Alessandro Caporlingua

A Systematic Review and Meta-Analysis of Treatment and Outcome of Blister-Like Aneurysms.

BACKGROUND AND PURPOSE: Blister-like aneurysms are uncommon but challenging lesions. Their small size and atypical location often make the diagnosis difficult. Microsurgery and endovascular procedures have been used for their treatment, but there is no consensus on the best treatment technique. We conducted a systematic review and meta-analysis of treatments and outcomes of these vascular lesions. MATERIALS AND METHODS: We reviewed English-language articles on “blood blister-like aneurysms” published between January 1997 and November 2014. All studies reporting patients with these aneurysms treated with surgery, endovascular procedures, or combined therapy with data on treatment modalities and clinical and/or angiographic outcomes were selected, including case reports and series. We performed a meta-analysis on the 2 largest treatment groups (surgery and endovascular management). RESULTS: Sixty studies with 334 patients met our inclusion criteria. Surgery was performed in 114 patients (34.2%), and endovascular treatment, in 199 patients (59.5%). A combined treatment was used in 19 patients (5.7%). A favorable outcome (mRS 0–2) was reported in 67.4% and 78.9% of patients treated with surgery and with endovascular therapy, respectively (P = .034). CONCLUSIONS: Blister-like aneurysms are challenging vascular lesions. The choice of treatment method must be based on the initial clinical presentation and an analysis of the radiologic features of the lesion to select the best technique. Endovascular treatment seems to have lower morbidity and mortality and provides a better outcome compared with surgical approaches. Further prospective studies must be performed to confirm such interesting results.

Flow diverter stent treatment for ruptured basilar trunk perforator aneurysms

Objective Basilar trunk perforator (BTP) aneurysms are rare. Treatment options traditionally considered for these uncommon lesions have included direct surgery, endovascular therapy, or conservative management. Flow diverters represent a newer therapeutic option for BTP aneurysms but pitfalls and complications are unknown. We describe three patients with BTP aneurysms treated with flow diverter stents. Methods All three patients had ruptured BTP aneurysms and, after loading doses of dual antiplatelet agents, underwent treatment with a flow diverter alone (two patients) or in combination with an intracranial stent (one patient). Results Complications directly (two thromboembolic events) or indirectly (one hemorrhage at the external ventricular drain site, probably facilitated by the dual antiplatelet therapy) occurred in all three patients and resulted in permanent morbidity in one case. Imaging follow-up confirmed obliteration in all three patients, and no episodes of rebleeding from the aneurysms were observed at follow-up. Conclusions Flow diverters are effective in obliterating BTP aneurysms. However, given the challenges and complications encountered, especially in patients with ruptured lesions, their use must be carefully weighed against other available therapeutic modalities, including observation.

New therapeutic strategies regarding endovascular treatment of glioblastoma, the role of the blood–brain barrier and new ways to bypass it

The treatment protocols for glioblastoma multiforme (GBM) involve a combination of surgery, radiotherapy and adjuvant chemotherapy. Despite this multimodal approach, the prognosis of patients with GBM remains poor and there is an urgent need to develop novel strategies to improve quality of life and survival in this population. In an effort to improve outcomes, intra-arterial drug delivery has been used in many recent clinical trials; however, their results have been conflicting. The blood–brain barrier (BBB) is the major obstacle preventing adequate concentrations of chemotherapy agents being reached in tumor tissue, regardless of the method of delivering the drugs. Therapeutic failures have often been attributed to an inability of drugs to cross the BBB. However, during the last decade, a better understanding of BBB physiology along with the development of new technologies has led to innovative methods to circumvent this barrier. This paper focuses on strategies and techniques used to bypass the BBB already tested in clinical trials in humans and also those in their preclinical stage. We also discuss future therapeutic scenarios, including endovascular treatment combined with BBB disruption techniques, for patients with GBM.

Brain AVMs: an endovascular, surgical, and radiosurgical update.

Brain arteriovenous malformations (bAVMs) are complex vascular lesions. Despite multiple studies, several classifications, and a great interest of the scientific community, case selection in AVM patients remains challenging. During the last few years, tremendous advancements widened therapeutic options and improved outcomes spreading indications for patients harboring lesions deemed inoperable in the past. Anatomical and biological case specific features, and natural history with a focus on presenting symptoms should be evaluated case by case and always kept in mind while planning a therapeutic management for a bAVMs. A multidisciplinary approach is strongly recommended when dealing with bAVMs and should involve physicians expertise in this kind of challenging lesions. The goal of this paper is to provide a focused review of the most recent acquisitions and therapeutic strategies regarding surgical, endovascular, and radiosurgical treatment.

Endovascular Treatment of Large and Giant Carotid Aneurysms with Flow-Diverter Stents Alone or in Combination with Coils: A Multicenter Experience and Long-Term Follow-up

BACKGROUND Although flow diverters (FDs) have been widely accepted by neurointerventionists, their safety has yet to be fully defined. Stratification by aneurysm size and location is essential for correct evaluation of treatment outcomes and risks of flow diversion. OBJECTIVE To compare neurological and anatomic outcomes and evaluate the risk of complications after endovascular treatment of large or giant internal carotid artery (ICA) aneurysms with FD/FDs alone or together with coil embolization. METHODS We reviewed all patients with large or giant, ruptured or unruptured ICA aneurysms who underwent endovascular treatment with flow diversion alone (group A) or with concomitant coiling (group B) in 4 international institutions between 2010 and 2015. Anatomic outcome was evaluated using the Byrne scale on digital subtraction angiography and/or angioMRI and/or angioCT scans 3, 6, 12, and 24 months postoperatively. RESULTS We collected 44 patients with large or giant ICA aneurysms. Four patients (9%) presented with aneurysmal subarachnoid hemorrhage (SAH). FD/FDs were used alone in 26 patients and in combination with coil embolization in the 18 remaining patients. The mortality rate due to procedure-related and/or neurological complications was 2.2%. Twelve months after the procedure, 88.6% (n = 39) of patients had a favorable neurological outcome. One year after the procedure, the aneurysm was completely occluded in 72.7% of patients: 61.5% (16/18) in group A and 88.9% (16/26) in group B. CONCLUSION Clinical outcomes and rates of intraoperative and postoperative complications did not differ significantly between the groups. Better anatomic results using FD/FDs combined with coils were documented 6 months after the procedure; this option seems to provide a higher aneurysm occlusion rate and reduce the need for retreatment.

Historical Landmarks in the Management of Aneurysms and Arteriovenous Malformations of the Central Nervous System

OBJECTIVE To describe the history of vascular and endovascular neurosurgery. METHODS A literature research was conducted including historical events from 2000 bc to the twenty-first century ad, and a timetable was filled with information regarding the most representative historical landmarks regarding vascular and endovascular neurosurgery. RESULTS Starting from approaches limited to the cervical carotid artery, vascular neurosurgery gained its way through the intracranial and finally endovascular space thanks to the introduction of both innovative and progressively less invasive procedures. With the invention of cerebral angiography in 1927, Egas Moniz paved the way for modern endovascular neurosurgery. CONCLUSIONS Numerous pioneers have been described through this historical reconstruction. Their genius, effort, dedication, and passion brought a massive contribution to vascular and endovascular neurosurgery as we know it today.

Relevancy of positive trends in mortality and functional recovery after surgical treatment of acute subdural hematomas. Our 10-year experience

Abstract Background: Among traumatic brain injuries, acute subdural hematoma (aSDH) is considered one of the most devastating still retaining poor surgical outcomes in a considerable percentage of affected patients. However, according to results drawn from published samples of aSDH patients, overall mortality and functional recovery have been progressively ameliorating during the last decades. Methods: We present a retrospective analysis of 316 consecutive cases of post-traumatic aSDH operated on between 2003 and 2011 at our institution. Results: Mortality was 67% (n = 212); a useful recovery was achieved in 16.4% cases (n = 52). Age >65 years, a preoperative Glasgow coma scale (GCS) ≤ 8, specific pre-existing medical comorbidities (hypertension, heart diseases) were found to be strong indicators of unfavorable outcomes and death during hospitalization. Conclusion: Our results, compared with those of the inherent literature, led the authors to question both the “aggressiveness” of neurosurgical care indications in certain subpopulations of patients being known to fare worse or even die regardless of the treatment administered and the relevance of the results concerning mortality and functional recovery reported by third authors.

Therapeutic approach in glioblastoma multiforme with primitive neuroectodermal tumor components: Case report and review of the literature

Glioblastoma multiforme (GBM) is the most common and aggressive malignant glioma that is treated with first-line therapy, using surgical resection followed by local radiotherapy and concomitant/adjuvant temozolomide (TMZ) treatment. GBM is characterised by a high local recurrence rate and a low response to therapy. Primitive neuroectodermal tumour (PNET) of the brain revealed a low local recurrence rate; however, it also exhibited a high risk of cerebrospinal fluid (CSF) dissemination. PNET is treated with surgery followed by craniospinal irradiation (CSI) and platinum-based chemotherapy in order to prevent CSF dissemination. GBM with PNET-like components (GBM/PNET) is an emerging variant of GBM, characterised by a PNET-like clinical behaviour with an increased risk of CSF dissemination; it also may benefit from platinum-based chemotherapy upfront or following failure of GBM therapy. The results presented regarding the management of GBM/PNET are based on case reports or case series, so a standard therapeutic approach for GBM/PNET is not defined, constituing a challenging diagnostic and therapeutic dilemma. In this report, a case of a recurrent GBM/PNET treated with surgical resection and radiochemotherapy as Stupp protocol, and successive platinum-based chemotherapy due to the development of leptomeningeal dissemintation and an extracranial metastasis, is discussed. A review of the main papers regarding this rare GBM variant and its therapeutic approach are also reported. In conclusion, GBM/PNET should be treated with a multimodal approach including surgery, chemoradiotherapy, and/or the early introduction of CSI and platinum-based chemotherapy upfront or at recurrence.

Infundibuloneurohypophysitis associated with autoimmune thrombocytopenia and chiasmal syndrome: a case report

Lymphocytic hypophysitis is an uncommon autoimmune disease. It may involve the adenohypophysis, neurohypophysis and pituitary stalk. It is most often encountered in pregnant women. Its diagnosis and management pose a significant challenge, as its clinical manifestation and appearance in imaging studies are difficult to distinguish from more common lesion of the sellar region (e.g., pituitary adenomas). We present the case of a 42-year-old man who presented with a chiasmatic syndrome, diabetes insipidus and hypopituitarism. Brain MRI documented a sellar lesion with suprasellar extension and optic chiasm dislocation. He underwent an endoscopic endonasal transsphenoidal resection of the mass. Histopathological examination revealed a lymphocytic hypophysitis. Visual symptoms improved dramatically postoperatively with permanent diabetes insipidus and panhypopituitarism. We discuss the indication for surgical resection in patients with inflammatory lesions extending to the suprasellar region associated with visual impairment.

Disseminated Cerebrospinal Embryonal Tumor in the Adult

Introduction. According to the 2016 World Health Organization classification of Tumors of the Central Nervous System, the term Primitive Neuroectodermal Tumor has been replaced by the term Embryonal Tumor (ET). We present a case of disseminated cerebrospinal ET presenting in an adult patient. Illustrative Case. A 49-year-old male presenting with low back pain, dysuria, and hypoesthesia of the lower extremities referred to our emergency department. Brain and whole spine contrast-enhanced MRI documented a diffusively disseminated heterogeneous neoplasm with intradural extra- and intramedullary involvement of the cervicothoracic tract and cauda equina. A primary biopsy of the lumbosacral localization was performed through L5 bilateral laminectomy. Histologic diagnosis was Embryonal Tumor Not Otherwise Specified. The patient underwent chemotherapy with postoperative adjuvant alternating Vincristine-Doxorubicin-Ifosfamide (VAI) and Ifosfamide-Etoposide (IE). Discussion. Spinal ETs are exceedingly rare especially when presenting in the adult patient. Neurosurgical and oncologic management is still unclear. When feasible, surgical removal should always be performed to obtain a histologic diagnosis. Postoperative adjuvant therapy might entail both chemo- and radiotherapy; however a consensus on this matter is still lacking.