been identified, including male sex, younger age at diagnosis, and spinal cord lesions. This article reviews two promising biomarkers, the central vein sign (CVS) and the paramagnetic rim sign (PRS), and their potential role in the diagnosis and prognosis of MS and RIS. Both CVS and PRS have been shown to be accurate diagnostic markers in MS, with high sensitivity and specificity, and have been useful in distinguishing MS from other disorders. Further research is needed to validate these findings and determine the clinical utility of these biomarkers in routine practice. [ABSTRACT FROM AUTHOR]

Idiopathic intracranial hypertension (IIH) is traditionally characterized by elevated intracranial pressure without an identifiable cause, primarily affecting obese women. However, recent evidence suggests that venous sinus stenosis may play a significant role in the pathophysiology of IIH, challenging its designation as “idiopathic.” This editorial discusses the limitations of the current nomenclatures and diagnostic criteria, highlighting the importance of routine venography in detecting venous sinus abnormalities, irrespective of a patient's demographic profile. We propose a new nomenclature of this subset of patients to venous sinus stenosis intracranial hypertension in order to promote more accurate diagnosis and targeted treatment, including potential endovascular interventions. [ABSTRACT FROM AUTHOR]

Cerebral venous sinus stenting (CVSS) is an effective treatment for idiopathic intracranial hypertension (IIH) secondary to dural venous sinus stenosis. Traditional selection of patients for CVSS has been made by microcatheter manometry, but pressure measurements are often equivocal. Here we present the results of a series of cases in which venous flat-panel CT (FP-CT) was used as an adjunct to microcatheter manometry to improve decision making and precise stent placement during CVSS.Ten consecutive patients with IIH underwent angiography with microcatheter manometry and venous FP-CT, with CVSS if indicated by the results. Cross-sectional measurements of the narrowed sinus were obtained on FP-CT before and after stenting. After the procedure, clinical outcomes were tracked. Follow-up with quantitative MRA with sinus flow measurements was also performed, when available.There was an exponential correlation between measured pressure gradient and degree of stenosis calculated using venous FP-CT. All patients with both a high degree of stenosis measured by FP-CT and a high pressure gradient across the stenosis showed a clinical benefit from stenting.True measurement of the cross-sectional area of the dural sinus, made by venous phase FP-CT, has a high degree of correlation with elevated venous pressure gradient across the point of stenosis. Even in a limited series of cases, we found an exponential decrease in flow with increasing severity of stenosis. Furthermore, patients with both an elevated venous pressure gradient and critical stenosis of the sinus on FP-CT showed symptomatic improvement after stenting. [ABSTRACT FROM AUTHOR]

Objectives: This study evaluates the feasibility, safety, and efficiency of using a balloon guide catheter (BGC) through transradial access (TRA) for mechanical thrombectomy (MT) in patients with anterior circulation strokes., Methods: A retrospective case series of patients who underwent MT using BGC through TRA for acute ischemic stroke in the anterior circulation was conducted. Data collected included procedural times (from puncture to revascularization), technical success, complication rates, and clinical outcomes. Patients' baseline characteristics, stroke severity, and post-procedural outcomes were also analyzed., Results: Thirty patients were included, with a mean age of 64.4 ± 13.6 years. The median admission NIHSS score was 13, and 17 % received intravenous thrombolysis before thrombectomy. Right-sided occlusions were more frequent (57 %). TRA was successful in 27 patients (90 %), with 3 (10 %) requiring conversion to femoral access. The median puncture-to-revascularization time was 32 minutes, and first-pass revascularization was achieved in 40 % of cases. A favorable TICI 2b or higher was accomplished in 97 %, with no access site complications. Hemorrhagic conversion occurred in 20 %, including one symptomatic intracerebral hemorrhage (3 %). At discharge, 57 % of patients had favorable outcomes (mRS 0-2), and by 90 days, 54 % achieved functional independence, with a mortality rate of 3 %., Conclusion: This case series highlights the feasibility of using BGC through TRA in MT for anterior circulation strokes, demonstrating promising safety and efficiency. Future multicenter studies with larger cohorts are necessary to compare clinical outcomes of TRA versus transfemoral access and guide standardized protocols for stroke interventions., Competing Interests: Declaration of Competing Interest There are no relevant conflicts of interest., (Copyright © 2024 The Authors. Published by Elsevier B.V. All rights reserved.)

Background: The concurrent presentation of meningioma and intracranial aneurysm (IA) poses diagnostic and therapeutic challenges, with no standardized management protocol available. This study aims to address this through an updated systematic review, delineating optimal strategies for managing this dual pathology., Methods: A systematic review was conducted across PubMed, Web of Science, and Embase databases. Articles were screened independently by two reviewers. Treatment strategies and patient outcomes were comprehensively analyzed to formulate a treatment framework based on several characteristics. In addition, one concurrent meningioma and IA case from our institution was presented., Results: A total of 69 articles comprising 115 patients were included in the study. The cohort exhibited a female predominance (80%) with a mean age of 56 (±13) years. Meningiomas were primarily localized to the frontotemporal and sellar regions, while aneurysms favored the anterior circulation - notably, 16.5% of cases presented with ruptured aneurysms. Management strategies varied based on the spatial relationship between lesions and aneurysm rupture status. In unruptured cases, 34% underwent a single craniotomy for simultaneous resection of both pathologies, while endovascular intervention was favored when the IA originated from an artery feeding the meningioma (73%). Remarkably, postoperative aneurysm rupture occurred in 33% of cases managed solely through tumor resection (range 0-30 days postop)., Conclusion: This study proposes a comprehensive treatment algorithm to guide neurosurgeons in managing concurrent meningioma and IA cases. By considering individual patient intricacies, the feasibility of simultaneous management, aneurysm rupture risk, and symptomatology, this framework is a valuable tool for clinical decision-making in these complex scenarios., Competing Interests: There are no conflicts of interest., (Copyright: © 2024 Surgical Neurology International.)

Objective: Extracranial-intracranial (EC-IC) bypass has been well described in chronic vaso-occlusive cerebrovascular diseases, including both moyamoya disease (MMD) and atherosclerotic disease (AD). This study aimed to compare factors associated with bypass occlusion between these two diseases., Methods: An institutional database of 357 patients with intracranial bypass procedures performed between August 2001 and May 2022 was retrospectively reviewed. Patients with MMD and AD were selected for study. Baseline characteristics, surgical technique, and flow-related measurements were compared in relation to the outcome of bypass occlusion., Results: A total of 232 patients met inclusion criteria (AD, n = 108; MMD, n = 124). The average age and sex differed significantly between groups (AD 57.2 years, 56.5% male; MMD 36.6 years, 31.5% male; p < 0.001). The modified Rankin Scale scores at surgery and at follow-up were higher in the AD group (p = 0.004 and p < 0.001, respectively), showing a slightly worse baseline functional status, and higher rates of stroke were observed in the AD group by last follow-up (p = 0.005). Patients with AD also were more likely to require an interpositional graft (p < 0.001). At last follow-up, rates of occlusion did not differ between AD and MMD groups (25.2% vs 25.4%, respectively). Of occluded bypasses, the AD group had more occlusions within 1 week compared to MMD (51.9% vs 35.5%, p = 0.176), although the difference was not significant. In patients with more than 1 year of follow-up and in those with more than 2 years of follow-up, MMD tended to have higher rates of occlusion (31.2% vs 26.1% [p = 0.558], and 26.4% vs 20.7% [p = 0.564]). Flow measurements did not differ between AD and MMD groups, but in subgroup analyses of patients with AD and those with MMD, both bypass flow and cut flow index predicted occlusion in both groups., Conclusions: Despite different disease etiologies treated with bypass, rates of occlusion at last follow-up did not vary between groups, although short-term follow-up would suggest earlier bypass failure in AD, and extended follow-up trended toward higher occlusion rates in MMD. Additionally, patients with AD were more likely to have further occurrences of stroke by last follow-up. Importantly, the bypass flow and cut flow index at the time of surgery predicted occlusion in both AD and MMD.