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Background: Pseudoaneurysms occur at the rupture site of true aneurysms and appear as irregularly shaped and partially thrombosed outpouchings of the main sac. Recanalization of thrombi inside pseudoaneurysmal sac is one of the putative mechanisms of rebleeding of unsecured aneurysms and of coil migration after endovascular treatment. We document "real time" pseudoaneurysm formation after rerupture of an anterior communicating artery aneurysm.Methods: Case report.Results: A 55-year-old man with aneurysmal subarachnoid hemorrhage from an anterior communicating aneurysm underwent catheter angiography. After the diagnostic angiogram while awaiting for the anesthesia team to proceed with endotracheal general anesthesia, a seizure occurred. Rebleeding was suspected and confirmed by a dynamic CT in the angio suite. A repeat angiogram showed a pseudoaneurysm arising from the previously ruptured aneurysm which had not been present on the original angiogram a few minutes earlier. Uneventful coiling of the aneurysm was undertaken and the patient was discharged home a week later.Conclusions: We document angiographic formation of a "pseudoaneurysm" at the site of rupture of an anterior communicating artery aneurysm. "Pseudoaneurysm" formation occurs after rupture of an intracranial aneurysm. They represent a weak spot in the aneurysm sac at the site of rupture and probably the result of persistent flow within the clot forming at the site of rupture. Presence of a pseudoaneurysm with characteristic angiographic features like the one herein described represents an unstable area within the aneurysm. This case also highlights the observation that, in patient harboring unsecured ruptured aneurysms, seizures or seizures-like phenomena are the clinical expression of rebleeding unless proven otherwise. [ABSTRACT FROM AUTHOR]

Abstract Introduction Intracranial schwannomas unrelated to the cranial nerves are uncommon. We report a new case of tentorial schwannoma unrelated to the cranial nerves, with extension into the pons. A literature review with discussion of the most relevant pathogenetic aspects is also performed. Case presentation A 42-year-old Caucasian man was admitted with right-sided paresthesias and weakness of his upper and lower extremities. The neurological examination revealed right hemiparesis and hemi-hypoesthesia. A brain magnetic resonance imaging scan revealed a cerebellopontine lesion, arising from the left free edge of the tentorium, and extending into his pons. A piecemeal removal was performed through a retrosigmoid approach. The lesion was not found to be associated with any cranial nerves. The histological examination revealed a schwannoma Antoni type A. His postoperative course was uneventful. At one year follow-up, the patient was neurologically intact and the magnetic resonance imaging of his brain performed at that time showed complete removal without signs of recurrence. Conclusion Tentorial schwannomas are rare clinical entities. Knowledge of their clinical, radiological and anatomical characteristics is very important for the correct diagnosis and management.

Abstract Introduction Two types of gliomatosis cerebri exist: Type I and Type II. We report the results of a histological and genetic study of two cases of gliomatosis cerebri Type II, correlating these results with therapy and prognosis. Case presentation Two patients, a 52-year-old man (Patient 1) and a 76-year-old man (Patient 2) with gliomatosis cerebri II were admitted to our institution; they underwent surgical treatment and received radiotherapy and chemotherapy. At the 24-month follow-up, Patient 1 was still alive, while Patient 2 had died. The poor prognosis of Patient 2 was underlined by molecular analysis which showed that the angiogenesis related genes VCAM1 and VEGF were overexpressed, reflecting the high degree of neovascularization. Conclusion Genes involved in drug resistance and metallothioneins were highly expressed in Patient 2 and this, associated with unmethylated O6-methylguanine methyltransferase, can explain the lack of response to chemotherapy.

Background: Epileptic seizures commonly burden low-grade glioma (LGG) patients and negatively impact quality of life, neurocognition, and general patient health. Anti-seizure medications (ASMs) are used to manage seizures but can result in undesired side effects. Our aim was to report our experience in epilepsy in one of the largest case series of LGG patients (reclassified in accordance with the WHO 2021 classification). Furthermore, we evaluate our postoperative seizure frequency difference between LGG patients who use preoperative ASMs and ones with no ASMs., Methods: Data were retrospectively collected from Salford Royal Hospital electronic records and Neuro-Oncology database from 2006 to 2022. Descriptive statistics were performed for demographic analysis, while multivariable analysis was used to determine postoperative seizure-free outcomes., Results: In total, 257 operations were performed on 206 patients. Postoperatively, 114 patients suffered from seizures, and approximately 45.2% of patients developed seizures at 3-12 months postsurgery, with the odds higher in patients on preoperative ASMs. There was no evidence to suggest a higher postoperative seizure rate in patients undergoing awake craniotomy versus general anesthetic. The extent of resection (EOR) was inversely related to seizure failure, with gross-total resection showing a statistically significant reduction in seizures in comparison to all other surgical resections., Conclusions: In our experience, there is no evidence to suggest a reduced postoperative seizure outcome when prescribing preoperative ASMs. EOR is an independent prognosticator for postoperative seizure failure with all other variables demonstrating nonsignificance. Overall, a larger study can investigate the role of ASMs in LGG in greater detail., Competing Interests: None declared., (© The Author(s) 2024. Published by Oxford University Press, the Society for Neuro-Oncology and the European Association of Neuro-Oncology.)

Background  Postoperative surgical site infections are a recognized complication following craniotomies with an associated increase in morbidity and mortality. Several studies have attempted to identify bundles of care to reduce the incidence of infections. Our study aims to clarify which perioperative measures play a role in reducing surgical infection rates further. Methods  This study is a retrospective audit of all elective craniotomies in years 2018 to 2019. The primary endpoint was the surgical site infection rate at 30 days and 4 months after the procedure. Univariate analysis was used to identify factors predictive of postoperative infection. Results  344 patients were included in this study. Postoperative infections were observed in 5.2% of our cohort. No postoperative infections occurred within 4 months in patients receiving perioperative hair wash and intrawound vancomycin powder. In univariate analysis, craniotomy size (Fisher's exact test, p  = 0.05), lack of perioperative hair wash, and vancomycin powder use (Fisher's exact test, p  = 0.01) were predictive of postoperative infection. No complications relative to the use of intrawound vancomycin were observed. Conclusion  Our study demonstrates that simple measures such as perioperative hair wash combined with intrawound vancomycin powder in addition to standard practice can help reducing infection rates with negligible risks and acceptable costs. Our results should be validated further in future prospective studies., Competing Interests: Conflict of Interest None declared., (Asian Congress of Neurological Surgeons. This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. ( https://creativecommons.org/licenses/by-nc-nd/4.0/ ).)

Background: The combination of awake craniotomy with multimodal neurophysiological mapping and monitoring in intra-axial tumour resection is not well described, but may have theoretical benefits which we sought to investigate., Methods: All patients undergoing awake craniotomy for tumour resection with cortical and/or subcortical stimulation together with one or more of electrocorticography (ECoG/EEG), motor or somatosensory evoked potentials were identified from the operative records of two surgeons at two centres over a 5 year period. Patient, operative and outcome data were collated. Statistical analysis was performed to evaluate factors predictive of intra-operative seizures and surgical outcomes., Results: 83 patients with a median age 50 years (18-80 years) were included. 80% had gliomas (37% low grade) and 13% metastases. Cortical mapping was negative in 35% (language areas) and 24% (motor areas). Complete or near total resection was achieved in 80% with 5% severe long-term neurological deficits. Negative cortical mapping was combined with positive subcortical mapping in 42% with no significant difference in extent of resection rates to patients undergoing positive cortical mapping ( p  = 0.95). Awake mapping could not be completed in 14%, but with no compromise to extent of resection ( p  = 0.55) or complication rates ( p  = 0.09). Intraoperative seizures occurred in 11% and were significantly associated with intra-operative EEG spikes ( p  = 0.003)., Conclusions: Awake multi-modal monitoring is a safe and well tolerated technique. It provides preservation of extent of resection and clinical outcomes in cases of aborted awake craniotomy. Negative cortical mapping in combination with positive subcortical mapping was also shown to be safe, although not hitherto well described. Electrocorticography further enables the differentiation of seizure activity from true positive mapping, and the successful treatment of spikes prior to full clinical seizures occurring.

Background: Glioblastoma is a high-grade aggressive neoplasm whose outcomes have not changed in decades. In the current treatment pathway, tumour growth continues and remains untreated for several weeks post-diagnosis. Intensified upfront therapy could target otherwise untreated tumour cells and improve the treatment outcome. POBIG will evaluate the safety and feasibility of single-fraction preoperative radiotherapy for newly diagnosed glioblastoma, assessed by the maximum tolerated dose (MTD) and maximum tolerated irradiation volume (MTIV)., Methods: POBIG is an open-label, dual-centre phase I dose and volume escalation trial that has received ethical approval. Patients with a new radiological diagnosis of glioblastoma will be screened for eligibility. This is deemed sufficient due to the high accuracy of imaging and to avoid treatment delay. Eligible patients will receive a single fraction of preoperative radiotherapy ranging from 6 to 14 Gy followed by their standard of care treatment comprising maximal safe resection and postoperative chemoradiotherapy (60 Gy/30 fr) with concurrent and adjuvant temozolomide). Preoperative radiotherapy will be directed to the part of the tumour that is highest risk for remaining as postoperative residual disease (hot spot). Part of the tumour will remain unirradiated (cold spot) and sampled separately for diagnostic purposes. Dose/volume escalation will be guided by a Continual Reassessment Method (CRM) model. Translational opportunities will be afforded through comparison of irradiated and unirradiated primary glioblastoma tissue., Discussion: POBIG will help establish the role of radiotherapy in preoperative modalities for glioblastoma., Trial Registration: NCT03582514 (clinicaltrials.gov)., Competing Interests: The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: POBIG is funded by UK Research and Innovation Medical Research Council (UKRI MRC). The research program of GB (Chief Investigator, senior author) is supported by Cancer Research UK RadNet Manchester., (© 2023 The Authors.)

Background: Awake neurosurgery is currently the mainstay for eloquent brain lesions. Opting for an awake operation is affected by a number of patient-related factors. We present a case of a patient with autistic spectrum disorder (ASD) that was successfully operated for a brain tumor through awake craniotomy. To the best of our knowledge, this is the first reported case in the literature., Case Description: A 42-year-old patient, with known ASD since his childhood, underwent awake craniotomy for a left supplementary motor area tumor. Detailed preoperative preparation of the patient was done to identify special requirements and establish a good patient-team relationship. Intraoperatively, continuous language and motor testing were performed. Conversation and music were the main distractors used. Throughout the operation, the patient remained calm and cooperative, even during a focal seizure. Mapping allowed for >80% resection of the tumor. Postoperatively, the patient recovered without any deficits., Conclusion: This case shows that with growing experience and meticulous preparation, the limits of awake craniotomy can be expanded to include more patients that were previously considered unfit., Competing Interests: There are no conflicts of interest, (Copyright: © 2022 Surgical Neurology International.)

Background: Posterior fossa surgery in the supine position remains a relatively underutilised approach, compared to the routinely performed prone, park-bench or sitting positions. This surgical approach may confer additional advantages over other modalities commonly restricted by patient co-morbidity and anaesthetic concerns. The purpose of this article is to highlight this approach as a potential viable, safe and alternative approach., Methods: We retrospectively collected data of all supine infra-tentorial/posterior fossa surgery by one surgeon between 2015 and the present via our electronic patient record system. Demographic data alongside duration of surgery, ASA grading, location of lesions, length of stay, presence of post-operative infections, presence of post-operative CSF leak/pseudomeningocele and post-operative mortality were assessed., Results: A total of 64 procedures on 58 patients were identified. Of the procedures, 60 were performed for neoplasms (93.8%). Mean overall surgical time was 176 min. Median ASA grade for tumour surgery was 3. Median length of stay was 3 days. Of the non-emergency tumour cases (n = 53), 43 (81.1%) lesions were located in the cerebellar hemisphere, the remainder were in the vermis and tentorium. There were 6 documented post-operative infections (9.4%). The rates of CSF-related complications were: CSF Leak 1.6% (1/64) and Pseudomeningocele 1.6% (1/64). 30-day mortality was 1.6% (1/64)., Conclusion: This study suggests that supine positioning is a safe alternative to be considered when operating upon posterior fossa lesions. Further studies are warranted to assess efficacy of this approach, but it can be considered for wider use in the UK and further afield., (Crown Copyright © 2022. Published by Elsevier Ltd. All rights reserved.)

Background: In patients with newly diagnosed glioblastoma, rapid early progression (REP) refers to tumor regrowth between surgery and postoperative chemoradiotherapy. This systematic review and meta-analysis appraised previously published data on REP to better characterize and understand it., Methods: Systematic searches of MEDLINE, EMBASE and the Cochrane database from inception to October 21, 2021. Studies describing the incidence of REP-tumor growth between the postoperative MRI scan and pre-radiotherapy MRI scan in newly diagnosed glioblastoma were included. The primary outcome was REP incidence., Results: From 1590 search results, 9 studies were included with 716 patients. The median age was 56.9 years (IQR 54.0-58.8 y). There was a male predominance with a median male-to-female ratio of 1.4 (IQR 1.1-1.5). The median number of days between MRI scans was 34 days (IQR 18-45 days). The mean incidence rate of REP was 45.9% (range 19.3%-72.0%) and significantly lower in studies employing functional imaging to define REP ( P  < .001). REP/non-REP groups were comparable with respect to age ( P  = .99), gender ( P  = .33) and time between scans ( P  = .81). REP was associated with shortened overall survival (HR 1.78, 95% CI 1.30-2.43, P  < .001), shortened progression-free survival (HR 1.78, 95% CI 1.30-2.43, P  < .001), subtotal resection (OR 6.96, 95% CI 4.51-10.73, P  < .001) and IDH wild-type versus mutant tumors (OR 0.20, 95% CI 0.02-0.38, P  = .03). MGMT promoter methylation was not associated with REP (OR 1.29, 95% CI 0.72-2.28, P  = .39)., Conclusions: REP occurs in almost half of patients with newly diagnosed glioblastoma and has a strongly negative prognostic effect. Future studies should investigate its biology and effective treatment strategies., (© The Author(s) 2022. Published by Oxford University Press, the Society for Neuro-Oncology and the European Association of Neuro-Oncology.)

Background: Surgical site infection (SSI) is a significant cause of postoperative morbidity and mortality. As oncologic care advances, the use of surgical adjuncts such as intraoperative ultrasound (US), 5-aminolevulinic acid (5-ALA), and neurophysiologic monitoring has increased. This study set out to identify whether the use of surgical adjuncts in supratentorial tumor surgery lead to increased operative time or increased rates of SSI., Methods: This is a retrospective study at a large tertiary clinical neurosciences center in the UK. We included all patients who underwent an elective supratentorial craniotomy for a tumor over a 12 month period. We retrospectively assessed whether patients had had a postoperative infection at 30 days or 4 months using our electronic patient record system., Results: A total of 267 patients were included. The median age was 58 years (range: 17-87 years) with roughly equal numbers of men and women (men: 138 of 267, 52%). Most operations were carried out for gliomas (149 of 267, 56%) or metastases (61 of 267, 23%). The median length of surgery was 3 hours 6 minutes, with 24% lasting >4 hours. The overall infection rate was 4.5%. Intraoperative monitoring and 5-ALA was associated with longer operative times although not necessarily larger craniotomy sizes, whereas intraoperative US was associated with a shorter operative time and smaller craniotomy size. These adjuncts were not associated with an increased risk of infection., Conclusions: This study adds reassurance that although some surgical adjuncts lead to increased operative times, in our study there was no apparent increased risk of infection as a result of this., (Copyright © 2022. Published by Elsevier Inc.)

Background: Concomitant dural arteriovenous fistulas (DAVFs) and meningiomas have been rarely described. DAVFs can be either continuous or at a distant location from the meningioma, with different pathophysiologic mechanisms involved in each situation., Case Description: We report the case of a 74-year-old woman presenting with left-sided hemiparesis secondary to a large right convexity meningioma, associated with a noncontiguous Borden 3 DAVF. Both lesions were treated surgically in the same setting. The patient improved after surgery, and postoperative imaging showed complete resection of the meningioma and absence of recurrence of the fistula at 4 years., Conclusion: To the best of our knowledge, this is the first case of concomitant surgical treatment of a meningioma and noncontiguous DAVF., Competing Interests: There are no conflicts of interest., (Copyright: © 2020 Surgical Neurology International.)

We report the case of a 33-year-old patient who underwent fenestration of a large symptomatic cranio-cervical junction arachnoid cyst., Competing Interests: There are no conflicts of interest., (Copyright: © 2020 Surgical Neurology International.)

Background: Minimally invasive resection of brain metastases aims to maximize resection while minimizing brain trauma., Methods: Patients with 1 or more metastases that underwent resection following neuro-oncology multidisciplinary meeting discussion from September 2014 to October 2018, with pre- and postoperative magnetic resonance imaging, were included. All patients including posterior fossa metastases or multiple metastases were positioned supine. Hair was not shaved. Volumetric postcontrast T1 magnetic resonance imaging was used for incision planning and neuronavigation. The craniotomy site was tailored to tumor depth according to keyhole principles and ranged between 2 and 5 cm. Intraoperative monitoring and awake mapping were carried out in selected cases., Results: Out of 320 consecutive patients with brain metastases, 44 patients were identified as suitable for minimally invasive resection. Nine patients had no postoperative imaging and were excluded. There were 38 metastases in 35 patients. There were 18 cerebellar metastases, 10 frontal, 3 parietal, 3 occipital, 2 temporal, 1 intraventricular, and 1 basal ganglia. Median length of stay was 3 days (range, 1-24). Average tumor volume was 54.7 cm 3 (range, 10-240 cm 3 ). Endoscopic assistance was used in 4 patients. Median performance status improved from 2 to 1 (range, preoperative: 0-4; postoperative: 0-2). Median survival was 14.7 months., Conclusions: Minimally invasive resection of brain metastasis is safe and effective, and in selected cases confers advantages compared with standard techniques., (Crown Copyright © 2019. Published by Elsevier Inc. All rights reserved.)

Competing Interests: There are no conflicts of interest.

Background: There is little information about clinical characteristics, management, and outcome of patients with intracranial aneurysms and internal carotid artery occlusion. We will describe clinical characteristics, treatment and outcome of patients with coexistent internal carotid artery occlusion and intracranial aneurysms., Methods: We conducted a retrospective chart review of 22 patients (eight males and 14 females) with coexistent internal carotid artery (ICA) occlusion and intracranial aneurysms., Results: This series includes 14 females and eight males with a mean age of 63 years (range, 49 to 80). These patients harbored a total of 35 aneurysms, which were located on the same side of the ICA occlusion in five cases, on the contralateral side in 20 cases, while in ten cases the aneurysm had a midline location (AcomA 9, Basilar tip 1). Treatment consisted of surgery for eight aneurysms and endovascular embolization for 13 aneurysms. No invasive treatment was recommended for 14 aneurysms (eight patients with single aneurysm). No permanent perioperative or periprocedural complications occurred in the selected group of patients undergoing invasive treatment. At a mean follow-up of 57 months (range, 3-203), no patient had a subarachnoid hemorrhage and three patients had died of causes not related to the aneurysm., Conclusion: Surgical and endovascular treatment can be accomplished safely in selected patients with coexistent ICA occlusion and intracranial aneurysms. Conservative treatment is a valid alternative, especially in elderly patients or in patients with very small aneurysms, especially if not located along the collateral pathway.

Background and Purpose: Coil embolization is an alternative to clipping for intracranial aneurysms. However, controversy exists regarding the best therapeutic strategy in patients with ruptured aneurysms, and there is great center- and country-related variability in the rates of clipping versus coiling. We performed a meta-analysis of prospective controlled trials of clipping versus coil embolization for ruptured aneurysms., Materials and Methods: We performed a search of the English literature for published prospective controlled trials comparing surgical clipping with endovascular coil embolization for ruptured intracranial aneurysms. Data were abstracted from the identified references. Outcomes of interest were the proportion of patients with a poor outcome at 1 year and episodes of rebleeding from the index treated aneurysm after the allocated treatment., Results: There were 3 prospective controlled trials eligible for inclusion. These studies enrolled 2723 patients. Meta-analysis of these studies showed that the rate of poor outcome at 1 year was significantly lower in patients allocated to coil embolization (risk ratio, 0.75; 95% confidence interval, 0.65-0.87). This relative effect is consistent with an absolute risk reduction of 7.8% and a number needed to treat of 13. The effect on mortality was not statistically different across the 2 treatments. Rebleeding rates within the first month were higher in patients allocated to endovascular coil embolization., Conclusions: On the basis of the analysis of the 3 high-quality prospective controlled trials available, there is strong evidence to indicate that endovascular coil embolization is associated with better outcomes compared with surgical clipping in patients amenable to either therapeutic strategy.

Few pituitary adenomas require removal through a transcranial route. This may be associated with more significant morbidity and mortality, compared to the transsphenoidal approach. An endoscopic, extended, transplanum-transtuberculum approach (ETTA) in selected pituitary adenomas may offer an alternative to the transcranial route. We describe our technique and experience of ETTA in pituitary adenomas over 10 years. Between 2000 and 2010, we performed 700 endoscopic endonasal procedures for pituitary adenomas. Nineteen patients (13 men; mean age, 48 years; range, 22-76 years) underwent 22 ETTAs. Thirteen patients had non-functioning adenomas. Three tumor groups were identified: (1) tumors developing in or around the pituitary stalk; (2) tumours with sub- frontal extension and (3) tumours with a major extrasellar component. Mean follow-up was 37 months (range 6-72 months). Gross total resection was achieved in 11 procedures (no recurrences), with partial tumour resection in 11 procedures. Of the 12 patients with visual symptoms, ten improved. Of eight patients with hormonal hypersecretion four were cured. Complications included CSF leak (14%), haemorrhage (9%), hemiplegia (5%). There were no mortalities. Experience using the ETTA for pituitary adenomas is limited because it is indicated in highly selected cases (3.1% of our series). An absolute indication is represented by ectopic secreting pituitary stalk/peri-stalk adenomas. ETTA is a useful option in midline frontal adenomas and adenomas with a major extrasellar component, but has a higher morbidity than that seen in the standard transsphenoidal approach. A study comparing ETTA versus transcranial resection is highly desirable.

Background and Purpose: Paraclinoid aneurysms represent challenging lesions for which endovascular techniques have gained widespread application in their treatment. A new endovascular strategy, flow diversion, is gaining importance in the treatment of these aneurysms. Before embracing flow diversion in larger numbers of patients with paraclinoid aneurysms, it is important to know the safety and efficacy of "traditional" endovascular methods for these aneurysms. We review complications and outcomes of patients with unruptured paraclinoid aneurysms treated with coils, with or without balloon and stent assistance, over the past 12 years at our institution., Materials and Methods: A retrospective review of 118 patients with 126 unruptured paraclinoid aneurysms, treated between 1999 and 2010, was performed. Clinical records, endovascular reports, angiographic results, and clinical outcomes were reviewed and analyzed., Results: Fifty-nine percent of aneurysms were carotid-ophthalmic, 27% were hypophyseal, 9% were posterior carotid wall, 3% were carotid cave, and 2% were transitional. Twenty-one percent of aneurysms were symptomatic, and 3% were recurrent aneurysms after previous treatment. Fifty (40%) were treated with balloon assistance and 18 (14%) with stent assistance. Technical complications causing permanent morbidity occurred in 1 patient (0.8%), while early clinical complications causing transient morbidity occurred in 5 (4%) patients. Complete occlusion was achieved in 40% of aneurysms immediately after treatment and in 66 (62%) aneurysms during follow-up (mean 31.9 ± 28.4 months). Recurrences occurred in 18 patients (17%) and 10 (9%) patients were retreated. Clinical outcome was good in 95% and poor in 5% of the 107 patients with follow-up (mean 37.0 ± 33.7 months). Only in 1 patient was poor outcome related to the endovascular procedure. Transient ischemic attacks occurred in 4% of patients. No cases of rebleeding were observed during follow-up., Conclusions: Modern endovascular coil treatment of unruptured paraclinoid aneurysms appears safe, with satisfactory, although not ideal, rates of complete occlusion. The introduction of flow diverters will probably increase the rate of complete angiographic occlusion, but this must be achieved with low complication rates.

Background and Purpose: Paraclinoid aneurysms are an uncommon cause of aneurysmal SAH, and their treatment is challenging. To assess the effectiveness and safety of endovascular treatment of ruptured paraclinoid aneurysms, we performed a retrospective analysis of 33 patients., Materials and Methods: Clinical and radiologic information on 33 patients undergoing endovascular therapy between 1999 and 2010 was retrospectively reviewed. Angiographic results were evaluated with the modified Raymond grading system, whereas clinical outcomes were evaluated with the mRS scale., Results: Seventeen (52%) aneurysms were classified as clinoid segment aneurysms, and 16 (48%), as ophthalmic segment aneurysms. Twenty-six (79%) aneurysms were small, 6 (18%) were large, 1 was (3%) giant, and 39% were wide-neck. Coiling was done with balloon assistance in 36% of cases and stent-assistance in 6%. Technical complications occurred in 1 patient, contributing to death. Early clinical complications causing permanent disability occurred in 3% of cases. One patient (3%) had fatal rebleeding 18 days after treatment. Overall, procedure-related morbidity and mortality were, respectively, 3% and 6%. Complete occlusion of the aneurysm was achieved in 36% of patients after initial treatment and in 65% during follow-up (average, 29.3 months). Seven patients had recurrences requiring retreatment (30%). Clinical outcome (average, 32.9 months) was good in 75% of patients and poor in 25%. No delayed complications related to treatment and/or the aneurysm occurred., Conclusions: Ruptured paraclinoid aneurysms are challenging lesions from an endovascular and surgical point of view. Despite the high rate of recurrences, good clinical results and protection against rebleeding can be achieved with current endovascular techniques.

Background: Extradural arteriovenous malformations (AVMs) are uncommon vascular malformations of the spine. They are characterized by an arteriovenous communication (localized in the paraspinal soft tissues and the epidural venous plexus) that may have retrograde intradural venous drainage. Surgical treatment of extradural AVMs can be challenging because of the common location ventral to the dural sac and the presence of arterialized venous lakes., Objective: To assess the effectiveness of embolization with a liquid embolic material (Onyx; ev3 Inc, Irvine, California) in 7 consecutive patients with extradural spinal AVMs and intradural venous drainage., Methods: We retrospectively collected information regarding patient characteristics, clinical presentation, symptom duration, diagnostic imaging, treatment, complications, and clinical and radiological follow-up., Results: Patients were 5 men and 2 women (mean age, 66 years; range, 45-76 years). Symptom duration varied from 2 months to 6 years. Six patients underwent embolization of the AVM as the primary treatment; 1 patient was treated after attempted surgery. Complete obliteration was demonstrated in each patient on completion angiography and was confirmed during follow-up in 6. Three patients had resolution of their preembolization symptoms. Three patients had improvement but not complete resolution of their motor deficits. In 1 patient, the AVM was an incidental finding during an investigation for chronic low-back pain; symptoms were not thought to be related to the AVM, and symptoms were not ameliorated by successful embolization., Conclusion: Our early experience with these uncommon lesions suggests that Onyx embolization is a valuable and effective strategy for extradural spinal AVMs and intradural venous drainage.

Seizures and seizure-like activity may occur in patients experiencing aneurysmal subarachnoid hemorrhage. Treatment of these events with prophylactic antiepileptic drugs remains controversial. An electronic literature search was conducted for English language articles describing the incidence and treatment of seizures after aneurysmal subarachnoid hemorrhage from 1980 to October 2010. A total of 56 articles were included in this review. Seizures often occur at the time of initial presentation or aneurysmal rebleeding before aneurysm treatment. Seizures occur in about 2% of patients after invasive aneurysm treatment, with a higher incidence after surgical clipping compared with endovascular repair. Non-convulsive seizures should be considered in patients with poor neurological status or deterioration. Seizure prophylaxis with antiepileptic drugs is controversial, with limited data available for developing recommendations. While antiepileptic drug use has been linked to worse prognosis, studies have evaluated treatment with almost exclusively phenytoin. When prophylaxis is used, 3-day treatment seems to provide similar seizure prevention with better outcome compared with longer-term treatment.

Aberrant methylation of CpG islands in the promoter regions of tumour cells results in loss of gene function. In addition to genetic lesions, changes in the methylation profile of the promoters may be considered a factor for tumour-specific aberrant expression of the genes.We investigated the methylation status of E-cadherin gene (CDH1) promoter in low-grade glioma and correlated it with clinical outcome. Eighty-four cases of low-grade glioma (43 diffuse astrocytomas, 27 oligodendrogliomas and 14 oligoastrocytomas) with assessable paraffin-embedded tumour blocks and normal brain tissue, derived from non-cancerous tissue adjacent to tumour and commercially normal brain tissue, were collected, from which we determined CDH1 promoter methylation status and E-cadherin protein expression by methylation-specific polymerase chain reaction (MSP) and immunohistochemistry, respectively. CDH1 promoter was found hypermethylated in 54 out of 84 low grade gliomas (64%) compared with 84 normal brain tissue. CDH1 hypermethylation was found in 65% astrocytomas, 66% oligodendrogliomas and 57% oligoastrocytomas. A significant correlation between hypermethylation status, patient survival and progression-free survival was found (P = 0.04). Survival and progression-free survival were lower in patients with hypermethylated CDH1 promoter. We found that 15 astrocytomas, 9 oligodendrogliomas and 6 oligoastrocytomas were immunoreactive for E-cadherin. The incidence of loss of immunoreactivity for E-cadherin decreased significantly with age, overall survival and progression-free survival (P = 0.001, Kaplan-Meier test). We have demonstrated that CDH1 promoter hypermethylation significantly associated with down-regulated E-cadherin expression and overall survival of patients. This may have a bearing on the prognosis of low-grade glioma.

Previous studies have reported that patients with Parkinson's disease (PD) show, in the "off medication" state, a reduced activation of tibialis anterior (TA) in the late swing-early stance phase of the gait cycle. In PD patients the pathophysiological picture may cause differences among the stride cycles. Our aims were to evaluate how frequently TA activity is reduced in the late swing-early stance phase and if there is a relationship between the TA pattern and the clinical picture. Thirty PD patients were studied 2 h after Levodopa administration ("on-med") and 12 h after Levodopa wash-out ("off-med"). They were evaluated by the Unified Parkinson's Disease Rating Scale (UPDRS III) and surface electromyography of TA and gastrocnemius medialis (GM). The root mean square (RMS) of the TA activity in late swing-early stance phase (RMS-A) was normalized as a percent of the RMS of the TA activity in late stance-early swing (RMS-B). RMS-A was reduced in 30% of patients in the "off-med" condition. Within these patients, the percentage of stride cycles with reduced RMS-A, ranged between 28% and 83%. After Levodopa intake, no stride cycle showed reduced RMS-A. Patients with reduced RMS-A had a lower UPDRS III total score in the "on-med" rather than in the "off-med" condition (p=0.02). Our data confirm and extend previous observations indicating that, in "off-med" the function of TA is impaired in those patients clinically more responsive to Levodopa. TA activation is reduced in a relatively high percent of gait cycles in the "off-med" state. Since the variability of TA activation disappears after Levodopa administration, this phenomenon could be the expression of an abnormal dopaminergic drive., (Copyright © 2010 Elsevier B.V. All rights reserved.)

Giant cell angiitis of the CNS is an uncommon form of vasculitis. Neurological manifestations, both of the peripheral and CNS, are common. The most frequent manifestations are visual loss and stroke. Hemorrhagic onset is uncommon. Most cases have a fatal outcome and a tissue diagnosis is rarely established in life. We describe an unusual case of giant cell angiitis beginning as a hemorrhagic tumoral-like lesion. The results of the histological and ultrastructural analysis have also been reported. Our case illustrates that giant cell angiitis should be considered as a cause of intracerebral hemorrhage, particularly when associated with a relapsing and remitting disease of the CNS.

Solitary fibrous tumors (SFT) are rare neoplasms of mesenchymal origin involving soft tissues, mainly serosal sites; the spinal cord location is uncommon. We report a case of SFT occurring in the thoracic spinal cord, discussing histological, ultrastructural and molecular aspects. A 75-year-old woman with an MRI suggesting a dorsal intracanalar lesion was admitted to our institution. T5-T7 laminectomies were performed and an intramedullary tumor was discovered. The tumor arose within the spinal cord and was completely removed. Tumor samples were processed for histological, ultrastructural and molecular analysis (comparative genomic hybridization [CGH], methylation status of O6-methylguanine-DNA methyltransferase [MGMT], p16, deleted in colorectal cancer [DCC] and death-associated protein kinase 1 [DAPK1]). The histological examination demonstrated a proliferation of spindle-shaped cells with a collagen-matrix background. Immunohistochemical staining was positive for vimentin and CD34 and negative for S-100 and epithelial membrane antigen. A histological diagnosis of SFT was made. The ultrastructural examination showed undifferentiated cells within a collagenous matrix and sparse extravascular basement membrane. CGH analysis revealed deletion of 9p21 and losses on 2q, 3p, 16q and 19q and gains on 7q; furthermore, no aberrant methylation pattern was found in the promoter region of MGMT, p16, DCC and DAPK1 genes. On the second-year follow-up, the patient was neurologically intact. The occurrence of SFT within the spinal cord parenchyma and its histological characteristics demonstrate that SFTs are not restricted to serosal surfaces. The course of spinal cord SFT is unknown and long-term follow-up is necessary. The histological, ultrastructural and molecular findings are important for the diagnosis and the authors provide a literature review of these aspects.

Carotid-cavernous sinus fistulas (CCF) are abnormal communications between the carotid artery and the cavernous sinus. Most spontaneous CCFs are low-flow fistulas, supplied by branches of the omolateral internal carotid artery or the external carotid artery. A 64-year-old man, with increasing diplopia, mild exophthalmos on the left side, blurred left vision and omolateral red eye, was admitted to our institution. The patient underwent a bilateral cerebral angiography that showed a left CCF fed by meningo-hypophyseal branches of the right internal carotid artery and draining from the cavernous sinus into a parahippocampal vein. A transarterial embolization of the carotid-cavernous fistula was performed, with complete obliteration of the fistula. Although anecdotal reports exist, there is a scarcity of well-documented cases of exclusively contralateral flow in the carotid-cavernous fistula. Most of the reported cases referred to contralateral flow into the carotid-cavernous fistula by the external carotid artery branches. To the best of our knowledge, there are no previous cases of a spontaneous CCF supplied by contralateral meningo-hypophyseal branches. A discussion of treatment options and a literature review are also performed.

Aneurysms arising from the extracranial portion of the posterior-inferior cerebellar artery (PICA) are considered extremely rare. To date, only ten cases have been reported in the literature. The authors report a case of a 29 year-old male patient admitted comatose in Hunt-Hess grade IV because of an subarachnoid haemorrhage predominantly involving the left cranio-vertebral junction up to C2 rather than the posterior fossa and the fourth ventricle. Angiography showed an extracranial aneurysm at left vertebral artery-PICA junction a few millimetres superior to the dural entry point of the vertebral artery (VA). A left extreme-lateral approach was performed and the aneurysm was successfully clipped. On first year follow-up the patient had completely recovered with no neurological deficits. This paper analyzes the literature review about these rare aneurysms and the technical notes regarding the cranio-vertebral junction approach to these lesions. Factors affecting the neurological outcome of these aneurysms are also reported.

Background: In modern clinical neuro-oncology, the pathologic diagnoses are very challenging, creating significant clinical confusion and affecting therapeutic decisions and prognosis., Methods: TP53 and PTEN gene sequences were analyzed, and microarray expression profiling was also performed. The authors investigated whether gene expression profiling, coupled with class prediction methodology, could be used to determine the prognosis of gliomatosis cerebri in a more consistent manner than standard pathology., Results: The authors reported the results of a molecular study in 59 cases of gliomatosis cerebri, correlating these results with prognosis. The well-known prognostic factors of gliomas (ie, age, Karnofsky performance status, histology [grade 2 vs 3], and contrast enhancement) were found to be predictive of response or outcome in only a percentage of patients but not in all patients. The authors identified a 23-gene signature that was able to predict patient prognosis with microarray gene expression profiling. With the aim of producing a prognosis tool that is useful in clinical investigation, the authors studied the expression of this 23-gene signature by real-time quantitative polymerase chain reaction. Real-time expression values relative to these 23 gene features were used to build a prediction method able to distinguish patients with a good prognosis (those more likely to be responsive to therapy) from patients with a poor prognosis (those less likely to be responsive to therapy)., Conclusions: The results of the current study demonstrated not only a strong association between gene expression patterns and patient survival, but also a robust replicability of these gene expression-based predictors.

Objective: To evaluate structural variations of the jugular tubercles (JTs) and their relationships with the vertebral artery, the posterior inferior cerebellar artery (PICA), and the vertebrobasilar junction (VBJ)., Methods: The depth, height, and width of the JTs were measured using 30 cadaveric basicranial specimens and 50 three-dimensional angiography computed tomographic (angio-CT) scans evaluating morphological variations between the 2 sides. Angio-CT analysis evaluated the relationships of the JTs with the vertebral arteries and the PICAs. The location of the VBJ with respect to the JT level in the coronal plane was evaluated., Results: In the cadaveric specimens, the mean JT depth ranged from 0.9 to 3.1 cm, the mean height ranged from 0.6 to 1.5 cm, and the mean width ranged from 0.4 to 1.2 cm. According to the 3-dimensional angio-CT scans, JT measurements ranged as follows: depth, 0.7 to 2.6 cm; height, 0.6 to 1.4 cm; and width, 0.3 to 1.2 cm. The vertebral artery was in close contact with the JT on the left side in 30% of cases and on the right side in 24% of the cases. On axial scans, the PICA origin was classified as anterior to the JT in 20.5% of patients on the left side and 17.4% on the right, at the JT level in 50% of patients on the left side and 45.7% on the right, and posterior to the JT in 29.5% of patients on the left side and 36.9% on the right. On coronal scans, the PICA origin was classified as superior to the JT in 13.6% of patients on the left side and 8.7% on the right, at the JT level in 54.6% of patients on the left side and 50% on the right, and inferior to the JT in 31.8% of patients on the left side and 41.3% on the right. In the coronal plane, the VBJ was located above the tubercles in 16 patients (32%), at the JT level in 28 patients (56%), and below the tubercles in 6 patients (12%)., Conclusion: A precise morphometric analysis of the JTs on 3-dimensional CT scans was quick and safe and showed significant variations in their size and shape. The relationship of the JT with vertebral artery and the PICA varied significantly, as well as with the VBJ location. Knowledge of these morphological variations can contribute to optimal preoperative surgical planning, minimizing retraction and reducing morbidity during extreme lateral infrajugular-transtubercular exposure surgery.

Background: Pedicular hook dislocation is a rare complication of spinal instrumentation. We report on the first case of hydrosyringomyelia secondary to intracanalar hook displacement after scoliosis surgery., Case Description: A 15-year-old girl presented to our institution with a 7-month history of persistent neck and occipital pain as well as numbness of the lower extremities and previous dorsolumbar instrumentation with dorsal pedicular hooks and lumbar screws. Magnetic resonance imaging showed intramedullary cystic cavity from C5 to T7, isointense to cerebrospinal fluid (CSF) on T1- and T2-weighted images. Computed tomographic scan showed intracanalar displacement of the left hook. On admission, the patient presented with mild weakness of the lower extremities, hypalgesia below the level of T4, and urinary disturbance. The patient underwent surgical hook removal, T4 laminectomy, and midline dural opening: the arachnoid membrane was found to be thick and adhered to the dura and dorsolateral spinal cord. The arachnoid scarring was dissected, and the cord was untethered. A small posterior-median myelotomy was performed, and a syringosubarachnoid catheter was placed into the subarachnoid space to restore CSF flow., Conclusions: Late intracanalar displacement of spinal devices is an event that may complicate spinal instrumentation for scoliosis. This case highlights the importance of correct spinal device positioning and that of careful follow-up after instrumentation to detect complications early. We also discuss the pathogenetic pathway of the postarachnoiditic syringomyelia in this case.

Objective: Ganglioglioma is a primary central nervous system low-grade tumor composed of mixed populations of glial and neuroepithelial elements., Methods: The authors report a case of ganglioglioma in a patient affected by Peutz-Jeghers syndrome, an autosomal dominant disease with varying expressions and incomplete penetrance responsible for an increased risk of gastrointestinal and other malignant tumor forms., Results: The polymerase chain reaction products of exon 6 of STK11/LKB1 showed an abnormal pattern in the single-strand conformation polymorphism analysis. Further sequencing analysis of the exon 6 identified a deletion of T and an insertion of AC at nucleotide 821 causing a shift of the reading frame. The same mutation was found in the patient's peripheral blood. The ribonucleic acid analysis on the ganglioglioma cells revealed an out-of-frame STK11 isoform, characterized by an exon 4 skipping, which resulted in nonsense mediated decay sensitive., Conclusion: This report details the molecular genetic analysis of a ganglioglioma that allowed the identification of a new mutation.

Objective: Schwannomas located at the craniovertebral junction are rare. Intratumoral microscopic bleeding may be a common finding, but an acute hemorrhagic presentation is an unusual occurrence., Clinical Presentation: We report the case of a 44-year-old woman with acute onset of a hemorrhagic schwannoma of the C2 nerve root., Intervention: An emergency left far-lateral approach and a hemilaminectomy extending from C2 to C5 was performed. The tumor appeared as a dark-reddish subarachnoid mass. Tumor dissection and total removal were achieved by fragmentation and aspiration with an ultrasonic aspirator. A histological examination revealed a schwannoma with a hemorrhagic component., Conclusion: Our case highlights the importance of early and proper management of the pathologies of the craniovertebral junction with acute onset. The suspicion of an intratumoral hemorrhagic event must be considered when an acute onset of symptoms is present, even in patients without coagulopathies.

Pituitary abscess is a rare entity and the correct diagnosis is still difficult before surgery. More than 210 cases have been reported in the medical literature, mostly in the form of isolated case reports. We report two cases of pituitary abscess treated endoscopically and we review the literature. A 30-year-old woman and a 35-year-old man were admitted with a history of pituitary dysfunction. Patient 1 presented with polyuria, polydipsia, amenorrhea, headache, and visual impairment. Magnetic resonance imaging showed a cystic intra- and supra-sellar lesion with ring enhancement after contrast injection. Patient 2 presented with frontal headache, proptosis, painful ophthalmoplegia, visual impairment, and fever. Eight years before the patient had undergone a transphenoidal surgery for Prolactinoma. Magnetic resonance imaging revealed a sellar lesion extending into the cavernous sinus and carotid artery bilaterally. Both patients underwent endoscopic transnasal-transsphenoidal exploration. Intraoperative diagnosis of pituitary abscess was made. The postoperative courses were uneventful. Antibiotic therapy was performed in both cases. Only three cases of endoscopic treatment of pituitary abscess have been reported in the literature. We recommend early management by endoscopic transphenoidal surgery for pituitary abscess: this technique is safe, with minimal blood loss, short operating time, low morbidity, and brief hospital stay.

The ventriculus terminalis (VT) is a small ependyma-lined cavity within the conus medullaris that is in direct continuity with the central canal of the anterior portion of the spinal cord. Normally, such a cavity is identifiable only histologically in children and adults and can be visualized using common neuroradiological techniques only after dilation. Currently, the mechanisms of isolated dilation are not documented. The present work describes 2 cases of VT in elderly patients. Data from a histological and ultrastructural study of a case of VT dilation are reported, and the results are compared with those obtained from the VT of 5 fetuses to explain the nosological aspects of nontumoral VT lesions. Our data suggest that the site, age, and histological characteristics of the lesion allow us to define VT dilation as a nosological entity distinct from other cystic dilations of the conus medullaris.