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To determine the effect of surgical technique on outcomes from ruptured middle cerebral artery aneurysms (RMCAA).A retrospective review was performed of patients with RMCAA, who were treated at the authors' institutions. The study compares the clipping efficacy, the postoperative CT findings as well as the clinical outcome in 87 acute operated patients. Forty patients who underwent a surgical adapted technique to the preoperative radiological findings in the last 2 ½ years were included in Group 1, and 47 previously operated cases who underwent a standardized pterional approach with aneurysm preparation from proximal to distal were included in Group 2.Angiographically assessed clip efficacy confirmed aneurysm occlusion in 87.5% of the patients in Group 1 and in 70.2% for Group 2 (p 0.05). In 13 cases (32.2%) of Group 1 versus 27 cases (57.4%) of Group 2, postoperative CT scan showed hypodense brain areas (p 0.05). In 2 cases of Group 1 versus 8 cases of Group 2, a residual haematoma was found. Three months after bleeding, 25 cases in Group 1 showed a good recovery, 10 a moderate disability, and 5 severe disability or death. In Group 2, 26 patients showed a good recovery, 9 a moderate disability, and 12 severe disability or death. There was a difference for patients with severe disability/death between both groups (p 0.001).Individually adapted surgical technique in patients with RMCAA improves the efficacy of aneurysm clipping and clot removal, reduces postoperative hypodense brain areas and improves the patients' outcome.

BACKGROUND: While standards for the treatment of newly diagnosed glioblastomas exist, therapeutic regimens for tumor recurrence remain mostly individualized. The role of a surgical resection of recurrent glioblastomas remains largely unclear at present. This study aimed to assess the effect of repeated resection of recurrent glioblastomas on patient survival. METHODS: In a multicenter retrospective-design study, patients with primary glioblastomas undergoing repeat resections for recurrent tumors were evaluated for factors affecting survival. Age, Karnofsky performance status (KPS), extent of resection (EOR), tumor location, and complications were assessed. RESULTS: Five hundred and three patients (initially diagnosed between 2006 and 2010) undergoing resections for recurrent glioblastoma at 20 institutions were included in the study. The patients' median overall survival after initial diagnosis was 25.0 months and 11.9 months after first re-resection. The following parameters were found to influence survival significantly after first re-resection: preoperative and postoperative KPS, EOR of first re-resection, and chemotherapy after first re-resection. The rate of permanent new deficits after first re-resection was 8%. CONCLUSION: The present study supports the view that surgical resections of recurrent glioblastomas may help to prolong patient survival at an acceptable complication rate.

To assess the influence of configuration and location of ruptured distal cerebral anterior artery aneurysms on their treatment modality and results.The influence of the aneurysm configuration (basic or complex configuration) and location (infracallosal or supracallosal) on the treatment-related radiological results (partial or complete aneurysm occlusion) and clinical outcome (favorable or unfavorable) was retrospectively analysed in all admitted patients with ruptured pericallosal aneurysms within the last 10 years. The expected benefit from each form of treatment was individually discussed.During this period, 21 patients with ruptured pericallosal aneurysms (three previously coiled in other departments) had been admitted to our department. Within the endovascular group (ten patients), five infracallosal basic aneurysms presented a complete occlusion and favorable patient outcome. Three patients with infracallosal complex aneurysms presented a favorable outcome (two aneurysms were partially occluded and a frustrated procedure was replaced by clipping). Two supracallosal basic aneurysms showed a complete occlusion with one unfavorable outcome and one frustrated procedure followed by clipping and favorable outcome. In the surgical group (11 patients), five infracallosal complex aneurysms presented a complete occlusion with four favorable and one unfavorable outcomes. One patient with a supracallosal basic aneurysm presented a complete occlusion with a favorable outcome, and five patients with supracallosal complex aneurysms presented a complete occlusion in four cases and favorable outcome in all of them.The results of this study suggest that patients with infracallosal basic configured aneurysms are expected to benefit from endovascular procedures, whereas better radiological and clinical results can be obtained in surgically treated patients harboring supra- or infracallosal aneurysms of complex configuration.

To review the angiographic and clinical outcomes from acute (first 6 hours after bleeding) interdisciplinary treated patients with ruptured intracranial aneurysm.An interventional neuroradiologist and a neurosurgeon set the emergent treatment of 100 consecutive patients with subarachnoid hemorrhage (SAH) harboring 111 cerebral aneurysms. Decisions were based on the patient's clinical condition, aneurysm's morphology and location, presence of intracranial mass-occupying process (IMOP), angiographic flow distribution patterns and treatment-related risk profit. The benefits of a joined case assessment were retrospectively analyzed, comparing our clinical and radiological results with those of the averaged literature series.Initially, 39 aneurysms in 34 patients were endovascularly (EV) treated and 68 aneurysms in 66 patients were surgically (S) treated. Four nonruptured aneurysms remain under control. Complete radiological aneurysm occlusion was initially achieved in 35 (89.7%) EV and 62 (95.4%) S treated aneurysms. Twenty-six patients in poor clinical condition with IMOP as well as ten patients with distally located, 18 with EV unfavorable and 12 with highly expected recanalization rate aneurysms required S treatment. Four aneurysm remnants (two EV and two S) remain unchanged. Two EV treated aneurysms grew and were surgically occluded, and another three patients required an additional coiling procedure after recanalization. Favorable evolution was observed in 27 (79.4%) EV and 55 (83.3%) S treated patients. Computed tomography-documented rebleedings (7:1), angiographic vasospasm (3:5) and occlusion of main vessels (2:2) were the method-related complications in the EV and S groups, respectively.After comparing the literature data, acute interdisciplinary treatment of patients with SAH increases the rate of aneurysm occlusion, improves patient's evolution and reduces the number of complications.

To assess the volume of large intracranial meningiomas and analyse their different microsurgical and clinical managements.The volume of 45 large meningiomas treated in our department during the last 9.5 years was retrospectively assessed using recorded neuronavigation data. The seven most employed microsurgical strategies and five important factors influencing the patient's outcome (tumor location, grade of peritumoral brain swelling, grade of brain atrophy, entrapment of neurovascular structures and the management of the vascular infused fluid volume) were individually analysed. The follow-up ranged from 14 to 84 months.The assessed volumes exceed 100 cm(3) in 38 supratentorial and 45 cm(3) in seven infratentorial tumors. The highest averaged volume in this series was assessed by tuberculum sellae and olfactory meningiomas (174 cc). A complete resection was achieved in 39 patients and was not influenced by the tumor volume. However, an averaged volume difference of 60 cc was observed between anterior skull base tumors in which their averaged greatest diameter variation was only 1.5 cm. Twelve of 24 patients with deep located tumors and entrapped neurovascular structures presented accentuated brain swelling. A new permanent post-operative neurological deficit was observed only in two patients. In the other patients, cranial nerve deficits, pre-operative hemiparesis and superior cerebral functions improved to varying degrees. Four cases with subtotal resection showed stable residual volumes after 4.5 year follow-up. Three cases underwent additional radiosurgery.Tumor volume assessment allows an improved meningioma size differentiation. Despite the large volume of the tumors in this series, satisfactory resection was still possible using single-stage procedures. Individual microsurgical strategies and fluids management contributed to reducing patient's morbi-mortality.

To assess intracranial aneurysms clipping efficacy (CE) employing different angiographic techniques in relation to the case difficulty.In the past 6 years, 152 patients harboring 179 aneurysms who underwent surgical clipping in our department were angiographically examined to confirm aneurysm occlusion. Intraoperative angiography (IA), post-operative conventional (PCA) and three-dimensional angiography were single or sequentially performed based on the surgeon's concern about case difficulty. The percentage of visualized angiographic abnormalities (PVAA) assessing CE and their impact on corrective treatment were retrospectively analysed.The PVAA of IA was 67.8% (19 of 28 aneurysms). Eighteen of them (eight aneurysm remnants, four parent vessel stenosis, two distal branch occlusions and five clip slippage phenomena) underwent immediate corrective treatment (clip reposition in 11 cases, complementary clipping in three cases and combined treatment in four cases). The impact on corrective treatment was 94.7%. The PVAA of PCA was 18.4% (33 of 179 aneurysms). Fifteen patients presented aneurysm remnants, six presented parent vessel stenosis, five presented distal branch occlusions and seven presented clip slippage phenomena. The impact of this technique on corrective treatment was 15.1% (five of 33 angiographic abnormalities). In only one case, PCA demonstrated an aneurysm remnant which was missed on IA. Twenty patients were additionally examined with three-dimensional angiography. The impact on corrective treatment of three-dimensional angiography was 25% (five of 20 examined patients with angiographic abnormalities).In pre-selected difficult cases, IA provides high PVAA and increased impact on corrective treatment. In non-selected patients, PCA shows low PVAA and reduced impact on corrective treatment. The complementary assessment with multiplanar three-dimensional angiography increases the impact on corrective treatment and facilitates decisions about the final case management.

Objective: The aim of this paper is to analyse and summarize the main advances in experimental research on cerebral arteriovenous fistulas. Methods: A detailed analysis of the literature and my own research experience were employed to outline the methodology whereby experimental cerebral arteriovenous fistulas are created and further studied. Results: The analysis and quantification of the anatomical and functional variables in different experimental cerebral arteriovenous fistula models make it possible to develop more appropriate and individual ways of treatment in affected patients. Conclusion: Experimental research on cerebral arteriovenous fistulas helps physicians to understand and predict more accurately the future evolution of arteriovenous malformations in humans.

The aim of this study was to evaluate the invasiveness and efficacy of 2 different keyhole approaches to large basal ganglia hematomas (LBGHs).The invasiveness and efficacy of the temporal (15 cases) and the frontal (15 cases) microsurgical keyhole approach were retrospectively evaluated in 30 early-operated patients with LBGH, using recorded neuronavigation data. Invasiveness was assessed calculating the angles of brain retraction and the volume of brain exposed to surgery. Reduced invasiveness was related to a fall of these values. Efficacy was evaluated by comparing the volume of microscopically visualized clot and the largest hemorrhage diameter exposed with the 2 different keyhole approaches. Increased efficacy was related to a rise in these parameters. All estimations were correlated to the volume of residual clot detected on postoperative computed tomography scan.The comparison between both approaches revealed a significant reduction of invasiveness (smaller angles of brain retraction [P.001] and reduced brain exposition [P.001]), as well as a raised efficacy (increased volume of visualized clot [P.001] and largest hemorrhage diameter exposed to surgery [P.001]) for frontally approached LBGH. These patients showed less postoperative residual hematomas (P.05). Residual clots were correlated to the evaluated brain retraction (P.001) and volume of brain (P.001), as well as volume of clot surgically exposed (P.05).We conclude that the frontal approach to LBGH leads to less invasiveness and higher efficacy as evaluated by using neuronavigation data. This approach shows a reduced number of patients with residual postoperative clots.

Carvi y Nievas M, Haas E, Hollerhage H-G, Lorey T, Klein P-J. Cerebral vein thrombosis associated with aneurysmal subarachnoid bleeding: implications for treatment. Surg Neurol 2004;61:95–8 Background Cerebral vein thrombosis associated with aneurysmal subarachnoid bleeding is an uncommon event rarely described in the literature. We report here a case and summarize the problems in the management of this patient. Case description A 48-year-old female suffered from two episodes of severe headache and vomiting 7 days before and on the day of admission. She was deeply somnolent with mild paresis of her right leg. Computed tomography (CT) scans revealed diffuse basal subarachnoid bleeding and a left parietal subcortical hemorrhagic area. A cerebral angiogram demonstrated an anterior communicating artery aneurysm. The angiographic late venous phase showed nonopacification of the cortical veins on the hemorrhagic area compatible with cerebral vein thrombosis. She underwent successful aneurysm clipping combined with moderate systemic anticoagulation. After 7 days of gradual clinical improvement she presented acute bilateral cerebral herniation signs and died 48 hours later. CT scan showed a generalized brain swelling. Postmortem examination confirmed the correct occlusion of the ruptured aneurysm sac and the presence of a postthrombotic subcortical left parietal hemorrhage as well as a complete obstruction of the superior sagittal sinus extended into both transverse sinus. Conclusion The fatal outcome with the documented extended thrombosis, despite careful anticoagulation therapy, indicates the necessity of closely meshed follow-up studies examining the sinus patency in such complicated cases with associated pathology.

Clinical experience about the management of patients with an unruptured intracranial aneurysm (UIA) presenting transient cerebral ischemic attacks (TIAs) is usually restricted to a few case reports. Some authors assume that it is safe to perform an endarterectomy without acutely increasing the risk of aneurysm rupture while others reported a post-operative aneurysmal bleeding even for aneurysms smaller than 10 mm between some days and several months after endarterectomy. The aim of this paper is to analyse the factors involved in the particular ischemic episodes, the examination methods to be employed, and the optional management for each individual case on a literature review and own experience-based data.

The purpose of this work was to analyse the surgical procedure used and the outcome from patients with solitary nerve associated benign tumors of the extremities (SNABTE)5 cm.A 15 year review was performed for all patients with SNABTE treated in our department. The surgical procedures used (complete or incomplete tumor removal, with or without nerve preservation), the needs for grafting techniques as well as the outcome were analysed.Nine (9.5%) of 94 patients with SNABTE met the study requirements. The histological diagnosis revealed a schwannoma in four cases, a neurofibroma in three cases, one lipoma and one lipofibroma. Seven lesions could be completely excised. Preservation of the nerve bundles with complete neurological recovery was possible in five cases. The resection of a 22 cm neurofibroma without preservation of the nerve did not add measurable residual neurological deficits. One patient with a peroneal neurofibroma required a grafting procedure. Intentional incomplete tumor excisions were performed in two patients with well preserved nerve functions where a median nerve lipofibroma and a radial nerve neurofibroma were diagnosed. All patients showed different degrees of improved outcome.We conclude that the complete resection of large SNABTE, excepting lipofibromas and some neurofibromas, is always possible and associated with an improved outcome. The nerve preservation should be attempted in all cases, particularly in those with conserved functionality of a major nerve trunk.

Object In this study the authors evaluated disease incidence, treatment, and outcome in patients with unusual sequestered disc fragments simulating spinal tumors or another space-occupying lesion on preoperative MR imaging. Methods The authors retrospectively reviewed data from the last 3000 patients with a histological diagnosis of disc herniation. Patients with preoperative MR imaging findings that simulated a spinal tumor or other spaceoccupying lesion were individually analyzed. Results In 11 patients (0.4%), MR imaging findings of unusual sequestered disc fragments were mistaken for another spinal space-occupying lesion. In 8 cases, the fragments had migrated to the posterior spinal space; in 3 cases, into the dural sac. In 3 patients, the fragments were distant from the original disc space. A heterogeneous mass was revealed with low-intensity or isointense signal on T1-weighted MR images as well as low signal (4 cases) or high signal (7 cases) intensity on T2-weighted images, relative to the spinal structures. A slight diffuse or peripheral Gd enhancement rim was observed in 7 patients. Disc fragments were located in the cervical (1 patient), thoracic (2 patients), and lumbar (8 patients) spine. All lesions were completely removed. Discectomy was required in 4 patients. A complete recovery occurred in 8 patients and a minor neurological deficit remained in 3. Conclusions Atypically located disc herniations should be considered in the differential diagnosis in patients with MR imaging data indicating spinal space-occupying disorders. All of these lesions, even those intradurally located, can be completely removed.

To analyse the surgical reliability of neuronavigation-assisted trans-sphenoidal tumor resections.In the past 7 years, all patients, who underwent neuronavigation-assisted trans-sphenoidal tumor resection in our department, were additionally intraoperatively controlled with a radioscopic device. Tumor removal was repeatedly checked up with the navigator and the tip of the pointer was correlated with the lateral intraoperative skull radiologic examination to confirm the real pointer deepness, spatial location and trajectory. The reliability of these assessments was analysed by simple images comparison and searching for tumor-related differences, and controlled with post-operative magnetic resonance studies.During the analysed period, a total of 36 patients were treated in our department. Diagnosis included 14 non-secreting adenomas, 18 secreting adenomas and four non-pituitary tumors. Tumors diameter ranged from 1.4 to 4.5 cm. A mean accuracy of 0.8 mm could be achieved for all patients. In all cases, the real deepness, position and trajectory of the navigator were identical to those observed with X-ray examinations. At least nine from ten pointer determinations were identical in all cases. Particularly, all pituitary tumors with suprasellar extension could be safely controlled, even during advanced stages of resection and before the tumor capsule detached from suprasellar neighbor structures. Intrasellar, clival and suprasellar tumors were adequately removed as confirmed with MRI.Radioscopic controlled neuronavigation shows high reliability and allows surgeons to be more confident during the trans-sphenoidal resection of skull base tumors. This offers the advantage to reduce the patient's X-ray exposure and the possibility of simultaneous multiplanar images evaluation.

Severe intracranial bleedings (SIBs) during endovascular procedures (EPs) are accompanied by acute intracranial hypertension and brain herniation signs. The purpose of this study was to determine the effectiveness of urgent surgical management and its related patient outcome in cases with such a fatal complication.Medical records were reviewed retrospectively for the last 750 patients treated in our department in the past 12 years with acute non-traumatic intracranial bleeding, who underwent a diagnostic or therapeutic EP. Patients with a severe intra-procedural bleeding episode undergoing urgent surgical management (within 30 minutes after bleeding) were analysed.Fourteen of 750 patients with ruptured vascular malformations presented a new SIB during EP. In nine patients, this occurred during initial angiography, two during aneurysm coiling, two during balloon angioplasty and one during arteriovenous malformation (AVM) embolization. The neurological condition 6 months later was good (independents patients) in seven cases with only a mild disability in two of them. Two patients showed a severe disability. Four patients died without recovering their consciousness. One patient presented a satisfactorily course but died weeks later owing to a pulmonary embolism.Despite the fatal spontaneous prognosis of severe intracranial bleeding occurring during endovascular diagnostic or therapeutic procedures, a favorable outcome can be expected if an appropriated treatment was set within 30 minutes of the bleeding.

This study assesses the clinical outcome after early combined cranioplasty (own frozen bone) and shunt implantation (Codman-Medos programmable VP shunt) in patients with skull bone defects and cerebrospinal fluid (CSF) circulation disorders.Medical records were reviewed retrospectively for the last 100 patients with CSF disorders after trauma or subarachnoid hemorrhage (SAH), who previously underwent decompressive craniotomy owing to therapy-resistant brain swelling. Patients treated with early (5 to 7 weeks after injury) combined cranioplasty and shunt implantation were analysed and a follow-up for the survivors was obtained.In 60 patients with a daily CSF external drainage over 150 ml and dilated ventricles in CT scan, a programmable VP shunt was implanted simultaneously with the cranioplasty within 5.1 weeks after decompression. The neurological condition 6 months later was good (independent patients) in 39 cases (65%); 12 patients (20%) survived with a severe disability; three patients (5%) remained in a persistent vegetative state and only six patients (10%) died. There were few complications: bone or shunt infection (three cases), post-operative intracranial bleeding (one case), transitory neurological impairment after bone reimplantation (two cases), bone resorption (two cases) and shunt dysfunction (three cases).The early reimplantation of the patient's own skull bone combined to the employment of a programmable shunt system allowed us a dynamic adjustment of the intracranial pressure (ICP) changes. The combined treatment reduced the number of required surgical procedures, complications and unsatisfactory patient outcomes.

This study assesses the benefits of adapting minimal invasive techniques (MIT) to selected patients with spontaneous supratentorial intracerebral hematomas (SSICHs).The study compares the post-operative residual clot volume and clinical outcome of 89 selected, MIT evacuated SSICH-patients to those of 138 unselected cases operated in our department. Selection criteria includes patient age, early admission and MIT treatment. MIT treatment included: 28 patients with deep SSICHs smaller than 30 cm3 associated with intraventricular bleeding who underwent neuronavigation-guided stereotactic catheter lysis, 37 patients with deep hematomas larger than 30 cm3 and 24 patients with a lobar hemorrhage compressing eloquent regions who underwent microsurgical (endoscopic or neuronavigation assisted) clot aspiration.In eight (9%) of the patients in the MIT group, the CT scan control showed a residual clot smaller than 30% of the initial hemorrhage. The neurological condition 3 months later revealed 24 (26.9%) of these patients having a severe disability and 46 (51.6%) patients independent or slightly disabled. Nineteen patients (21.9%) died or remained vegetative. In the control group, 48 (34.7%) cases showed residual clots (30%). Sixty-two (44.9%) patients of this group were severely disabled and only 40 (28.9%) were independent. Thirty-six (26%) patients died or were vegetative. There was a p0.001 significant difference in volume of residual clots as well as p0.01 for the outcome between the two groups.Adapting minimally invasive techniques to case selection improves the effectiveness of clot removal and the outcome of the patients with SSICHs.

The objective of this study was to examine early changes of intracranial pressure (ICP) and brain oxygenation before, during, and after cerebral angiography in patients with poor-grade subarachnoid hemorrhage (SAH).Fourteen patients with poor-grade SAH without intracerebral hematoma were studied. A significant change in monitored variables (arterial gases, ICP, brain-tissue oxygen pressure [Ptio(2)], brain-tissue carbon dioxide pressure, and pH) was defined as a register deviation of more than 20% compared with the baseline. Critical Ptio(2) values (15 mm Hg) or significant Ptio(2) decreases were considered to be impaired brain oxygenation. These data were correlated with the angiography findings and the presence of massive brain edema and hypodense areas in follow-up computed tomography (CT) scan controls.Neurotrend data were unavailable in 4 patients because of calibration failure. Impaired brain oxygenation during angiography was observed in 5 patients. Initial critical Ptio(2) values were found in 1 patient. Four patients developed a linear Ptio(2) and pH decrease after the angio-catheter canalized the examined vessels in the neck. Statistically significant correlation was found between brain pH and Ptio(2) changes in these patients (P.001, Spearman rho). Arterial gases, ICP, and cerebral perfusion pressure did not show significant alterations at this time. Significant correlations existed between severe intracranial angiographic arterial caliber reduction and impaired Ptio(2) values (P.01). Patients with impaired Ptio(2) values frequently showed lesions in CT scan controls (P.05).This study documented several fluctuations in the brain oxygenation of patients with poor-grade SAH during angiography. Patients with severe intracranial angiographic arterial caliber reduction at this time have an increased risk for impaired brain oxygenation.

We describe a patient in whom two non-symptomatic internal carotid artery and middle cerebral artery pseudo-aneurysms were diagnosed 1 year following the surgical removal of a clinoidal meningioma. The unusual number, location, form and evolution (actual follow up of 6 years) of these pseudo-aneurysms differentiate them from other vascular lesions associated with surgery. It is important to understand the mechanism of vascular injury in order to understand imaging features and the possible methods of treatment.

Patients with spontaneous intracerebral hematomas experience higher mortality and suffer more severe deficits than any other stroke subtype. Although significant intracerebral hematoma (ICH)-related death and severe neurological deficits arise from hematoma mass effect and intraventricular extension, further clinical deterioration related to rebleeding and/or perihematomal brain edema development often occurs. Many studies have shown that the level of disability and mortality after ICH also depends on the Glasgow Coma Scale (GCS) score, hemorrhage size and patient age. Despite major advances in brain-imaging examination procedures, improvements in neurosurgical critical care, and refinements in microsurgical techniques, only a few subgroups of patients with spontaneous intracerebral hematomas are usually listed as candidates for surgical treatment in the reported series. One of the most commonly used clinical indications for surgery is neurological deterioration, but this is also a predictor of poor outcome. The recognized trials on the surgical management of intracerebral hematomas make exhaustive analyses of neither the potential advantage of setting patient selection criteria nor the role of early-applied, modern, minimally invasive techniques. In addition, all over the world considerable differences in the treatment of spontaneous intracerebral hematomas make the physicians involved uncertain about the need for surgery. The aim of this paper is to provide clear statements concerning the surgical management of spontaneous intracerebral hematoma patients based on a detailed analysis of the literature and on own experience-based data.

This report analyzes the treatment of six patients with transient cerebral ischemic episodes in combination with large unruptured aneurysm. Priority treatment of the symptomatic lesions had to be delayed in five cases because the large aneurysms were ipsilateral to stenoses of the internal carotid artery. The hemodynamic effect of surgery on the compromised cerebral circulation was pre-examined with digital subtraction angiography and technetium-99m ((99m)Tc) single photon emission computed tomography. The data were correlated to aneurysm location and anatomical territory of the transient ischemic episodes. Only one patient showing a severe carotid stenosis contralateral to the large aneurysm, with decreased technetium uptake in the symptomatic hemisphere, required surgical correction of the stenosis first. In five patients, areas of reduced (99m)Tc uptake were mostly found within vascular boundary zones with angiographically verified effective collateral circulation. Clipping of the large aneurysms in these patients ipsilaterally to the stenotic lesion or on the anterior communicating artery as first option did not substantially increase the risk of subsequent stroke.

OBJECTIVE The goal of this study was to determine whether the complementary use of computed tomographic angiographic (CTA) assessments would provide additional benefits in the evaluation and treatment of ruptured vertebrobasilar artery aneurysms. METHODS In the past 4.5 years, 35 patients with an infratentorial dominant pattern of subarachnoid hemorrhage were complementarily examined with CTA scanning, after undergoing one or more three-dimensional rotational projection digital subtraction angiographic (DSA) studies. The results of these studies were interpreted by the treating neurosurgeon and an interventional radiologist, to examine the usefulness of the findings for the detection of aneurysms and to determine the grade of parent artery vascular filling and the optical definition of the aneurysm. This information provided additional benefits for case management. RESULTS Thirty-three aneurysms were detected. For 10 patients, no aneurysm was identified in repeated examinations with the two methods. We detected only 16 of the 25 ruptured aneurysms (64%) on the first DSA scans and, even with repeated examinations, 6 aneurysms were not clearly identified with this technique. CTA scanning revealed the ruptured aneurysms in 25 cases and demonstrated increased vascular filling and improved optical definition of the aneurysms, compared with DSA scanning, in 12 cases (48%). The information obtained from the CTA scans allowed the selection of five patients for endovascular treatment and facilitated the surgical procedures in five cases. CONCLUSION Complementary CTA examination of the vertebrobasilar complex provides a higher rate of aneurysm detection and improves the optical definition and anatomic projection of these aneurysms, compared with DSA scanning alone. This facilitates therapeutic decision-making (surgical versus endovascular procedures) and allows neurosurgeons to use more restricted surgical exposures.

In this manuscript a comprehensive coverage of recent developments in the drug therapy of vasospasm while providing the background information that neuroscientists need to understand its rationale. The range of new agents

Background: This study assesses the tract alterations observed before and after resection of solid posterior fossa tumors (PFTs) using diffusion tensor imaging (DTI) and white matter tractography (WMT). Materials and Methods: Pre- and post-surgical DTI and WMT data were acquired in eight patients undergoing surgical resections of PFT. A tensor deflection algorithm was used to reconstruct the tracts adjacent to the lesions. The tracts were evaluated regarding their spatial orientation and integrity. A software additionally assessed the luminosity and pixel values from specific regions of interest (ROIs) quantifying the magnitude of tract alterations. The individual neurological condition was additionally evaluated. Results: In eight tumors (metastases (4), neurinomas (2) and meningiomas (2), the preoperative WMT revealed different tract alterations, including deviation (all cases), deformation (7 cases), thinning (8 cases) and apparent tract interruption (4 cases). The ROI histograms from noncompromised tracts showed a tendency for value concentration and peak formation, while affected tracts showed different dispersion patterns. After tumor resection, the compromised white matter tracts showed a resolution (3 cases) or reduction (5 cases) of the deviation. Postoperatively, 7 cases of tract thinning and 3 cases with tract interruptions showed an improvement. The comparison between ROI histograms from preoperative and postoperative compromised tracts mostly revealed a postoperative accentuated reduction of the luminosity with a simultaneous increase of pixels and improved histogram definition (homogeneous values distribution). At this time (5 weeks post-surgery), several neurological functions had improved to different levels. Conclusions: Preoperative and postoperative tract alterations in patients with solid PFT can be accurately assessed with WMT. The magnitude of tract changes can be quantitatively analyzed by assessing color, signal brightness in compromised bundles.