World Neurosurg
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Arteriovenous malformations have a significant cumulative risk for hemorrhage. Treatment options include observation, microsurgical resection, stereotactic radiosurgery, embolization, and multimodal treatment. Treatment selection and timing are based on arteriovenous malformation (AVM) features including size, location in eloquent versus noneloquent parenchyma, pattern of venous drainage, surgical access, rupture status, and previous treatments. ⋯ Embolization in the treatment of AVMs is thus most commonly used as a preoperative or, occasionally, preradiosurgical adjunct. The concept of curative AVM embolization is an attractive one that has emerged within the past few decades, with increasing clinical evidence for its safety and efficacy in recent years. Obliteration rates for curative AVM embolization will be improved by innovation in endovascular techniques and technologies.
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Trapped or isolated fourth ventricle is a known, late sequela after lateral ventricular shunt placement for hydrocephalus, particularly after infection or hemorrhage. It may cause brainstem compression and insidiously present with ataxia, dysarthria, and intracranial hypertension, further delaying diagnosis. There is no universally agreed on treatment algorithm, and options include open fenestration through a suboccipital craniotomy, fourth ventricle shunting, and minimally invasive options including endoscopic stenting and fenestration through a precoronal approach. ⋯ Magnetic resonance imaging (MRI) demonstrated complex, loculated hydrocephalus and a dilated fourth ventricle. Under electromagnetic navigation, we endoscopically fenestrated his fourth ventricle using a rarely described suboccipital, transaqueductal approach. He tolerated the procedure without complication and improved neurologically, although his follow-up MRI demonstrated no change in fourth ventricular dilation at 1 year. Although there was no decrease in size of the fourth ventricle on follow-up MRI, we describe an alternative, well-tolerated, suboccipital approach for the management of a trapped fourth ventricle. Fenestration of a web of tissue in the aqueduct of Sylvius provided long-term clinical improvement and may provide a rescue approach for patients who are not candidates for standard approaches.
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No widely accepted gold standard for diagnosis of shunt infection exists, with definitions variable among clinicians and publications. This article summarizes the utility of commonly used diagnostic tools and provides a comprehensive review of optimal measures for diagnosis. ⋯ The definition of shunt infection is variable across studies, with CSF culture and/or symptomatology being the most commonly utilized parameters.
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Observational Study
Follow-up and treatment of patients with coexisting brain tumor and intracranial aneurysm.
The association of primary brain tumors with coexisting unruptured intracranial aneurysms (UIAs) has been debated, and treatment strategies have not yet been established. We evaluated the flow association between brain tumors and coexisting UIAs and the outcomes of patients with brain tumor who did not receive treatment of coexisting UIAs. ⋯ The incidence of UIAs among patients with primary brain tumors appears to be greater than that in the general population. An interval increase in aneurysm size and aneurysmal rupture was observed in 2 patients with astrocytic or oligodendroglial tumors. We would recommend perioperative treatment of flow-related UIAs in patients with astrocytic or oligodendroglial tumors and noninvasive evaluations such as magnetic resonance angiography if coexisting UIAs remain untreated.
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To identify causes of recurrent hemifacial spasm (HFS) after initial microvascular decompression (MVD) and to assess the feasibility of redo MVD. ⋯ Redo MVD remains a feasible treatment option for patients with HFS who failed to benefit from previous MVD, but it is associated with an increased risk of cranial nerve and vascular injuries.