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This study aimed to compare the degree of posterior malleolar exposure, the tension of the flap containing the posteromedial neurovascular bundle (NVB), and the distance between the surgical incision and the NVB using three different posteromedial ankle approaches. Three approaches were compared: medial posteromedial (MePM) modified posteromedial (MoPM) and posteromedial (PM). We measured the minimal tension of the flap containing the NVB that allowed proper exposure. In the second stage, an axial cut was performed, and we measured the degree of posterior malleolar exposure and the distance between the incision and the NVB There were significant differences between the three approaches examined regarding the degree of posterior malleolar exposure and distance from the incision to the NBV,favoring the PM approach (71,00% ± 1.83 and 25.50 mm ± 4.20). The PM approach provided a significantly lower tension to the flap containing the posteromedial NVB (6.18 N ± 1.28) compared to the other two approaches The PM approach achieved the highest degree of posterior malleolar exposure, the lowest tension to the posteromedial NVB, and the greatest distance between the incision and the NBV. Thus, we believe it should be considered the approach of choicefor large fractures of the posteromedial aspect of the PM. [ABSTRACT FROM AUTHOR]

Abstract Background Remimazolam is a short-acting benzodiazepine newly approved for the induction and maintenance of general anesthesia. Remimazolam emerges as an ideal drug for the neurosurgical population due to its rapid emergence, enabling early neurological assessment, and its ability to maintain perfusion pressure, which is crucial for preventing cerebral ischemia. However, the use of benzodiazepine has been associated with an increased risk of postoperative delirium (POD). There is currently limited evidence about the relationship between remimazolam-based total intravenous anesthesia (TIVA) and POD. Methods In this double-blind, randomized, non-inferiority trial, we plan to include 696 adult patients with American Society of Anesthesiologists physical status class I to III, undergoing elective neurovascular surgery under general anesthesia. After informed consent, the patients will be randomized to receive either remimazolam or propofol-based TIVA with a 1:1 ratio. The primary outcome is the incidence of POD within 5 days after surgery. Secondary outcomes include subtypes, number of positive assessments and severity of POD, emergence agitation, intraoperative awareness and undesirable patient movement, intraoperative hypotension, and postoperative cognitive function. The data will be analyzed in modified intention to treat. Discussion This trial will evaluate the effect of remimazolam on the development of POD compared to propofol anesthesia. The results of this trial will provide evidence regarding the choice of optimal anesthetics to minimize the risk of POD in neurosurgical patients. Trial registration The study protocol was prospectively registered at the Clinical trials ( https://clinicaltrials.gov , NCT06115031, principal investigator: Jiseon Jeong; date of first registration: November 2, 2023, before the recruitment of the first participant.

Background: Remimazolam is a short-acting benzodiazepine newly approved for the induction and maintenance of general anesthesia. Remimazolam emerges as an ideal drug for the neurosurgical population due to its rapid emergence, enabling early neurological assessment, and its ability to maintain perfusion pressure, which is crucial for preventing cerebral ischemia. However, the use of benzodiazepine has been associated with an increased risk of postoperative delirium (POD). There is currently limited evidence about the relationship between remimazolam-based total intravenous anesthesia (TIVA) and POD. Methods: In this double-blind, randomized, non-inferiority trial, we plan to include 696 adult patients with American Society of Anesthesiologists physical status class I to III, undergoing elective neurovascular surgery under general anesthesia. After informed consent, the patients will be randomized to receive either remimazolam or propofol-based TIVA with a 1:1 ratio. The primary outcome is the incidence of POD within 5 days after surgery. Secondary outcomes include subtypes, number of positive assessments and severity of POD, emergence agitation, intraoperative awareness and undesirable patient movement, intraoperative hypotension, and postoperative cognitive function. The data will be analyzed in modified intention to treat. Discussion: This trial will evaluate the effect of remimazolam on the development of POD compared to propofol anesthesia. The results of this trial will provide evidence regarding the choice of optimal anesthetics to minimize the risk of POD in neurosurgical patients. Trial registration: The study protocol was prospectively registered at the Clinical trials (https://clinicaltrials.gov, NCT06115031, principal investigator: Jiseon Jeong; date of first registration: November 2, 2023, before the recruitment of the first participant. [ABSTRACT FROM AUTHOR]

Intraoperative neurophysiological monitoring (IONM) is a crucial advancement in neurosurgery, enhancing procedural safety and precision. This technique involves continuous real-time assessment of neurophysiological signals, aiding surgeons in timely interventions to protect neural structures. In addition to inherent limitations, IONM necessitates a detailed anesthetic plan for accurate signal recording. Given the growing importance of IONM in neurosurgery, we conducted a narrative review including the most relevant studies about the modalities and their application in different fields of neurosurgery. In particular, this review provides insights for all physicians and healthcare professionals unfamiliar with IONM, elucidating commonly used techniques in neurosurgery. In particular, it discusses the roles of IONM in various neurosurgical settings such as tumoral brain resection, neurovascular surgery, epilepsy surgery, spinal surgery, and peripheral nerve surgery. Furthermore, it offers an overview of the anesthesiologic strategies and limitations of techniques essential for the effective implementation of IONM. [ABSTRACT FROM AUTHOR]

Background: Urinary tract infection (UTI) associated with Klebsiella pneumoniae poses a serious threat for inpatients. This study aimed to describe the genomic characteristics of K. pneumoniae causing UTI in a tertiary-care hospital in Beijing, China. Methods: A total of 20 K. pneumoniae strains collected from 2020 to 2021 were performed whole-genome sequencing. The Antibiotic susceptibility of 19 common antimicrobial agents was tested against all strains. The multi-locus sequence types (MLSTs) and serotypes were determined from the WGS data. De novo assemblies were used to identify resistance and virulence genes. The presence and characteristics of the plasmids were detected using hybrid assembly of long and short-read data. Results: These K. pneumoniae strains were clustered into nine sequence types (STs) and twelve K-serotypes. All the carbapenem-resistant K. pneumoniae (CRKP) strains acquired carbapenemase blaKPC-2 (n=7). Two CRKP strains exhibited increased resistance to Polymyxin B with MIC ≥ 4 mg/L due to insertion of an IS5-like sequence in the mgrB gene, and they were also involved in a transmission event in Intensive Care Unit. Long-read assemblies identified many plasmids co-carrying multiple replicons. Acquisition of a new IncM2_1 type blaCTX-M-3 positive plasmid was observed after transfer from ICU to neurovascular surgery by comparing the two strains collected from the same patient. Conclusion: K. pneumoniae is a significant pathogen responsible for urinary tract infections. The ST11-KL47 strain, prevalent at our hospital, exhibits a combination of high drug resistance and hypervirulence. It is imperative to enhance ongoing genomic surveillance of urinary tract infection-causing pathogens. [ABSTRACT FROM AUTHOR]

Neurosurgical training continuously seeks innovative methods to enhance the acquisition of essential technical skills for neurosurgeons worldwide. While various training models have been employed, few truly replicate real-life conditions optimally. Human placenta is a good model for neurosurgical microsurgery training due to its anatomic similarities to neurovascular structures. Placental vessels exhibit a branching pattern and caliber comparable with intracranial vessels, making them suitable for practicing microsurgical techniques. The study aims to delineate the anatomic zones of the placenta and propose a segmented training model, resulting in a reproducible, cost-effective, and realistic neurosurgical microsurgery training environment. Twenty human placentas were meticulously prepared, injected with dyes, and categorized into zones on the basis of anatomic features. Measurements of placental vessels were recorded and compared with cerebral vessels. The placenta was divided into 4 quadrants to facilitate specific training techniques. Our results revealed varying vessel diameters across placental zones, closely resembling cerebral vessels. Different microsurgical techniques were applied to specific placental zones, thereby optimizing training scenarios. The applicability section described exercises such as membrane dissection, vessel skeletonization, aneurysm creation, vascular bypass, and tumor dissection within the placental model, providing detailed guidance on the zones suitable for each exercise. Human placenta serves as an effective microsurgical training model for neurosurgery, enhancing neurosurgeons' skills through anatomic segmentation. Integrating this model into training programs can significantly contribute to skill acquisition and improved surgical outcomes. Further research is warranted to refine and expand its utilization, complemented by clinical experiences and other simulation tools. [ABSTRACT FROM AUTHOR]

Calcaneal osteotomies correct hindfoot deformities and are often performed using a minimally invasive technique. The aim was to compare the safety of three calcaneal osteotomy techniques (oblique, chevron with apex anterior and chevron with apex posterior). Each osteotomy technique was performed on five cadavers (n = 15). These were then dissected to identify any injury to the neurovascular bundles. The distance between the burr and these structures was measured. Using the apex posterior technique, the burr was closer to the medial and lateral neurovascular structures, and in one case the sural nerve was injured. There were no neurovascular injuries using the other techniques. Minimally invasive surgery using a burr is generally a safe, reliable method for performing calcaneal osteotomies. The chevron with apex posterior osteotomy should be performed with caution given the closer relationship between the burr and neurovascular bundles. The other two techniques provide safer alternatives. 4 [ABSTRACT FROM AUTHOR]

Various surgical and anatomical classifications have been proposed to date related to ACoA aneurysm projection. Nonetheless, a universally accepted classification system is yet to be established. This study is aimed at establishing a standardized classification system for ACoA aneurysms with utilization 3D technology and defining reference lines for their projections. The goal is to create a simple, understandable, surgically beneficial, and reliable classification system based on neurovascular structures in the region, including safe and hazardous zones. The radiologic data of 96 patients with ACoA aneurysm who were treated in our university hospital between 2012 and 2020 were retrospectively analyzed, and a planned classification scale was developed with the data obtained. The classification aimed to create 9 main projection groups in the sagittal plane: superior, inferior, anterior, and posterior in linear orientation, and anterosuperior, posterosuperior, anteroinferior, posteroinferior, and complex in quadrant orientation. The coronal and axial planes included medial, lateral, and midline classifications, resulting in a 3-dimensional classification system with 25 projections. Among the 96 patients, 32 had linear and 64 had quadrant projections. In the sagittal plane, the linear projection breakdown was as follows: superior (28%), inferior (6.25%), anterior (53%), and posterior (12.5%). For the quadrant projection, the distribution was as follows: anterosuperior (53%), posterosuperior (12.5%), anteroinferior (21.87%), posteroinferior (3.12%), and complex (9.37%). Overall, 35.4% aneurysms were anterosuperior, 17.7% anterior, 14.58% anteroinferior, 9.37% superior, 8.3% posterosuperior, 6.25% complex, 4.16% posterior, 2.08% posteroinferior, and 2.08% inferior projection. Our study proposes a projection classification that utilizes 3D technology for safe surgery based on neurovascular structures in the region and thus better reveals safe and hazardous zones, including three plans, three dimensions, and two orientations. The use of this classification system offers valuable guidance for daily practice in the treatment of ACoA aneurysms. [ABSTRACT FROM AUTHOR]

Surgical treatment of neurovascular lesions like intracranial aneurysms, arteriovenous malformations and arteriovenous dural fistulas is still associated with high morbidity. Several recent studies are providing increasing insights into reliable tools to improve surgery and reduce complications. Inadvertent vessel compromise and incomplete occlusion of the lesion represent the most possible complications in neurovascular surgery. It is clear that direct visual examination alone does not allow to identify all instances of vessel compromise. Various modalities, including angiography, microvascular Doppler and neurophysiological studies, have been utilized for hemodynamics of flow vessels in proper clipping of the aneurysm or complete obliteration of the lesion. We intended to review the current knowledge about the intraoperative microvascular Doppler (iMDS) employment in the most updated literature, and explore the most recent implications not only in intracranial aneurysms but also in neurovascular lesions like arteriovenous malformations (AVMs) and arteriovenous dural fistulas (AVDFs). According to the PRISMA guidelines, systematic research in the most updated platform was performed in order to provide a complete overview about iMDS employment in neurovascular surgery. Twelve articles were included in the present paper and analyzed according to specific research areas. iMDS employment could represent a crucial tool to improve surgery in neurovascular lesions. The safety and effectiveness of the surgical treatment of neurovascular lesions like intracranial aneurysm and other neurovascular lesions like AVMs and AVDFs requires careful and accurate consideration regarding the assessment of anatomy and blood flow. Prognosis may depend on suboptimal or incomplete exclusion of the lesion. [ABSTRACT FROM AUTHOR]

Objective: Transradial approach (TRA) is increasingly used as a viable alternative to the traditional transfemoral approach (TFA) in neuroendovascular therapy (NET) owing to its potential anatomical benefits and lower puncture-site complication rates. However, the real-world challenges of implementing TRA-NET have not been thoroughly studied, particularly those related to guide catheter (GC) placement. In this study, we aimed to explore the feasibility and challenges of TRA-NET, with a specific focus on GC placement. Methods: This retrospective observational study included patients who underwent NET at our institution between December 2019 and May 2022. Procedural success was defined as the successful placement of a GC in the target vessel. Cases in which a Simmons-shaped GC was used or the approach was changed to TFA were classified as difficult. Safety was assessed based on the rate of severe puncture-site complications requiring either blood transfusion or surgical intervention. Results: Among the 310 patients who underwent NET during the study period, 222 (71.6%) with a median age of 74 years were selected for TRA-NET. The target vessel was in the left anterior circulation (LtAC) in 101 (45.5%) patients, and 8-F GCs were the most frequently used (40.1%). TRA-NET achieved a 95.0% success rate, with a switch to TFA required in 5.0% of the cases. Procedural challenges occurred in 42 (18.9%) patients, primarily in those with LtAC lesions. Specifically, a type III aortic arch (p <0.0001) and age =80 years (p = 0.01) were significantly associated with procedural difficulties. Radial artery evaluation was confirmed in 66 cases (29.7%), revealing one instance (1.5%) of radial artery occlusion. No severe puncture-site complications were observed. Conclusion: TRA-NET may provide substantial therapeutic benefits without significant limitations in device use. However, it may be challenging, particularly in older patients and those with a type III aortic arch with LtAC lesions. Consequently, careful selection of the approach route is imperative. [ABSTRACT FROM AUTHOR]

This document is a memorial tribute to Professor Juha Hernesniemi, a highly respected and influential microneurosurgeon. It highlights his expertise in managing intracranial aneurysms, arteriovenous malformations, and dural arteriovenous fistulae. Professor Hernesniemi's impact extended beyond surgery, as he mentored numerous healthcare practitioners and established the annual Helsinki Live Demonstration Course in Operative Microneurosurgery. His legacy includes the Hernesniemi Fellows and his extensive publication record. The document also discusses his groundbreaking research, commitment to innovation, international collaborations, and impact on neurosurgical care in Peru. It concludes with a note about ongoing projects and a request for support in publishing a book. [Extracted from the article]

Many large randomized trials in interventional cardiology have shown a significant advantage of transradial access (TRA) over transfemoral access (TFA). However, TRA has yet been widely used in Neurovascular interventional surgery. The purpose of this retrospective comparative study is to compare the effectiveness and safety of transradial and transfemoral accesses for cerebral angiography. A total of 380 patients underwent cerebral angiography in our center between January 2019 and January 2021. Among them, 192 patients underwent TRA, and 188 patients via TFA. The success rate of cerebral angiography, X-ray time, total absorbed dose, dose-area product (DAP), complications, and other clinical data were extracted. The operative success (94.27% vs 97.87%; P = 0.071) and the puncture failure (1.56% vs 1.60%) were not significantly different between the TRA and TFA groups. Only arterial spasm, which is more common in the TRA group, was substantially different between the two groups in terms of surgical consequences (P = 0.015). In addition, there were no significant differences between the groups in total absorbed dose (P = 0.604) and DAP(P = 0.097). However, the X-ray time of the TRA group [281.50(216.30,342.00)] was shorter than the TFA group [296.50(230.80,363.50)] (P = 0.019). TRA is effective and safe in cerebral angiography, and its use may be expanded. [ABSTRACT FROM AUTHOR]

The supraorbital "keyhole" approach has been described for the treatment of basilar artery aneurysms. Transpalpebral approach (TPA) is an alternative minimally invasive route to aneurysms of the Circle of Willis with excellent functional and cosmetic outcomes. 53-years-old female who presented with an incidentally found 6.3 mm BA aneurysm with 3.1 mm neck diameter, admitted to our department of neurovascular surgery. Clipping was performed through TPA, with endoscope assistance and intraoperative ICG angiography. The patient's postoperative course was uneventful and was discharged home on postoperative day 5 without any complications. First time in the literature described keyhole TPA with eyelid incision to BA aneurysm. TPA is technically difficult and requires some experience to work through deep and limited surgical corridor. This technique can be good alternative to traditional fronto-lateral, supraorbital keyhole craniotomies. [ABSTRACT FROM AUTHOR]

Augmented reality (AR) involves the overlay of computer-generated images onto the user's real-world visual field to modify or enhance the user's visual experience. With respect to neurosurgery, AR integrates preoperative and intraoperative imaging data to create an enriched surgical experience that has been shown to improve surgical planning, refine neuronavigation, and reduce operation time. In addition, AR has the potential to serve as a valuable training tool for neurosurgeons in a way that minimizes patient risk while facilitating comprehensive training opportunities. The increased use of AR in neurosurgery over the past decade has led to innovative research endeavors aiming to develop novel, more efficient AR systems while also improving and refining present ones. In this review, we provide a concise overview of AR, detail current and emerging uses of AR in neurosurgery and neurosurgical training, discuss the limitations of AR, and provide future research directions. Following the guidelines of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA), 386 articles were initially identified. Two independent reviewers (GH and AC) assessed article eligibility for inclusion, and 31 articles are included in this review. The literature search included original (retrospective and prospective) articles and case reports published in English between 2013 and 2023. AR assistance has shown promise within neuro-oncology, spinal neurosurgery, neurovascular surgery, skull-base surgery, and pediatric neurosurgery. Intraoperative use of AR was found to primarily assist with surgical planning and neuronavigation. Similarly, AR assistance for neurosurgical training focused primarily on surgical planning and neuronavigation. However, studies included in this review utilize small sample sizes and remain largely in the preliminary phase. Thus, future research must be conducted to further refine AR systems before widespread intraoperative and educational use. [ABSTRACT FROM AUTHOR]

The article discusses the benefits and importance of traveling to other neurosurgical centers for medical students, neurosurgical trainees, and early-career neurosurgeons. It highlights the historical significance of traveling in neurosurgery, citing Harvey Cushing's travels as an example. The article emphasizes the value of gaining new insights, learning different surgical techniques, and understanding variations in disease epidemiology and clinical practices. It also acknowledges the challenges of language barriers, licensing, resource limitations, and healthcare inequality. The article concludes by emphasizing the importance of global neurosurgery and the need to promote education, training, and professional networks in the international neurosurgical community. [Extracted from the article]

Background: Surgical mortality indicators should be risk-adjusted when evaluating the performance of organisations. This study evaluated the performance of risk-adjustment models that used English hospital administrative data for 30-day mortality after neurosurgery. Methods: This retrospective cohort study used Hospital Episode Statistics (HES) data from 1 April 2013 to 31 March 2018. Organisational-level 30-day mortality was calculated for selected subspecialties (neuro-oncology, neurovascular and trauma neurosurgery) and the overall cohort. Risk adjustment models were developed using multivariable logistic regression and incorporated various patient variables: age, sex, admission method, social deprivation, comorbidity and frailty indices. Performance was assessed in terms of discrimination and calibration. Results: The cohort included 49,044 patients. Overall, 30-day mortality rate was 4.9%, with unadjusted organisational rates ranging from 3.2 to 9.3%. The variables in the best performing models varied for the subspecialties; for trauma neurosurgery, a model that included deprivation and frailty had the best calibration, while for neuro-oncology a model with these variables plus comorbidity performed best. For neurovascular surgery, a simple model of age, sex and admission method performed best. Levels of discrimination varied for the subspecialties (range: 0.583 for trauma and 0.740 for neurovascular). The models were generally well calibrated. Application of the models to the organisation figures produced an average (median) absolute change in mortality of 0.33% (interquartile range (IQR) 0.15–0.72) for the overall cohort model. Median changes for the subspecialty models were 0.29% (neuro-oncology, IQR 0.15–0.42), 0.40% (neurovascular, IQR 0.24–0.78) and 0.49% (trauma neurosurgery, IQR 0.23–1.68). Conclusions: Reasonable risk-adjustment models for 30-day mortality after neurosurgery procedures were possible using variables from HES, although the models for trauma neurosurgery performed less well. Including a measure of frailty often improved model performance. [ABSTRACT FROM AUTHOR]

In this paper, we analyze the experience and propose a method of incision and stitching of the postoperative scalp wound without shaving hair in elective neurosurgical interventions. Between January 2021 and May 2022, 44 patients with various neurovascular pathologies were included in the study. The age of the patients varied from 28 to 58 years. All patients underwent elective surgical interventions with intradermal cosmetic sutures without shaving hair. The results of published observational series of neurosurgical patients with unshaved hair were also analyzed. Treatment of the surgical field, scalp, and incision were performed without shaving hair in 44 cases. The technique of intradermal suture without shaving hair was used in 31 cases of the classical pterional approach, in 11 cases of minipteronal, in 1 case of parasagittal, and in 1 case of retrosigmoid suboccipittal approaches. The mean age of the patients was 47.5 years (±8.82). The average length of stay in the clinic was 8.02 days (±2.04). The sutures were removed on the fifth–eighth day. All cases were operated on for elective neurovascular interventions: aneurysms without rupture (95.4%), arteriovenous malformations (2.3%), and cavernous angiomas (2.3%). All but one patient (2.3%) had no wound complications—the suture ruptured at the stage of its removal from the skin. Our results also show that the use of a nonresorbable intradermal suture combined with hair preservation does not affect the risk of infection. [ABSTRACT FROM AUTHOR]

Study Design: Retrospective single-arm study. Objective: To propose a novel technique named the gantry crane technique for treating severe thoracic spinal stenosis and myelopathy caused by thoracic ossification of the ligamentum flavum (TOLF) and investigate its clinical results. Methods: From June 2017 to January 2019, 18 patients presenting with severe spinal stenosis and myelopathy caused by TOLF were included in our study. All patients were treated with gantry crane technique, pre-operative JOA score, as well as 3 days-, 3 months-, 6 months-, 12 months-, 24 months after operation, and Hirabayashi recovery rate were reported. Pre- and post-operative image were utilized for the assessment of post-operative effect. Peri-operative complications were recorded to assess the safety of the gantry crane technique. Results: The JOA score increased from 10.56 ± 3.76 preoperatively to 12.94 ± 3.33, 13.56 ± 3.48, 13.94 ± 3.32, 14.17 ± 3.70 and 14.06 ± 3.54 in 3 days, 3 months, 6 months, 12 months and 24 months after surgery, respectively. The post-operative JOA scores were improved with statistical significance at the level of P < 0.05. The recovery rate was (39.09 ± 33.85) %, (51.35 ± 42.60) %, (55.79 ± 36.10) %, (64.98 ± 29.24) % and (60.98 ± 35.96) % for 3 days, 3 months, 6 months, 12 months and 24 months after surgery, respectively. There were 2 cases of SSI (surgical site infection), 1 case of NI (neurovascular injury) and 1 case of cerebrospinal fluid (CSF) leakage. Conclusions: This study highlights a safe and effective technique, the gantry crane technique, for treating severe thoracic spinal stenosis and myelopathy caused by TOLF. [ABSTRACT FROM AUTHOR]

Few data about the electroencephalogram and its calculated indices, such as the bispectral index (BIS), have been reported in rabbits. We aimed to evaluate whether a clinically stable anesthesia was mirrored by consistent and stable BIS values and to investigate the effects of modified cerebral blood supply, due to bilateral carotid clamping and re-opening, on BIS values. We also investigated the effects of fentanyl, as an antinociceptive drug, on the BIS. Sixty-eight rabbits undergoing general anesthesia for surgical creation of carotid bifurcation aneurysms were enrolled. The BIS values were recorded at nine selected time points (TPs) during each procedure and before and after fentanyl administration. The BIS values over time were compared with two-way repeated-measures analysis of variance followed by Tukey test, while the Wilcoxon signed rank test was performed to compare values at clamping and re-opening of the carotids as well as before and after fentanyl administration. The BIS values were significantly lower during anesthesia than at the end of anesthesia and at tracheal extubation; no significant differences were found among other TPs. Adequate depth of anesthesia was mirrored by consistent BIS values among rabbits, and alteration of cerebral blood supply did not modify BIS values, except once. Following fentanyl, BIS values did not change in a clinically relevant way. [ABSTRACT FROM AUTHOR]

Abbreviations aSAH Aneurysmal subarachnoid hemorrhage AVM Arteriovenous malformation; DAVF Dural arteriovenous fistula sIA Saccular intracranial aneurysm Publisher's note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. He was the I Ace of Aces i by microneurosurgical kills of intracranial aneurysms, arteriovenous malformations (AVMs), and dural arteriovenous fistulae (DAVFs), with sleep as leisure time in his I Art of War i . Professor Juha Hernesniemi was one of the greatest microneurosurgeons of the last four decades, known to the entire neurosurgical world through his Live Microneurosurgery Courses and site visits. [Extracted from the article]

Xenon possesses some, but not all, of the clinical features of an ideal anesthetic agent. Besides well-known advantages of rapid awakening, stable hemodynamics and lack of biotransformation, preclinical data lead to the expectation of xenon's advantageous use for settings of acute ongoing brain injury; a single randomized clinical trial using an imaging biomarker for assessing brain injury corroborated xenon's preclinical efficacy in protecting the brain from further injury. In this review, we discuss the mechanisms and hence the putative applications of xenon for brain protection in neurosurgery. Although the expense of this rare monoatomic gas will likely prevent its widespread penetration into routine clinical neurosurgical practice, we draw attention to the theoretical benefits of xenon anesthesia over other anesthetic regimens for awake craniotomy and for neurosurgery in older, high-risk, and sicker patients.

This article is an obituary for Dr. Annaswamy Raja, a renowned neurosurgeon and educator in India. Dr. Raja passed away at the age of 73, leaving behind a legacy of excellence in neurosurgery, medical education, and professional leadership. He was known for his expertise in neurovascular surgery and his commitment to patient care. Dr. Raja was also a founding member of the Indian Society of Cerebrovascular Surgery and played a crucial role in its growth and development. He will be deeply missed by his family, friends, colleagues, and the countless patients whose lives he touched. [Extracted from the article]

Background/aim: Discontinuation of aspirin (ASA) prior to elective craniotomies is common practice. However, patients treated with ASA for secondary prevention bear a higher risk for thromboembolic complications. Aim of this systematic review is to investigate the risks and benefits of perioperative continuation and discontinuation of ASA in elective craniotomies. Methods: PubMed and Embase databases were searched. Inclusion criteria were retro- and prospective studies, reporting hemorrhagic and thromboembolic complications in patients in whom ASA was either continued or discontinued perioperatively in elective craniotomies. We excluded shunt operations and emergency cases. The MINORS (Methodological index for non-randomized studies) score was used to quantify the methodological quality of the eligible studies. Results: Out of 523 publications, 7 met the eligibility criteria (cumulative cohort of 646 patients). The mean MINORS score for the comparative studies was 18.7/24 (± SD 2.07, range: 17–22) and 9/16 for the unique non-comparative study, indicating an overall weak methodological quality of the included studies. 57.1% of the patients underwent craniotomy for intra- and extra-axial tumor removal, 39.0% for bypass surgery and 3.9% for neurovascular lesions (other than bypass). In 31.0% of the cases, ASA was prescribed for primary and in 69.0% for secondary prevention. ASA was continued perioperatively in 61.8% and discontinued in 38.2% of the cases. The hemorrhagic complication rate was 3% (95% CI [0.01–0.05]) in the ASA continuation group (Con-Group) and 3% (95% CI [0.01–0.09]) in the discontinuation group (Disc-Group) (p = 0.9). The rate of thromboembolic events in the Con-Group was 3% (95% CI [0.01–0.06]) in comparison to 6% (95% CI [0.02–0.14]) in the Disc-Group (p = 0.1). Conclusion: Perioperative continuation of ASA in elective craniotomies does not seem to be associated with an increased hemorrhagic risk. The potential beneficial effect of ASA continuation on thromboembolic events needs to be further investigated in patients under ASA for secondary prevention. [ABSTRACT FROM AUTHOR]

Variations of the brachialis muscle are uncommon in the literature. During regular cadaveric dissection, we observed the unilateral presence of an accessory muscle in the front of the right arm of a female cadaver, taking its origin from the medial aspect of the brachialis and the adjacent intermuscular septum. The muscle belly descended downwards, crossed the neurovascular bundle in the cubital fossa and merged with the fibres of the pronator teres. There is no doubt regarding its significance in the etiogenesis of numerous compression syndromes due to its close topographical relationship with the neurovascular bundle. In our report, we consider the potential developmental process and therapeutic implications of this variation, which can aid surgeons in their strategy and management. [ABSTRACT FROM AUTHOR]

In this era of imagination and technological innovation, mixed reality systems such as virtual reality (VR) and augmented reality (AR) are contributing to a wide array of neurosurgical care, from the betterment of surgical planning and surgical comfort to novel treatments and improved resident education. These systems can augment procedures that require high-level dexterity such as minimally invasive surgery and tumor excisions, as well as peripheral and neurovascular surgery. We define and compare the technological features, indications, and characterized outcomes of VR and AR systems in the context of neurosurgery through a review of the literature to date. Moreover, this review discusses the limitations of VR and AR and includes an overview of the cost-effectiveness of each of these systems. An extensive review of the literature on AR and VR was performed using PubMed, OVID Medline, and Embase from January 1, 2006 to April 2, 2022. Terms used for the search included AR, spinal surgery, VR, and neurosurgery. The search yielded full-text English language–related articles regarding VR and AR application, limitations, and functional outcomes in neurosurgery. An initial set of 121 studies were screened and reviewed for content. Thirteen studies were included, which involved 162 patients, 550 screw placements, 58 phantom spines, and learning points from simulation training of 276 involved residents. This literature review examines recent research into VR and AR applications in neurosurgical care. The literature establishes that there are technological features, indications, outcomes, limitations, and cost-effectiveness differences between these systems. Based on ongoing and evolving applications of the VR and AR systems, the innovative potential that they make available to the future of neurosurgical patient care makes clear the need for further studies to understand the nuances between their differing technological advances. [ABSTRACT FROM AUTHOR]

Talus fractures are rare (<1% of all fractures), and their rarity limits the number of studies available to guide management. In instances such as this, cadaveric studies can play an important role. The purpose of this scoping review was to identify and describe the current body of literature on cadaveric studies of fractures of the talus. Through multiple electronic database searches (Medline, Embase, Scopus) we identified a broad body of cadaveric research into talus fractures, and these were classified into 4 main themes. Study characteristics were summarised along with any descriptive results and conclusions. The search yielded 484 articles of which 19 met the inclusion criteria. They provide valuable insights into benefits and drawbacks of surgical approaches to the talus, particularly with regard to direct visualisation of anatomic reduction, and risks of neurovascular or tendon compromise. For talar neck fractures it is clear that cannulated screws offer superior fixation over plates, however, are inferior when considering anatomic reduction of the fracture. Direct visualisation of fracture reduction is far superior to intraoperative radiographic assessment, and mal-reduction leads to reduced subtalar joint range of motion, midfoot deformity, and increased joint contact pressures. This study provides a summary of the existing literature surrounding the use of cadaver studies in fractures of the talus. We have identified gaps in the literature, particularly surrounding strength of fixation of new locking plate fixation techniques. [ABSTRACT FROM AUTHOR]

Low- and middle-income countries experience numerous challenges in the provision of neurosurgical care. However, limited information exists on the neurosurgical workforce and the constraints under which care is delivered in Ghana, West Africa. A 19-item survey assessing neurosurgical workforce, infrastructure, and education was administered to Ghanaian consultant neurosurgeons and neurosurgeon trainees between November 8, 2021, and January 20, 2022. The data were analyzed using summary descriptions, and qualitative data were categorized into themes. There were 25 consultant neurosurgeons and 8 neurosurgical trainees (from 2 training centers) identified at 11 hospitals in Ghana totaling a workforce density of 1 neurosurgeon per 1,240,000. Most neurosurgical centers were located in Accra, the capital city. Almost half of the population did not have access to a hospital with a neurosurgeon in their region. Of hospitals, 82% had in-house computed tomography and/or magnetic resonance imaging scanners. In the operating room, most neurosurgeons had access to a high-speed drill (91%) but lacked microscopes and endoscopic sets (only 64% and 36% had these tools, respectively). There were no neurointensivists or neurological intensive care units in the entire country, and there was a paucity of neurovascular surgeries and functional neurosurgical procedures. The provision of neurosurgical care in Ghana has come a long way since the 1960s. However, the neurosurgical community continues to face significant challenges. Alleviating these barriers to care will call for systems-level changes that allow for the prioritization of neurosurgical care within the Ghanaian health care system. [ABSTRACT FROM AUTHOR]

Introduction: Most of the versatility of the pterional approach is based on a series of variations progressively reported by several authors, but little emphasized over the years. The present study condenses the technical notes which the authors adopted in their practice to maximize the surgical freedom of the pterional approach and to lessen the approach-related complication rate. Methods: Data of a series of patients who underwent a pterional approach between January 2011 and May 2021 were retrospectively reviewed focusing on the technical variations compared to the original description by Yaşargil. The anatomical rationale, technique, and advantages of these variations were outlined and validated through the appraisal of functional and cosmetic complications. Results: 994 patients were reviewed. Head extension was avoided in the case of anterior clinoidectomy. A single double-layered galea-pericranium flap was used for duraplasty. The submuscular technique, with compulsive preservation of deep temporal fascia and deep temporal arteries, was preferred for temporalis muscle dissection. McCarty keyhole was never used, thus avoiding exposing the orbit if unnecessary. Widening of the superior orbital fissure and thinning of the orbital roof allowed to significantly increase the working area. The average clinical follow-up was 7.2 years. The overall rate of functional and cosmetic complications was 2.1. Discussion: According to the authors' experience, the gradual adoption of technical variations related to the positioning of the patient, soft tissue dissection, bony work, dura opening, and reconstruction, allowed to enhance the versatility of the pterional approach, concurrently decreasing the risk of functional and cosmetic complications. [ABSTRACT FROM AUTHOR]

Objective: Anterior choroidal artery (AChA) aneurysms account for 2%-5% of all intracranial aneurysms. Treatment considerations include microsurgical clipping, flow diversion, or coiling with or without adjunctive devices. AChA aneurysms pose challenges in treatment due to the origination of the aneurysm from the origin or proximal segment of the AChA. The AChA is particularly susceptible to vasospasm and occlusion during treatment with devastating neurological deficits, including hemiparesis, hemianesthesia, lethargy, neglect, and hemianopia. In this study, the authors performed a meta-analysis to quantify the outcomes and complication rates across treatment modalities for AChA aneurysms and to identify risk factors reported in the literature., Methods: The authors performed a systematic review of AChA aneurysms treated with surgical clipping, endovascular coiling, or flow diversion and reported in the PubMed, Embase, Scopus, and Cochrane search databases. Single-arm meta-analyses of the selected outcomes were performed in RStudio., Results: Literature review yielded 25 studies that met the inclusion criteria. In total, 1627 patients were included in the analysis, with 554 males, 1009 females, and 64 unspecified. The rate of any complication in the full cohort was 11.6%, with a rate of ischemic complications of 5.5% and a favorable recovery rate of 90.3% of all patients treated. In total, 1064 patients underwent surgical clipping, 443 were treated with coiling, and 120 patients with flow diversion. In clipped patients, the rate of total surgical complications was 17.6%, with an ischemic complication rate of 9.4%. The rate of good functional recovery, defined on the basis of a Glasgow Outcome Scale score of 4-5 or modified Rankin Scale score of 0-2, was 88.0%, and complete obliteration was achieved in 84.5% of surgically clipped aneurysms. The complication rate in coiled patients was 10.3%, with an ischemic complication rate of 3.0%. Good functional recovery was achieved in 88.6% of coiled patients and complete aneurysm obliteration in 74.1%. Flow diversion resulted in a complication rate of 1.3%, with 0.7% rate of ischemic complications. Good functional recovery was achieved in 98.4% of patients and complete aneurysm obliteration in 79.0% in the flow diversion group. Aneurysm morphological features that impacted the complication rate were also identified to augment quantitative data and to help guide treatment selection for AChA aneurysms., Conclusions: Flow diversion showed significantly lower total and ischemic complications and improved outcomes compared to clipping and coiling. There may be differences in outcomes between treatment types, especially when considering the varied patient presentations that guide treatment selection.

Although at least half of medical students are women, neurosurgery is not often preferred by women, and the proportion of female neurosurgeons who can participate in the academic platform is very low. In this study, we aimed to show the role of female neurosurgeons in the Turkish Neurosurgical Society and to describe the number and the location of female neurosurgeons in Turkey. We examined the age, academic rank, years of work in the profession, membership rate in society subgroups, h-index parameters, and relationships of certificated female neurosurgeons registered in the Turkish Neurosurgical Society. We examined gender rate differences between society subgroups using chi-square tests. A P value < 0.05 was considered statistically significant. According to the year-end 2020 data of the Turkish Neurosurgery Society, 94 (5.5%) of the 1699 neurosurgery specialists registered in Turkey are women. There are currently 94 board-certified female neurosurgeons between the ages of 31 and 92 years; 10 are full professors (10.6%), 16 are associate professors (17%), 5 are assistant professors (5.3%), and 63 are neurosurgery specialist physicians (67%). Female neurosurgeons are present among six of the subfields categorized by the Turkish Neurosurgical Society: 7 in pediatric neurosurgery (11.47%); 8 in spinal and peripheral nerve surgery (2.4%); 3 in neurovascular surgery (2.02%); 7 in functional neurosurgery (5.8%); 11 in neuroanatomy (9.2%); and 23 in neurooncology (6.9%). The number of female neurosurgeons in Turkey continues to grow each year. To increase the proportion of women in this field, it is important to support female neurosurgeons and enable them to take on more tasks. [ABSTRACT FROM AUTHOR]

The use of three-dimensional (3D) printing in neurosurgery has become more prominent in recent years for surgical training, preoperative planning, and patient education. Several smaller studies are available using 3D printing; however, there is a lack of a concise review. This article provides a systematic review of 3D models in use by neurosurgical residents, with emphasis on training, learning, and simulation. A structured literature search of PubMed and Embase was conducted using PRISMA guidelines to identify publications specific to 3D models trialed on neurosurgical residents. Criteria for eligibility included articles discussing only neurosurgery, 3D models in neurosurgery, and models specifically tested or trialed on residents. Overall, 40 articles were identified that met inclusion criteria. These studies encompassed different neurosurgical areas including aneurysm, spine, craniosynostosis, transsphenoidal, craniotomy, skull base, and tumor. Most articles were related to brain surgery. Of these studies, vascular surgery had the highest overall, with 13 of 40 articles, which include aneurysm clipping and other neurovascular surgeries. Twenty-two articles discussed cranial plus tumor surgeries, which included skull base, craniotomy, craniosynostosis, and transsphenoidal. Five studies were specific to spine surgery. Subjective outcome measures of neurosurgical residents were most commonly implemented, of which results were almost unanimously positive. 3D printing technology is rapidly expanding in health care and neurosurgery in particular. The technology is quickly improving, and several studies have shown the effectiveness of 3D printing for neurosurgical residency education and training. [ABSTRACT FROM AUTHOR]

The risks and benefits of coagulating intradural venous elements during a retrosigmoid approach for trigeminal neurovascular decompression has not been accurately established. The objectives of this study were to identify the veins that drain into the superior petrosal sinus, classify them in relation to the suprameatal tubercle, and determine the implication of their coagulation. A retrospective study of 3-dimensional surgical videos of retrosigmoid approaches for trigeminal neurovascular decompression from the Laboratory of Neurosurgical Innovations of Tucumán (LINT) digital archive was carried out. The veins encountered were classified into 3 groups: retromeatal, meatal and premeatal. The neurosurgical postoperative complication scale proposed by Landriel et al. was utilized to assess complications from venous coagulation. A grade 0 was added for patients without complications. The STATA 14 program was utilized for statistical analysis. The pontocerebellar-petrosal veins of 28 patients who underwent trigeminal decompressive surgery were analyzed. In 7 cases these were found in the retromeatal region; 100% were sacrificed. Eleven cases revealed veins within the meatal region; 90.91% were coagulated. Veins in the premeatal region were found in 14 cases; 57.14% were sacrificed. In the postoperative follow-up, 27 patients were grade 0 and 1 patient developed postoperative meningitis (grade Ib complication). No patient suffered vascular complications. The venous elements identified in trigeminal neurovascular decompressive surgery are variable. We propose classifying them into retromeatal, meatal, and premeatal groups. Retromeatal and meatal veins can be safely sacrificed for appropriate visualization of the neurovascular conflict. The premeatal venous elements should be coagulated only in justified cases. [ABSTRACT FROM AUTHOR]

Fred Gentili, MD, FRCSC (1947-2022): Say it loud, say it clear And you know, that Fred Gentili is a much better person than Fred Gentili the skull base surgeon. In early June 2021, I - and many others - received a very sad email from Dr Gelareh Zadeh, Dan Chair and Professor of Neurosurgery at the University of Toronto. She was announcing to the world that her mentor and partner, skull base neurosurgeon extraordinaire, teacher of legions, friend to many, one of the most loveable figures in neurosurgery, Fred Gentili, had just been diagnosed with a most aggressive multifocal Glioblastoma and was due to undergo surgery in a few days. [Extracted from the article]

This study aims to investigate the correlation between the enhancement degree of contrast-enhanced ultrasound (CEUS) and the expression of CD147 and MMP-9 in carotid atherosclerotic plaques in patients with carotid endarterectomy and evaluate the diagnostic efficacy of CEUS using pathological results as the gold standard. Thirty-eight patients who underwent carotid endarterectomy (CEA) for carotid stenosis in the Department of Neurovascular Surgery of the Second People's Hospital of Shenzhen from July 2019 to June 2020 were selected. Preoperatively, two-dimensional (2D) ultrasound scan was performed on all patients to assess the characteristics of the plaque and degree of stenosis, and CEUS was used to evaluate the surface morphology of the plaque and the distribution of neovascularization. Postoperatively, pathological sections and immunohistochemical analysis of CD147 and MMP-9 levels in the plaque were performed on the stripped plaque tissue, and the results were analyzed against the CEUS grading and pathological results. Among the 38 patients, pathological results showed that 10 and 28 were in the stable and vulnerable plaque groups, respectively. There were more smokers in the vulnerable plaque group than in the stable plaque group, with higher intraplaques CD147 and MMP-9. The difference in ultrasound plaque surface morphology grading and CEUS grading between the two groups was statistically significant. There was no significant difference in age, sex, incidence of complications such as hypertension, diabetes, and coronary heart disease between the two groups. CD147 was higher in the CEUS grade IV group than in the grades I (P = 0.040) and II (P = 0.010) groups. MMP-9 was higher in the CEUS grade IV group than in the grade II group (P = 0.017); MMP-9 was higher in the grade III group than in the grade II group (P = 0.015). Intraplaque contrast enhancement intensity was positively correlated with CD147 (r = 0.462, P = 0.003) and MMP-9 (r = 0.382, P = 0.018) levels. There was moderate consistency between the assessment of plaque vulnerability by 2D-ultrasound and by histopathological hematoxylin-eosin (HE) (kappa = 0.457, P > 0.05). 2D diagnosis of vulnerable plaque had a sensitivity of 85.7%, a specificity of 60.0%, a positive predictive value of 85.7%, a negative predictive value of 60.0%, and an accuracy of 78.0%. There was a strong consistency between the assessment of plaque vulnerability by CEUS and histopathological HE (kappa = 0.671, P < 0.01). CEUS had a sensitivity of 89.2%, a specificity of 80.0%, a positive predictive value of 92.6%, a negative predictive value of 72.7%, and an accuracy of 86.8% for the diagnosis of vulnerable plaques; CEUS is a reliable, non-invasive test that can show the distribution of neovascularization within vulnerable plaques, evaluate the vulnerability and risk of intraplaque hemorrhage, with a high consistency with pathological findings. The degree of intraplaque enhancement and the levels of CD147 and MMP-9 in the tissue were positively correlated. [ABSTRACT FROM AUTHOR]

The expanding use of three-dimensional (3D) printing in open vascular and endovascular neurosurgery presents a promising new tool in resident learning as well as operative planning. Recent studies have investigated the accuracy, efficacy, and practicality of 3D-printed models of patient-specific disease. To review the literature exploring 3D modeling in neurovascular and endovascular surgery for training, simulation, and surgical preparation. A systematic search of the PubMed database was conducted using keywords relating to 3D printing and neurovascular or endovascular surgery. Articles were manually screened to include those that focused on resident training, surgical simulation, or preoperative planning. Information on fabrication method, materials, cost, and validation measures was collected. A total of 27 articles were identified that met inclusion criteria. Twenty-one studies used 3D printing to produce aneurysm models, 5 produced arteriovenous malformation models, and 1 produced aneurysm and arteriovenous malformation models. Stereolithography was the most common fabrication method used, with acrylonitrile butadiene styrene and VeroClearTangoPlus (Stratasys) being the most frequently used materials. The mean manufacturing cost per model was U.S. $624.83. Outcomes included model measurement accuracy, concordance of intraoperative devices with those selected preoperatively, and qualitative feedback. Models generated by 3D printing are anatomically accurate and aid in resident learning as well as operative planning in open vascular and endovascular neurosurgery. As advancements in printing methods are made and manufacturing costs decrease, this tool may supplement training on a wider scale in a field in which direct exposure to cases is limited. [ABSTRACT FROM AUTHOR]

Background and Aim: Neurovascular lesions can cause death or disability. Some of them are operable, but surgical approaches are complicated, and proper access to these lesions is crucial. A few of these surgeries occur during the residency educational program, and residents' experience in operating these lesions may be quite inadequate. Using new technologies like 3D-reconstruction of vascular lesion images may result in better training and improve residents' knowledge and understanding of these operations. Methods and Materials/Patients: Four senior neurosurgery residents were enrolled in this study. They were taught to use a 3D image rebuilding program (3D Slicer). They were then asked to rebuild a 3D image of every patient lesion, practice different surgical views, and review anatomical structures around the lesion before surgery Results: All residents mentioned that their knowledge of surgical approaches improved, and they learned more from each operation. Two of them commented that more self-trust during surgeries led to more effective education. Their ability in surgical planning was enhanced too. Attending physicians of these residents believed that this practice improved the residents' skills and educational quality. Conclusion: New technologies can promote residency educational programs. It seems that working on 3D images of lesions before surgery can boost residents' educational attributes. [ABSTRACT FROM AUTHOR]

Objectives: Anatomy of circulus arteriosus cerebri (CAC) shows wide variation in different individuals, and population groups and has vital clinical significance in causation and presentation of clinical disease. The literature revealed a connection between the variations of CAC and cerebrovascular disease, ischemia, stroke, aneurysms, and atherosclerosis. Material and Methods: In this study, 513 patients without clinical manifestation in regard to cerebrovascular diseases, who are considered healthy on CAC anatomy, are included. Patients were instructed by clinicians for head imagery with magnetic resonance angiography examination during 2016-2017 periods. Results: After statistical analysis, 43.27% were male while 56.72% female, 39% were younger than 40 years old. Age interval lies from 11 to 84 years old, mean age 46. The most common variations or 9.74% is when communicant anterior artery absence and absence of both posterior communicant arteries (Type G*/E) more rarely is H*/G (0.2%), G*/D (1.75%), G*/G (0.6%), H*/D (0.4%), H*/E (3.39%), H*/H (0.4%), J*/E (0.6%), while combination J*/D, J*/G, J*/H, G*/H not found. The most often combination is absence of anterior communicant artery and absence of both posterior communicant artery (Type G*/E), more in male 10.36% than female 9.6%. Conclusion: The CAC is considered to play a critical role in preventing future stroke events in patients with absent of any of the arteries. Knowledge on variations in arteries forming the CAC is with clinical significance, as it is one of the components of CAC which stabilizes cerebral blood flow when principle conduits fail. Knowing the structure of arteries provide clinical knowledge to the surgeons before planning neurovascular surgeries. [ABSTRACT FROM AUTHOR]

Introduction: In the last two decades and driven by the International Subarachnoid Aneurysm Trial (ISAT), the management of aneurysmal subarachnoid haemorrhage (aSAH) has undergone extensive change from predominantly neurosurgical (clipping) to predominantly neuroradiological (coiling) treatment. In 2013, the UK's national Confidential Enquiry into Patient Outcome and Death (NCEPOD) recommended aSAH to be definitively treated within 48h of ictus. The aim of this survey was to assess how this recommendation is being followed across the UK and Ireland 17 years after ISAT and 6 years after the NCEPOD. Methods: An online survey consisting of 9 questions was electronically distributed to neurosurgical consultants and trainees. Missing or ambivalent data was collected or verified by emailing consultant neurosurgeons to ensure the coverage of all 32 neurosurgical units in the UK and Ireland. Results: Only 9 (28%) of units provide 7 days a week interventional neuroradiology service, but all 32 (100%) units have established networks with other neuroradiology centres to provide aSAH treatment within 48h of ictus assuming no delays in patient transfer. For aSAH patients requiring neurosurgical clipping, 27 (84%) of units provide (locally or through networks) aneurysm repair within 48h of ictus, whereas 5 (16%) units may breach this recommendation by keeping the aSAH patients that present after 5PM on Fridays and delaying their clipping to the subsequent Monday. Conclusion: Assuming no delays in patient transfer, 32 (100%) neurosurgical centres in the UK and Ireland meet the <48h ictus-to-treatment target for endovascular coiling and 27 (84%) units for neurosurgical clipping of aSAH. [ABSTRACT FROM AUTHOR]

Post-stroke cognitive impairment (PSCI) is a major source of disability, affecting up to two thirds of stroke survivors with no available therapeutic options. The condition remains understudied in preclinical models due to its delayed presentation. Although hypertension is a leading risk factor for dementia, how ischemic stroke contributes to this neurodegenerative condition is unknown. In this study, we used a model of hypertension to study the development of PSCI and its mechanisms. Spontaneously hypertensive rats (SHR) were compared to normotensive rats and were subjected to 1-h middle cerebral artery occlusion or sham surgery. Novel object recognition, passive avoidance test and Morris water maze were used to assess cognition. In addition, brain magnetic resonance images were obtained 12-weeks post-stroke and tissue was collected for immunohistochemistry and protein quantification. Stroked animals developed impairment in long-term memory at 4-weeks post-stroke despite recovery from motor deficits, with hypertensive animals showing some symptoms of anhedonia. Stroked SHRs displayed grey matter atrophy and had a two-fold increase in apoptosis in the ischemic borderzone and increased markers of inflammatory cell death and DNA damage at 12 weeks post-stroke. This indicates that preexisting hypertension exacerbates the development of secondary neurodegeneration after stroke beyond its acute effects on neurovascular injury. [ABSTRACT FROM AUTHOR]

The arm is less often concerned by reconstructive surgeries than more distal parts of the upper extremity. However, when affected, the arm is frequently part of complex mutilating injuries involving composite defects. For a given traumatic or oncologic defect, there are several reconstructive options and choosing the right sequence may pose a challenge even to the most experienced surgeon. The latter must integrate not only functional and esthetic requirements, but also the surgeon's habits, especially in situations of emergency. Once life-threatening conditions are averted, wound debridement, bony stabilization, neurovascular, and cutaneous reconstruction tailored to the defects should be performed in a single-stage procedure. Functionally, prompt bony stabilization is necessary to allow early mobilization. Diaphyseal shortening of the humerus can be a salvage procedure to avoid nerve and vascular grafting, with good biomechanical tolerance up to 5 cm. Restoration of adequate elbow motion sometimes requires muscle transfer and should be a main concern, as proper positioning of the hand during daily activities demands a functional elbow joint. Esthetically, the surgeon must choose the most cosmetic skin coverage option whilst limiting morbidity of the donor site area. The flaps vascularized by the sub- scapular or thoraco-dorsal vessels are the most useful flaps for arm reconstruction. This paper discusses the reconstructive sequence of complex defects of the arm and provides a review of commonly used reconstructive techniques supported with illustrative cases. [ABSTRACT FROM AUTHOR]

The article offers information about the lessons learned from Reinvigorating medical student mentorships in neurosurgery during the Covid-19 pandemic in Iraq. It mentions that how pandemic impacted the neurosurgical mentorship, along with explores that Iraq's medical graduates have little interest in pursuing a career in neurosurgery in Iraq due to the high demanding job and few incentives in return.

Virtual reality (VR) technology had its early development in the 1960s in the U.S. Air Force and has since evolved into a budding area of scientific research with many practical medical purposes. From medical education to resident training to the operating room, VR has provided tangible benefits to learners and trainees and has also improved surgery through enhanced preoperative planning and efficiency in the operating room. Neurosurgery is a particularly complex field of medicine, in which VR has blossomed into a tool with great usefulness and promise. In spinal surgery, VR simulation has allowed for the practice of innovative minimally invasive procedures. In cranial surgery, VR has excelled in helping neurosurgeons design unique patient-specific approaches to particularly challenging tumor excisions. In neurovascular surgery, VR has helped trainees practice and perfect procedures requiring high levels of dexterity to minimize intraoperative complications and patient radiation exposure. In peripheral nerve surgery, VR has allowed surgeons to gain increased practice and comfort with complex microsurgeries such as nerve decompression. Overall, VR continues to increase its potential in neurosurgery and is poised to benefit patients in a multitude of ways. Although cost-prohibiting, legal, and ethical challenges surrounding this technology must be considered, future research and more direct quantitative outcome comparisons between standard and VR-supplemented procedures would help provide more direction regarding the feasibility of widespread adoption of VR technology in neurosurgery. [ABSTRACT FROM AUTHOR]

Endovascular surgery has become the standard of care to treat most vascular diseases using a minimally invasive approach. The CorPath system further enhances the potential and enables surgeons to perform robotic-assisted endovascular procedures in interventional cardiology, peripheral vascular surgery, and neurovascular surgery. With the introduction of this technique, the operator can perform multiple steps of endovascular interventions outside of the radiation field with high precision movements even from long-geographical distances. The first and second-generation CorPath systems are currently the only commercially available robotic devices for endovascular surgery. This review article discusses the clinical experiences and outcomes with the robot, the advanced navigational features, and the results with recent hardware and software modifications, which enables the use of the system for neurovascular interventions, and long-distance interventional procedures. A high procedural success was achieved with the CorPath robotic systems in coronary and peripheral interventions, and the device seems promising in neurovascular procedures. More experience is needed with robotic neurovascular interventions and with complex peripheral arterial cases. In the future, long-distance endovascular surgery can potentially transform the management and treatment of acute myocardial infarction and stroke, with making endovascular care more accessible for patients in remote areas. [ABSTRACT FROM AUTHOR]

Surgical management of basilar apex aneurysms remains one of the most challenging areas in neurovascular surgery. Technical demands of treating these aneurysms have inspired several generations of neurosurgeons to push the limitations of technical achievement. Advances in neuroanesthesia, cerebral protection paradigms, and critical care management have enhanced surgical outcomes of these lesions. Several approaches have been described to reach these lesions from anterolateral or lateral corridors. Each surgical approach has its own advantages and limitations and should be chosen for each patient according to the aneurysm's position, projection, parent arteries, and perforators. In this review, we will discuss pros and cons of the common approaches to these aneurysms with description of the important steps of each surgical procedure. [ABSTRACT FROM AUTHOR]