Rodolfo Maduri

Regression of Benedikt's syndrome after single-stage removal of mesencephalic cavernoma and temporal meningioma: A case report

1. IntroductionWe herein report a unique association of midbrain cavernomaand Benedikt’s syndrome (BS) that was reversed after microsur-gical removal of the lesion. BS was originally described by MoritzBenedikt in 1889, characterized by the presence of an oculomotornerve palsy and cerebellar ataxia including tremor and ascribedclinical constellation of signs to a lesion of the cerebral pedun-cle [1]. Subsequently, Charcot [2] and de la Tourette and Charcot[2] reported other cases, and in the latter case, involvement ofthe red nucleus, substantia nigra, third nerve root and sparing thecerebral pedunclewerereported[3].Inthisreport,theauthorques-tioned theinvolvementofthecorticospinaltractasakeyfeatureofBS [3]. By that time, midbrain ischemic lesions and tuberculomasappeared to be the most frequent causes of BS, which was neverreversible when midbrain structures were disrupted.Our case helps to elucidate the clinicopathologic characteristicsof BS,thepotentialreversibilityofwhichmayindicatesurgeryevenin severely disabled patients with noninfiltrating midbrain masslesions.

Predictors of In-Hospital Death After Aneurysmal Subarachnoid Hemorrhage: Analysis of a Nationwide Database (Swiss SOS [Swiss Study on Aneurysmal Subarachnoid Hemorrhage])

Background and Purpose— To identify predictors of in-hospital mortality in patients with aneurysmal subarachnoid hemorrhage and to estimate their impact. Methods— Retrospective analysis of prospective data from a nationwide multicenter registry on all aneurysmal subarachnoid hemorrhage cases admitted to a tertiary neurosurgical department in Switzerland (Swiss SOS [Swiss Study on Aneurysmal Subarachnoid Hemorrhage]; 2009–2015). Both clinical and radiological independent predictors of in-hospital mortality were identified, and their effect size was determined by calculating adjusted odds ratios (aORs) using multivariate logistic regression. Survival was displayed using Kaplan–Meier curves. Results— Data of n=1866 aneurysmal subarachnoid hemorrhage patients in the Swiss SOS database were available. In-hospital mortality was 20% (n=373). In n=197 patients (10.6%), active treatment was discontinued after hospital admission (no aneurysm occlusion attempted), and this cohort was excluded from analysis of the main statistical model. In the remaining n=1669 patients, the rate of in-hospital mortality was 13.9% (n=232). Strong independent predictors of in-hospital mortality were rebleeding (aOR, 7.69; 95% confidence interval, 3.00–19.71; P<0.001), cerebral infarction attributable to delayed cerebral ischemia (aOR, 3.66; 95% confidence interval, 1.94–6.89; P<0.001), intraventricular hemorrhage (aOR, 2.65; 95% confidence interval, 1.38–5.09; P=0.003), and new infarction post-treatment (aOR, 2.57; 95% confidence interval, 1.43–4.62; P=0.002). Conclusions— Several—and among them modifiable—factors seem to be associated with in-hospital mortality after aneurysmal subarachnoid hemorrhage. Our data suggest that strategies aiming to reduce the risk of rebleeding are most promising in patients where active treatment is initially pursued. Clinical Trial Registration— URL: http://www.clinicaltrials.gov. Unique identifier: NCT03245866.

Interrater Agreement in the Radiologic Characterization of Ruptured Intracranial Aneurysms Based on Computed Tomography Angiography

OBJECTIVEnTo determine interrater agreement in the initialxa0radiologic characterization of ruptured intracranial aneurysms based on computed tomography angiography (CTA) with special emphasis on the raters level of experience.nnnMETHODSnOne junior and one senior rater of 5 high-volume neurovascular tertiary centers evaluated anonymized CTA images of 30 consecutive patients with aneurysmal subarachnoid hemorrhage. Each rater described location, side, size, and morphology in a standardized manner. Interrater variability was analyzed using intraclass correlation and Fleiss kappa analysis.nnnRESULTSnThere was a high level of agreement for location (κxa0= 0.76, 95% confidence interval [CI] 0.74-0.79), side (κxa0= 0.95, CI 0.91-0.99), maximum diameter (intraclass correlation coefficient [ICC] 0.81, CI 0.70-0.90), and dome (ICC 0.78, CI 0.66-0.88) of intracranial aneurysms. In contrast, a lower level of agreement was observed for aneurysms neck diameter (ICC 0.39, CI 0.28-0.58), the presence of multiple aneurysms (κxa0= 0.35, CI 0.30-0.40), and aneurysm morphology (blister κxa0= 0.11, CI -0.05 to 0.07; fusiform κxa0=xa00.54, CI 0.48-0.60; multilobular, κxa0= 0.39 CI 0.33-0.45). The interrater agreement in the senior rater group was greater than in the junior rater group.nnnCONCLUSIONSnInterrater agreement confirms the benefit of CTA as initial diagnostic imaging in ruptured intracranial aneurysms but not for aneurysm morphology and presence of multiple aneurysms. A trend towards greater interrater agreement between more experienced raters was noticed.

Paraplegia after posterior fossa surgery in prone position: can we prevent it?

Dear Editor: Spinal cord infarction after posterior fossa surgery is a very rare complication described by several authors but with few cases reported to date [1]. The majority of spinal cord infarction is reported after posterior fossa surgery in the sitting position and only two cases (cervical cord) are described due to surgeries in the prone position [2, 3]. Here, we describe to our knowledge the first case of post-operative paraplegia due to thoracic spinal cord infarction after posterior fossa surgery in the prone position. This 18-year-old boy presented with a residual pilocytic astrocytoma of the fourth ventricle (earlier operated in 2009), and an MRI study revealed the volumetric progression of the residual lesion at the level of the right Foramen of Luschka. Under general anesthesia, the patient was placed in the Concorde position with the head fixed in the Mayfield clamp and the chin flexed up to 2 cm from the sternum. The trunk was elevated 10 cm above the horizontal line and the head was elevated slightly higher than the heart. Pneumatic stockings were placed. Cranial nerve monitoring (NIM Eclipse®, Medtronic) was conducted for cranial nerve from III to XII. Motor evoked potentials (MEPs) were not monitored. The earlier midline surgical incision allowed access to the posterior fossa. During the exposure, vertebral arteries were not visualized. The floor of the fourth ventricle was then entered with preservation of the tonsillar PICA segments. The tumor was detected at the level of the foramen of Luschka as a soft mass. Concomitant mapping of the floor of the fourth ventricle with a monopolar probe (Xomed®, Medtronic) permitted safe removal of the tumor without traction on the adjacent brainstem. No hypotension was documented during the surgery. The overall surgical time was 310 min and blood loss was estimated to be approximately 400 ml. Postoperatively, the patient was found to have a complete paraplegia with a sensory level at T7. An early MRI study showed a T2W hyperintensity from T3 to T5 segment predominantly in the left hemicord, suggesting a dorsal cord infarction (Fig. 1). Transesophageal Doppler ultrasound demonstrated no interatrial septum defect. The patient underwent a lumbar drain insertion with a drainage of 10 mL/h for 5 days. During this time, the mean arterial blood pressure (MAP) was kept above 90 mmHg, to ensure a high cord perfusion pressure. In addition, steroid therapy was administered for a week. Intensive physiotherapy for neurologic rehabilitation was started at day 6. The integrity of craniocervical junction was later assessed as was found to be normal. The patient showed progressive sensori-motor recovery starting on day 8. Anal sphincter recovered progressively with normal function at the end of hospitalization. A complete neurological recovery was documented 3 months from surgery. * Rodolfo Maduri rodolfo.maduri@gmail.com

Computed tomography angiography spot sign predicts intraprocedural aneurysm rupture in subarachnoid hemorrhage

IntroductionTo analyze whether the computed tomography angiography (CTA) spot sign predicts the intraprocedural rupture rate and outcome in patients with aneurysmal subarachnoid hemorrhage (aSAH).MethodsFrom a prospective nationwide multicenter registry database, 1023 patients with aneurysmal subarachnoid hemorrhage (aSAH) were analyzed retrospectively. Descriptive statistics and logistic regression analysis were used to compare spot sign-positive and -negative patients with aneurysmal intracerebral hemorrhage (aICH) for baseline characteristics, aneurysmal and ICH imaging characteristics, treatment and admission status as well as outcome at discharge and 1-year follow-up (1YFU) using the modified Rankin Scale (mRS).ResultsA total of 218 out of 1023 aSAH patients (21%) presented with aICH including 23/218 (11%) patients with spot sign. Baseline characteristics were comparable between spot sign-positive and -negative patients. There was a higher clip-to-coil ratio in patients with than without aICH (both spot sign positive and negative). Median aICH volume was significantly higher in the spot sign-positive group (50xa0ml, 13-223xa0ml) than in the spot sign-negative group (18xa0ml, 1–416; pu2009<u20090.0001). Patients with a spot sign-positive aICH thus were three times as likely as those with spot sign-negative aICH to show an intraoperative aneurysm rupture [odds ratio (OR) 3.04, 95% confidence interval (CI) 1.04–8.92, pu2009=u20090.046]. Spot sign-positive aICH patients showed a significantly worse mRS at discharge (pu2009=u20090.039) than patients with spot sign-negative aICH (median mRS 5 vs. 4). Logistic regression analysis showed that the spot sign was an aICH volume-dependent predictor for outcome. Both spot sign-positive and -negative aICH patients showed comparable rates of hospital death, death at 1YFU and mRS at 1YFU.ConclusionIn this multicenter data analysis, patients with spot sign-positive aICH showed higher aICH volumes and a higher rate of intraprocedural aneurysm rupture, but comparable long-term outcome to spot sign-negative aICH patients.

Current Perspectives in the Surgical Treatment of Severe Traumatic Brain Injury

BACKGROUNDnThe available surgical options to control increased intracranial pressure and to limit secondary brain damage in the setting of severe traumatic brain injury (TBI) include decompressive craniectomy, cisternostomy, and other methods to divert cerebrospinal fluid (CSF) such as placement of an external ventricular drain.nnnMETHODSnWe discuss the rationale and the limitations of these surgical techniques based on preclinical and clinical evidence. A detailed description of the differences between ventricular CSF drainage and cisternal drainage is added based on recent hypotheses on TBI physiopathology and CSF circulation.nnnRESULTSnCisternostomy seems a more physiological approach to the treatment of brain swelling, with the potential of effectively controlling intracranial pressure and reducing the effects of secondary brain damage.nnnCONCLUSIONSnFurther clinical studies need to be performed to validate the efficacy of this emerging surgical procedure for severe TBI.

Posterior reversible encephalopathy syndrome (PRES) due to neuroblastoma in a child presenting with acute hydrocephalus

Dear Editor, Posterior reversible encephalopathy syndrome (PRES) is a polyhedral entity, and its diagnosis remains challenging due to the large spectrum of clinical and radiological manifestations. Here, we report the first case of PRES directly related to neuroblastoma in a child who did not have any anticancer treatment and neither surgery and who was admitted with symptoms of acute hydrocephalus. A 2-year-old boy, with no antecedent illnesses, presented with 2 days history of headache and vomiting followed by fever, descreased consciousness (GCS 8/14), and focal motor seizures on the right side. His vital signs included blood pressure of 221/127 mmHg, pulse rate of 200/min, and oxygen saturation of 75%. The physical examination revealed a soft tissue mass in the peri-umblical region. He was sedated and intubated. The systemic hypertension was controlled with intravenous labetalol. Cerebral CT scan showed obstructive hydrocephalus due to compression of the aqueduct secondary to posterior fossa edema (Fig. 1a). The obstructive hydrocephalus was treated by the placement of an external ventricular drain (EVD). The abdominal CT scan showed a retroperitoneal enhancing mass compatible with a neuroblastoma (Fig. 1b). Cerebral MRI showed symmetrical hyperintense areas on T2-weighted sequences located in the midbrain, pons, cerebellum, and deep white matter diffusely (Fig. 1c–d). Diffusion-weighted sequences revealed restriction of signal intensity at the pons and midbrain and in the left sub-cortical parietal white matter and the splenium of the corpus callosum. These features were highly suggestive of PRES. The retroperitoneal mass was biopsied and analysis revealed a neuroblastoma. Oncologic treatment was instituted with vincristine, cyclophosphamide, and doxorubicin. The patient was weaned off progressively of the ventricular drain within 14 days. Followup MRI demonstrated the regression of the inflammatory lesions, posterior fossa edema, and the hydrocephalus (Fig. 2 a– b) confirming the diagnosis of PRES. PRES is a rare neurological condition characterized by headache, seizures, altered mental status, and visual loss associated with vasogenic edema affecting predominantly the occipital and parietal lobes [1]. Posterior fossa involvement, as in our patient, is considered an atypical PRES variant and can be occasionally associated with obstructive hydrocephalus [2]. The physiopathology of PRES remains debatable. Several factors are implicated in the physiopathology of PRES like hypertensive crises, pre-eclampsia, chronic renal failure, dialysis, autoimmune diseases, immunosuppressive, and chemotherapeutic agents [2]. In literature to date, the association of PRES and neuroblastoma has only been described in the contest of antineoplastic treatment, such as the administration of monoclonal antibodies [3], immunosoppressive agents (e.g., tacrolimus and cyclosporine-A), anticancer drugs, and surgery [4]. The mechanism by which antineoplastic treatments can predispose patients to PRES still remains uncertain [3]. In our patient, the neuroblastoma and PRES were diagnosed at the same time, before the child was started on any specific antineoplastic medications. We believe that the PRES was related to the hypertensive crisis that was seen at initial clinical presentation. The hypertensive crisis led to the * V. Aureli viviana.aureli@chuv.ch

Semi-quantitative assessment of flow dynamics during indocyanine green video-angiography in the treatment of intracranial dural arteriovenous fistulas: how I do it

BackgroundIndocyanine green video-angiography (IG-VA) is applied for intraoperative localisation and verification of surgical disconnection of intracranial dural arteriovenous fistulas (iDAVFs).MethodWe describe the technique of semiquantitative flow analysis using Flow800 software that implements conventional IG-VA. Our method relies on simple comparison of the fluorescence curves of the exposed vessels, allowing precise localisation of the DAVF draining vein and verification of its surgical disconnection.ConclusionsSemi-quantitative flow analysis with Flow800 software during IG-VA is a reproducible technique that may overcome the limitations of conventional IG-VA in the surgical treatment of DAVFs.

Obstructive Hydrocephalus in Newborn Due to Cerebral Atrium Diverticulum Formation: Complete Resolution After Subdural Hematoma Evacuation.

BACKGROUNDnCerebral atrium diverticula are focal enlargements of the ventricular system that may develop in the presence of persistent intracranial hypertension, but they are rarely described in cases of acute intracranial hypertension. Here we present a unique case of obstructive hydrocephalus in a newborn due to the formation of a cerebral atrium diverticulum compressing the ventricular system.nnnCASE DISCUSSIONnA preterm 38-week-old boy was born with urgent caesarian section due to severe hydrocephalus. Magnetic resonance imaging showed the presence of a subacute right subdural hematoma with secondary obstructive hydrocephalus. The cystic lesion was characterized as a right ventricular atrium diverticulum. The child underwent urgent burr-hole evacuation of the right subdural hematoma with complete regression of the obstructive hydrocephalus and right atrial diverticulum.nnnCONCLUSIONnCerebral atrium diverticula are rare focal dilatations of the ventricular system, and their radiologic diagnosis may be challenging. Accurate diagnosis of atrial diverticula and understanding of the underlying physiopathology is mandatory to establish the appropriate operative strategy.

Extended Endoscopic Endonasal Approach for Craniopharyngioma Removal

Objective Endoscopic transsphenoidal extended endoscopic approach (EEA) represents a valid alternative to microsurgery for craniopharyngiomas removal, especially for retrochiasmatic lesions without large parasellar extension. The present video illustrates the salient surgical steps of the EEA for craniopahryngioma removal. Patient A 52‐year‐old man presented with a bitemporal hemianopia and a bilateral decreased visual acuity. MRI showed a Kassam type III cystic craniopharyngioma with a solid component (▸Fig. 1, panels A and B). Fig. 1 Preoperative sagittal (A) and axial (B) MRI showing a Kassam III cystic craniopharyngioma with a solid component, exerting mass effect on the optic chiasm. Postoperative sagittal (C) and axial (B) MRI showing complete resection of the craiopharyngioma. Surgical Procedure The head is rotated 10 degrees toward the surgeons. The nasal step is started through the left nostril with a middle turbinectomy. A nasoseptal flap is harvested and positioned in the left choana. The binostril approach allows a large sphenoidotomy to expose the key anatomic landmarks. The craniotomy boundaries are the planum sphenoidale superiorly, the median opticocarotid recesses, the internal carotid artery laterally and the clival recess inferiorly. After dural opening and superior intercavernous sinus coagulation, the tumor is entirely removed (▸Fig. 2, panels A and B). Skull base reconstruction is ensured by fascia lata grafting and nasoseptal flap positioning. Fig. 2 Operative pictures of the intradural phase. (A) shows tumor dissection from its adhesions to the right ON. (B) shows the resection of the residual craniopharyngioma after careful dissection from the right ON. The EEA allows wide exposure of the anterior communicating vascular complex, both optic nerves, the optic chiasm and tracts, the pituitary stalk. Abbreviations. AComA, anterior communicating artery; OptCh, optic chiasm; ON: optic nerve, OT, optic tract. Results Postoperative MRI showed the complete tumor resection (▸Fig. 1, panels C and D). At 3 months postoperatively, the bitemporal hemianopia regressed and the visual acuity improved. A novel left homonymous hemianopia developed secondary to optic tract manipulation. Conclusions The extended EEA is a valid surgical approach for craniopharyngioma resection. A comprehensive knowledge of the sellar and parasellar anatomy is mandatory for safe tumor removal with decreased morbidity and satisfactory oncologic results. The link to the video can be found at: https://youtu.be/NrCPPnVK2qA.