Marco Cenzato

Cerebral Angiography for Multimodal Surgical Planning in Epilepsy Surgery: Description of a New Three-Dimensional Technique and Literature Review.

OBJECTIVE Cerebrovascular imaging is critical for safe and accurate planning of Stereo-ElectroEncephaloGraphy (SEEG) electrode trajectory. We developed a new technique for Cone Beam Computed Tomography (CBCT) Three-Dimensional Digital Subtraction Angiography (3D DSA). METHODS The workflow core is the acquisition of computed tomography datasets without (bone mask) and with selective injection of contrast medium in the main brain-feeding arteries, followed by dataset registration and subtraction. The images were acquired with the O-armTM 1000 System (Medtronic). Images were postprocessed with FSL software package. We retrospectively analyzed 191 3D DSA procedures and qualitatively analyzed the quality of each 3D DSA dataset. RESULTS The quality of 3D DSA was good in 150 procedures, sufficient in 37, and poor in 4. 3D rendering of the vascular tree was helpful for both SEEG implantation and resective surgery planning. Angiography complications occurred in only one procedure that was aborted due to a major allergic reaction to contrast medium. No other complications directly related to 3D DSA occurred. Minor intracerebral hemorrhage occurred in 2/191 patients after SEEG implantation, with no permanent sequelae. CONCLUSIONS CBCT 3D DSA is a safe diagnostic procedure for SEEG electrode trajectory planning and for 3D reconstructions of the vascular tree in multimodal scenes for resections. The high fidelity and geometric accuracy contribute to the safety of electrode implantation.

Spinal dural arteriovenous fistulas: outcome and prognostic factors.

The aim of this study is to review the clinical outcome of patients treated for spinal dural arteriovenous malformations and investigate the presence of pretreatment indicators of outcome after short- and midterm follow-up. The authors retrospectively reviewed the records of 65 consecutive patients treated either surgically or endovascularly in 3 neurosurgery departments between 1989 and 2009. After treatment, 80% of patients reported improvement of at least 1 symptom. Motor symptoms improved more than sensory disorders, pain, or sphincter impairment. Spinal dural arteriovenous fistulas at the thoracic level, and in particular at the lower level, responded better than those in other spinal areas. Spinal dural arteriovenous fistula is a rare pathology with a malignant course that should be treated aggressively. This study appears to confirm that neurological status before treatment, anatomical location of the fistula, and symptoms at presentation are all factors that can predict outcome. Early diagnosis of spinal dural arteriovenous malformations in the lower thoracic area in patients with an Aminoff scale score < 3 was associated with the most favorable outcome.

Arterial and venous aneurysms associated with arteriovenous malformations.

OBJECTIVE To identify prioritization based on hemorrhagic risk and indications for treatment of arterial and venous aneurysms associated with arteriovenous malformation (AVM). METHODS From a global series of 400 consecutively treated AVMs, 34 patients (8.5%) with 45 arterial or venous aneurysms were extrapolated. These 45 lesions were classified as unrelated aneurysms (n = 5 cases; 11.%), flow-related aneurysms (n = 18 cases; 40%), and intranidal and postnidal venous aneurysms (n = 22; 49.%). The 18 flow-related aneurysms were further divided into remote (n = 6 cases) and adjacent (n = 12 cases) types. Of 45 aneurysms associated with AVMs, 15 were unruptured with a 5-year mean follow-up. Various possible risk indicators were considered and measured by univariate and multivariate analyses. RESULTS During the follow-up period, 1 of 15 unruptured aneurysms bled, and the patient died. A significantly different bleeding incidence was found between unrelated aneurysm and flow-related aneurysm types (P = 0.002). Bleeding was significantly less probable in flow-related remote aneurysm type than in venous and flow-related adjacent aneurysm types (P = 0.007). The location of the aneurysm was the only true risk factor for bleeding; the other parameters had no influence on bleeding. CONCLUSIONS In this series, different subtypes of aneurysms associated with AVMs had different clinical behaviors. The bleeding risk of the unrelated aneurysm and the flow-related remote aneurysm types should be considered almost the same as any other unruptured aneurysm. In other words, bleeding risk should be considered taking into account the parameters established by the International Study of Unruptured Intracranial Aneurysms (location, size, and morphology). Conversely, flow-related adjacent aneurysm and venous aneurysm types have significantly higher bleeding potentials.

Traumatic (Type II) Odontoid Fracture with Transverse Atlantal Ligament Injury: A Controversial Event

OBJECTIVE Traumatic (Type II) odontoid fractures are very common injuries. Nevertheless, their connection with transverse atlantal ligament injury is controversial and poorly defined. The aim of this study is to report a single case of traumatic (type II) odontoid fracture with transverse atlantal ligament injury and to critically analyze the role of ligaments and membranes together with neuroradiological tools in the management of craniovertebral junction-traumatized patients. METHODS We report 27 consecutive cases of traumatic (type II) odontoid fractures who underwent magnetic resonance imaging (MRI) in the acute phase injury (<72 hours), focusing our attention on the transverse atlantal ligament. RESULTS One patient (3.7%) demonstrated a transverse atlantal ligament injury on MRI. The patient underwent surgery. CONCLUSIONS Traumatic (type II) odontoid fracture with transverse atlantal ligament avulsion can be considered an unusual event. It is our opinion that the routine use of MRI for all patients with type II odontoid fracture could be unjustified in clinical practice. Strict clinical surveillance of all patients managed conservatively and the use of MRI in selected cases could be a reasonable management option.

European consensus conference on unruptured brain AVMs treatment (Supported by EANS, ESMINT, EGKS, and SINCH)

In December of 2016, a Consensus Conference on unruptured AVM treatment, involving 24 members of the three European societies dealing with the treatment of cerebral AVMs (EANS, ESMINT, and EGKS) was held in Milan, Italy. The panel made the following statements and general recommendations: (1) Brain arteriovenous malformation (AVM) is a complex disease associated with potentially severe natural history; (2) The results of a randomized trial (ARUBA) cannot be applied equally for all unruptured brain arteriovenous malformation (uBAVM) and for all treatment modalities; (3) Considering the multiple treatment modalities available, patients with uBAVMs should be evaluated by an interdisciplinary neurovascular team consisting of neurosurgeons, neurointerventionalists, radiosurgeons, and neurologists experienced in the diagnosis and treatment of brain AVM; (4) Balancing the risk of hemorrhage and the associated restrictions of everyday activities related to untreated unruptured AVMs against the risk of treatment, there are sufficient indications to treat unruptured AVMs grade 1 and 2 (Spetzler–Martin); (5) There may be indications for treating patients with higher grades, based on a case-to-case consensus decision of the experienced team; (6) If treatment is indicated, the primary strategy should be defined by the multidisciplinary team prior to the beginning of the treatment and should aim at complete eradication of the uBAVM; (7) After having considered the pros and cons of a randomized trial vs. a registry, the panel proposed a prospective European Multidisciplinary Registry.

Traumatic injuries to the craniovertebral junction: a review of rare events

The craniovertebral junction is a specific region of the spine with unique anatomical and biomechanical properties that yields a wide variety of injury patterns. Junctional traumatic fractures and/or dislocations are widely reported in clinical practice, but we could identify only a subgroup of upper cervical spine traumatic injuries with very few cases reported in the literature, and for this reason may be considered rare. In some of these cases, the absence of spinal biomechanical instability, in association with moderate clinical symptoms (neck stiffness and pain) and the difficulty in fracture identification through standard cervical radiographs, leads to a high percentage of missed injuries. In other cases, traumatic events have been commonly described only in autopsy series due to the high degree of spinal biomechanical instability. Herein, we have summarized all the relevant literature concerning this issue and also included our cases, with the aim of emphasizing prompt diagnosis and correct management. We provide a guide for correctly identifying “rare” craniovertebral junction traumatic injuries.

Torcular Meningioma with Multi-Venous Sinus Invasion: Compensatory Drainage Veins and Surgical Strategy

BACKGROUND Torcular meningiomas involving major dural venous sinuses are rare entities and a great challenge for neurosurgeons. The deep knowledge of the patency of occlusion of the sinuses, the extent of the occlusion and potentially new developing of extra and intracranial collateral venous drainage as compensatory venous channels, are at the base of a correct operative strategy. CASE DESCRIPTION A 45-year-old woman presented with persistent headache. Magnetic resonance imaging of the brain and digital subtraction angiography demonstrated a huge torcular meningioma with complete multi-venous sinus occlusion and a wide venous network for brain and tumor drainage. In these rare cases, we have hypothesized the presence of venous drainage shared by the brain and the tumor, which could generate undesirable venous occlusion during operative resection. This could be a cause of the well-known surgical complications, such as brain swelling and hemorrhagic infarction. CONCLUSIONS We report our experience with a huge torcular meningioma with multi-venous sinus invasion and a literature review, with a special emphasis on compensatory drainage veins and surgical strategy.

Single fracture in the atlas vertebral arch: analysis of an unusual event.

Study Design: Retrospective study. Objective: The aim of this study is to show that a single traumatic fracture of the atlas is unusual but not rare and requires specific management strategies, which can be highlighted by the study of the junctional ligaments and membranes. Summary of Background Data: A single traumatic fracture of the atlas arch is considered a rare event and has been analyzed in few case reports. Ligaments and membranes play a primary role in providing stability to the craniovertebral junction area. Methods: Here, we report 10 cases of a single traumatic fracture of the atlas arch: 4 cases were part of our series of spine injuries and were studied by magnetic resonance imaging during the acute phase to assess the junctional ligaments. The remaining 6 cases were obtained from the Literature. Results: Indirect signs of a traumatic ligamentous injury were found only in 1 patient. However, in all cases, these fractures were considered biomechanically stable and all patients were discharged with a rigid collar. During the follow-up, all patients reported an improvement in their neck pain and tenderness, with radiologic signs of bone healing. Conclusions: A single fracture of the atlas arch is an unusual traumatic event that results from slow-force impact. Medical experience in treating this specific fracture subtype is nowadays poor because of the paucity of the literature; thus, this unusual condition may either be underestimated or even overstudied and overtreated. Nowadays, it seems reasonable to assume that the management should be conservative in all cases and that magnetic resonance imaging often plays only a marginal role.

Use of Laser in Arteriovenous Malformation Surgery

BACKGROUND Arteriovenous malformation surgery is particularly demanding owing to the need to control bleeding of small, deep white matter vessels during and after removal of the nidus; this is probably one of the most critical moments of arteriovenous malformation surgery. The aim of this article is to describe a useful technique based on the use of tweezers to temporarily stop the blood flow followed by coagulation with the thulium laser. METHODS Surgery was performed in 20 patients with unruptured cerebral arteriovenous malformations. In each case, the superficial feeder vessels were easily coagulated with nonstick bipolar tips. The finer and deeper feeder vessels were coagulated with use of tweezers and thulium laser. RESULTS All patients were treated successfully. Optimal intraoperative hemostasis was achieved. CONCLUSIONS Results were good with no postoperative complications. Our results could encourage a more standardized use of the described technique.

Unruptured Versus Ruptured AVMs: Outcome Analysis from a Multicentric Consecutive Series of 545 Surgically Treated Cases

BACKGROUND Recent literature strongly challenged indications to perform preventive surgery in unruptured arteriovenous malformation (AVM) claiming that invasive AVM treatment is associated with a significant risk of complications and thus conservative management may be a preferable alternative in many patients. On the other hand, the recent improvement of surgical instrumentation and treatment strategies (both surgical and interventional) yielded better outcomes than those achieved only a decade ago. Therefore, even among specialists, a wide variety of opinions, concerning the treatment of unruptured AVM, can be found. METHODS This multicenter retrospective study analyzes a consecutive series of 545 surgically treated AVMs in 10 different hospitals in Italy. RESULTS Patients with AVMs treated after hemorrhage had an unfavorable (modified Rankin Scale score >1) outcome in more than one third (37.69%) of the cases. Conversely, with proper indications, unruptured AVMs treated preventively have a good outcome in 93.8% of cases, increasing to 95.7%, with no death, if only Spetzler-Martin grades 1-3 are considered (P < 0.05). Outcomes on discharge significantly (P < 0.05) improve at 6 months with the disappearance of many of the initial neurologic deficits that turn out to be transient. CONCLUSIONS In unruptured low-risk AVMs (Spetzler-Martin grades 1-3), over time, the risk of surgery-associated neurologic deficits becomes lower than that linked to spontaneous hemorrhage, with a crossover point at 6.5 years. Because the average bleeding age is less than 45 years, preventive surgery can be advocated to safeguard the patient and overcome the risks associated with the natural history of AVMs.