Chronic subdural hematoma treatment

Chronic subdural hematoma treatment


Corticosteroids are associated with reduced recurrence but also increased morbidityDrains reduce the risk of recurrence, but the position of drain (subdural vs subgaleal) did not influence recurrenceMiddle meningeal artery embolization is a promising treatment warranting further evaluation in randomized trial1).


Surgical therapies involve the irrigation and removal of the blood products, sometimes with partial resection of these vascular membranes 2).

Investigational medical therapies have employed various strategies, which include reducing the rate of microhemorrhage from the membranes, changing the osmotic environment, or altering angiogenesis 3).

Endovascular therapies are aimed at de-vascularizing these membranes 4) 5) 6) 7).


Providing a high level of evidence to propose a standard of care for this frequent pathology is of utmost importance. However, two surveys in the UK and in France have shown a wide range of practice, without major rationale 8) 9).

A variety of clinical factors must be taken into account in the treatment of chronic subdural hematoma (cSDH), and the multifaceted treatment paradigms continue to evolve 10).

There is lack of uniformity about the treatment strategies, such as the role of burr holetwist drillcraniotomy, etc., in CSDH amongst various surgeons. There is also disagreement about the use of drainirrigation, and steroid 11) 12).

Surgery is usually the treatment of choice, but conservative treatment may be a good alternative in some situations.

Chronic subdural hematoma recurrence after evacuation occurs in approximately 10% of chronic subdural hematomas, and the various Chronic subdural hematoma surgery interventions are approximately equivalent. Corticosteroids are associated with reduced recurrence but also increased morbidityDrains reduce the risk of recurrence, but the position of drain (subdural vs subgaleal) did not influence recurrenceMiddle meningeal artery embolization is a promising treatment warranting further evaluation in randomized trial13).


Soleman et al., provide a systematic review of studies analysing the conservative treatment options and the natural history of cSDH. Of 231 articles screened, 35 were included in this systematic review. Studies evaluating the natural history and conservative treatment modalities of cSDH remain sparse and are predominantly of low level of evidence. The natural history of cSDH remains unclear and is analysed only in case reports or very small case series. “Wait and watch” or “wait and scan” management is indicated in patients with no or minor symptoms (Markwalder score 0-1). However, it seems that there are no clear clinical or radiological signs indicating whether the cSDH will resolve spontaneously or not (type C recommendation). In symptomatic patients who are not worsening or in a comatose state, oral steroid treatment might be an alternative to surgery (type C recommendation). Tranexamic acid proved effective in a small patient series (type C recommendation), but its risk of increasing thromboembolic events in patients treated with antithrombotic or anticoagulant medication is unclear. Angiotensin converting-enzyme inhibitors were evaluated only as adjuvant therapy to surgery, and their effect on the rate of recurrence remains debatable. Mannitol showed promising results in small retrospective series and might be a valid treatment modality (type C recommendation). However, the long treatment duration is a major drawback. Patients presenting without paresis can be treated with a platelet activating factor receptor antagonist (type C recommendation), since they seem to promote resolution of the haematoma, especially in patients with subdural hygromas or low-density haematomas on computed tomography. Lastly, atorvastatin seems to be a safe option for the conservative treatment of asymptomatic or mildly symptomatic cSDH patients (type C recommendation). In conclusion, the knowledge of the conservative treatment modalities for cSDH is sparse and based on small case series and low grade evidence. However, some treatment modalities seem promising even in symptomatic patients with large haematomas. Randomised controlled trials are currently underway, and will hopefully provide us with good evidence for or against the conservative treatment of cSDH 14).

The aim of a study was to survey aspects of current practice in the UK and Ireland. A 1-page postal questionnaire addressing the treatment of primary (i.e. not recurrent) CSDH was sent to consultant SBNS members in March 2006. There were 112 responses from 215 questionnaires (52%). The preferred surgical technique was burr hole drainage (92%). Most surgeons prefer not to place a drain, with 27% never using one and 58% using drain only in one-quarter of cases or less. Only 11% of surgeons always place a drain, and only 30% place one in 75% of cases or more. The closed subdural-to-external drainage was most commonly used (91%) with closed subgaleal-to-external and subdural-to-peritoneal conduit used less often (3 and 4%, respectively). Only 5% of responders claimed to know the exact recurrence rate. The average perceived recurrence rate among the surgeons that never use drains and those who always use drains, was the same (both 11%). Most operations are performed by registrars (77%). Postoperative imaging is requested routinely by 32% of respondents and 57% of surgeons prescribe bed rest. Ninety four per cent surgeons employ conservative management in less than one-quarter of cases. Forty-two per cent of surgeons never prescribe steroids, 55% prescribe them to those managed conservatively. This survey demonstrates that there are diverse practices in the management of CSDH. This may be because of sufficiently persuasive evidence either does not exist or is not always taken into account. The current literature provides Class II and III evidence and there is a need for randomized studies to address the role of external drainage, steroids and postoperative bed rest 15).


Cenic et al. developed and administered a questionnaire to Canadian Neurosurgeons with questions relating to the management of chronic and subacute subdural hematoma. Our sampling frame included all neurosurgery members of the Canadian Neurosurgical Society.

Of 158 questionnaires, 120 were returned (response rate = 76%). The respondents were neurosurgeons with primarily adult clinical practices (108/120). Surgeons preferred one and two burr-hole craniostomy to craniotomy or twist-drill craniostomy as the procedure of choice for initial treatment of subdural hematoma (35.5% vs 49.5% vs 4.7% vs 9.3%, respectively). Craniotomy and two burr-holes were preferred for recurrent subdural hematomas (43.3% and 35.1%, respectively). Surgeons preferred irrigation of the subdural cavity (79.6%), use of a subdural drain (80.6%), and no use of anti-convulsants or corticosteroids (82.1% and 86.6%, respectively). We identified a lack of consensus with keeping patients supine following surgery and post-operative antibiotic use.

The survey has identified variations in practice patterns among Canadian Neurosurgeons with respect to treatment of subacute or chronic subdural hematoma (SDH). Our findings support the need for further prospective studies and clinical trials to resolve areas of discrepancies in clinical management and hence, standardize treatment regimens 16).


1) , 13)

Henry J, Amoo M, Kissner M, Deane T, Zilani G, Crockett MT, Javadpour M. Management of Chronic Subdural Hematoma: A Systematic Review and Component Network Meta-analysis of 455 Studies With 103 645 Cases. Neurosurgery. 2022 Dec 1;91(6):842-855. doi: 10.1227/neu.0000000000002144. Epub 2022 Sep 28. PMID: 36170165.
2)

Markwalder TM . The course of chronic subdural hematomas after burr-hole craniostomy with and without closed-system drainage. Neurosurg Clin N Am 2000;11:541–6.doi:10.1016/S1042-3680(18)30120-7
3)

Sun TF , Boet R , Poon WS . Non-surgical primary treatment of chronic subdural haematoma: preliminary results of using dexamethasone. Br J Neurosurg 2005;19:327–33.doi:10.1080/02688690500305332
4)

Link TW , Boddu S , Marcus J , et al . Middle meningeal artery embolization as treatment for chronic subdural hematoma: a case series. Oper Neurosurg 2018;14:556–62.doi:10.1093/ons/opx154
5)

Link TW , Boddu S , Paine SM , et al . Middle meningeal artery embolization for chronic subdural hematoma: a series of 60 cases. Neurosurgery 2018;121.doi:10.1093/neuros/nyy521
6)

Link TW , Rapoport BI , Paine SM , et al . Middle meningeal artery embolization for chronic subdural hematoma: Endovascular technique and radiographic findings. Interv Neuroradiol 2018;24:455–62.doi:10.1177/1591019918769336
7)

Link TW , Schwarz JT , Paine SM , et al . Middle meningeal artery embolization for Chronic subdural hematoma recurrence: a case series. World Neurosurg 2018;118:e570–4.doi:10.1016/j.wneu.2018.06.241
8)

M. Guénot, Hématome sous-dural chronique. Introduction et résultats de l’enquête de la SFNC, Neurochirurgie 4 (2001) 459–460 https://doi.org/ NCHIR-11-2001-47- 5-0028-3770-101019-ART7.
9)

] T. Santarius, R. Lawton, P.J. Kirkpatrick, P.J. Hutchinson, The management of primary chronic subdural haematoma: a questionnaire survey of practice in the United Kingdom and the Republic of Ireland, Br. J. Neurosurg. 22 (2008) 529–534, https://doi.org/10.1080/02688690802195381.
10)

Sahyouni R, Goshtasbi K, Mahmoodi A, Tran DK, Chen JW. Chronic Subdural Hematoma: A Historical and Clinical Perspective. World Neurosurg. 2017 Dec;108:948-953. doi: 10.1016/j.wneu.2017.09.064. Epub 2017 Sep 19. Review. PubMed PMID: 28935548.
11) , 15)

Santarius T, Lawton R, Kirkpatrick PJ, Hutchinson PJ. The management of primary chronic subdural haematoma: a questionnaire survey of practice in the United Kingdom and the Republic of Ireland. Br J Neurosurg. 2008 Aug;22(4):529-34. doi: 10.1080/02688690802195381. PubMed PMID: 18686063.
12)

Cenic A, Bhandari M, Reddy K. Management of chronic subdural hematoma: a national survey and literature review. Can J Neurol Sci. 2005 Nov;32(4):501-6. PubMed PMID: 16408582.
14)

Soleman J, Noccera F, Mariani L. The conservative and pharmacological management of chronic subdural haematoma. Swiss Med Wkly. 2017 Jan 19;147:w14398. doi: smw.2017.14398. PubMed PMID: 28102879.
16)

Cenic A, Bhandari M, Reddy K. Management of chronic subdural hematoma: a national survey and literature review. Can J Neurol Sci. 2005 Nov;32(4):501-6. PubMed PMID: 16408582.

t

A variety of clinical factors must be taken into account in the treatment of chronic subdural hematoma (cSDH), and the multifaceted treatment paradigms continue to evolve 1).

There is lack of uniformity about the treatment strategies, such as the role of burr holetwist drillcraniotomy, etc., in CSDH amongst various surgeons. There is also disagreement about the use of drainirrigation, and steroid 2) 3).

Surgery is usually the treatment of choice, but conservative treatment may be a good alternative in some situations.

see DECSA trial.

see Middle Meningeal Artery Embolization.

Chronic subdural hematoma surgery

Systematic reviews

Soleman et al., provide a systematic review of studies analysing the conservative treatment options and the natural history of cSDH. Of 231 articles screened, 35 were included in this systematic review. Studies evaluating the natural history and conservative treatment modalities of cSDH remain sparse and are predominantly of low level of evidence. The natural history of cSDH remains unclear and is analysed only in case reports or very small case series. “Wait and watch” or “wait and scan” management is indicated in patients with no or minor symptoms (Markwalder score 0-1). However, it seems that there are no clear clinical or radiological signs indicating whether the cSDH will resolve spontaneously or not (type C recommendation). In symptomatic patients who are not worsening or in a comatose state, oral steroid treatment might be an alternative to surgery (type C recommendation). Tranexamic acid proved effective in a small patient series (type C recommendation), but its risk of increasing thromboembolic events in patients treated with antithrombotic or anticoagulant medication is unclear. Angiotensin converting-enzyme inhibitors were evaluated only as adjuvant therapy to surgery, and their effect on the rate of recurrence remains debatable. Mannitol showed promising results in small retrospective series and might be a valid treatment modality (type C recommendation). However, the long treatment duration is a major drawback. Patients presenting without paresis can be treated with a platelet activating factor receptor antagonist (type C recommendation), since they seem to promote resolution of the haematoma, especially in patients with subdural hygromas or low-density haematomas on computed tomography. Lastly, atorvastatin seems to be a safe option for the conservative treatment of asymptomatic or mildly symptomatic cSDH patients (type C recommendation). In conclusion, the knowledge of the conservative treatment modalities for cSDH is sparse and based on small case series and low grade evidence. However, some treatment modalities seem promising even in symptomatic patients with large haematomas. Randomised controlled trials are currently underway, and will hopefully provide us with good evidence for or against the conservative treatment of cSDH 4).

Surveys

The aim of a study was to survey aspects of current practice in the UK and Ireland. A 1-page postal questionnaire addressing the treatment of primary (i.e. not recurrent) CSDH was sent to consultant SBNS members in March 2006. There were 112 responses from 215 questionnaires (52%). The preferred surgical technique was burr hole drainage (92%). Most surgeons prefer not to place a drain, with 27% never using one and 58% using drain only in one-quarter of cases or less. Only 11% of surgeons always place a drain, and only 30% place one in 75% of cases or more. The closed subdural-to-external drainage was most commonly used (91%) with closed subgaleal-to-external and subdural-to-peritoneal conduit used less often (3 and 4%, respectively). Only 5% of responders claimed to know the exact recurrence rate. The average perceived recurrence rate among the surgeons that never use drains and those who always use drains, was the same (both 11%). Most operations are performed by registrars (77%). Postoperative imaging is requested routinely by 32% of respondents and 57% of surgeons prescribe bed rest. Ninety four per cent surgeons employ conservative management in less than one-quarter of cases. Forty-two per cent of surgeons never prescribe steroids, 55% prescribe them to those managed conservatively. This survey demonstrates that there are diverse practices in the management of CSDH. This may be because of sufficiently persuasive evidence either does not exist or is not always taken into account. The current literature provides Class II and III evidence and there is a need for randomized studies to address the role of external drainage, steroids and postoperative bed rest 5).


Cenic et al. developed and administered a questionnaire to Canadian Neurosurgeons with questions relating to the management of chronic and subacute subdural hematoma. Our sampling frame included all neurosurgery members of the Canadian Neurosurgical Society.

Of 158 questionnaires, 120 were returned (response rate = 76%). The respondents were neurosurgeons with primarily adult clinical practices (108/120). Surgeons preferred one and two burr-hole craniostomy to craniotomy or twist-drill craniostomy as the procedure of choice for initial treatment of subdural hematoma (35.5% vs 49.5% vs 4.7% vs 9.3%, respectively). Craniotomy and two burr-holes were preferred for recurrent subdural hematomas (43.3% and 35.1%, respectively). Surgeons preferred irrigation of the subdural cavity (79.6%), use of a subdural drain (80.6%), and no use of anti-convulsants or corticosteroids (82.1% and 86.6%, respectively). We identified a lack of consensus with keeping patients supine following surgery and post-operative antibiotic use.

The survey has identified variations in practice patterns among Canadian Neurosurgeons with respect to treatment of subacute or chronic subdural hematoma (SDH). Our findings support the need for further prospective studies and clinical trials to resolve areas of discrepancies in clinical management and hence, standardize treatment regimens 6).

Glucocorticoids

Since glucocorticoids have been used for treatment of cSDH in 1962 their role is still discussed controversially in lack of evident data. On the basis of the ascertained inflammation cycle in cSDH dexamethasone will be an ideal substance for a short lasting, concomitant treatment protocol.

A study is designed as a double-blind randomized placebo-controlled trial 820 patients who are operated for cSDH and from the age of 25 years are included after obtaining informed consent. They are randomized for administration of dexamethasone (16-16-12-12-8-4 mg/d) or placebo (maltodextrin) during the first 48 hours after surgery. The type I error is 5% and the type II error is 20%. The primary endpoint is the reoperation within 12 weeks postoperative.

This study tests whether dexamethasone administered over 6 days is a safe and potent agent in relapse prevention for evacuated cSDH 7).

Chronic subdural hematoma seizure prophylaxis

Anticoagulation resumption after chronic subdural hematoma

References

1)

Sahyouni R, Goshtasbi K, Mahmoodi A, Tran DK, Chen JW. Chronic Subdural Hematoma: A Historical and Clinical Perspective. World Neurosurg. 2017 Dec;108:948-953. doi: 10.1016/j.wneu.2017.09.064. Epub 2017 Sep 19. Review. PubMed PMID: 28935548.
2) , 5)

Santarius T, Lawton R, Kirkpatrick PJ, Hutchinson PJ. The management of primary chronic subdural haematoma: a questionnaire survey of practice in the United Kingdom and the Republic of Ireland. Br J Neurosurg. 2008 Aug;22(4):529-34. doi: 10.1080/02688690802195381. PubMed PMID: 18686063.
3)

Cenic A, Bhandari M, Reddy K. Management of chronic subdural hematoma: a national survey and literature review. Can J Neurol Sci. 2005 Nov;32(4):501-6. PubMed PMID: 16408582.
4)

Soleman J, Noccera F, Mariani L. The conservative and pharmacological management of chronic subdural haematoma. Swiss Med Wkly. 2017 Jan 19;147:w14398. doi: smw.2017.14398. PubMed PMID: 28102879.
6)

Cenic A, Bhandari M, Reddy K. Management of chronic subdural hematoma: a national survey and literature review. Can J Neurol Sci. 2005 Nov;32(4):501-6. PubMed PMID: 16408582.
7)

Emich S, Richling B, McCoy MR, Al-Schameri RA, Ling F, Sun L, Wang Y, Hitzl W. The efficacy of dexamethasone on reduction in the reoperation rate of chronic subdural hematoma – the DRESH study: straightforward study protocol for a randomized controlled trial. Trials. 2014 Jan 6;15(1):6. doi: 10.1186/1745-6215-15-6. PubMed PMID: 24393328; PubMed Central PMCID: PMC3891985.

Basal ganglia hemorrhage surgery

Basal ganglia hemorrhage surgery

The main surgical techniques for spontaneous basal ganglia hemorrhage include stereotactic aspirationendoscopic aspiration, and craniotomy. However, credible evidence is still needed to validate the effect of these techniques.

Outcome analysis was stratified using hematoma volume, ICH score, preoperative GCS score, and decompressive craniectomy (DC).

Results: The mean hematoma volume was 70.8 mL, and 68 patients (26.9%) underwent DC. The mean postoperative ICP was 28.8 ± 6.7 mmHg for patients without DC, and only 17.5 ± 8.6 mmHg for patients with DC. Twenty-five patients (9.9%) died within 30 days of the operation, and 88 patients (34.8%, GOS ≥ 4) had good outcome 3 months after surgery. ICH volume > 50 mL, preoperative GCS score ≤ 8, and ICH score ≥ 3 are risk factors for unfavorable outcomes.

Conclusions: DC can be used for patients with low preoperative GCS score, and it effectively reduces ICP and 30-day mortality. Hematoma volume, preoperative GCS score, and ICH score are of predictive value for surgical outcome of large basal ganglia hemorrhage 1).

A total of 61 patients with hypertensive basal ganglia hemorrhage were recruited at the Binzhou Medical University Hospital, between October 2019 and January 2021, and their clinical information was retrospectively analyzed. Based on the surgical approach used, patients were assigned into either laser navigation or small bone window groups depending on the surgical approach. Then, they compared the operation times, intraoperative blood loss, clinic stay, Glasgow Outcome Scale (GOS) rating at 30 days, Barthel index (BI) rating at 6 months, postoperative pneumonia incidences, and intracranial contamination complications between groups. Intraoperative blood lossoperation time, and sanatorium were significantly low in the laser navigation group, relative to the small bone window group. At the same time, there were no significant differences between the groups with regard to postoperative hematoma volume, lung contamination, cerebrospinal fluid (CSF) leak, and intracranial contamination, as well as the 6-month BI and 30-day GOS rating. There were no deaths in either group. Compared with traditional small bone window surgery, laser-guided puncture, and drainage is a low-cost, accurate, and safe method for the treatment of basal ganglia hemorrhage, which is suitable for promotion in developing countries and economically underdeveloped areas 2)

Postoperative hemorrhage is a severe complication, and it’s relative to neurosurgical techniques.

The favorable outcome group was slightly younger (p-value 0.050*). Also, the volume and extension of hematoma into the ventricular system, hydrocephalic dilatation, and midline shift greater than 5 mm had a significantly worse outcome with a statistically significant difference.

The early surgical management with the removal of the hematoma led to a dramatic reduction of ICP and improved the prognosis. Patients with signs of brain herniation, a midline shift > 5 mm, hydrocephalic dilatation, ventricular hemorrhage, and a depressed level of consciousness have a poor prognosis 3)


1)

Li Q, Yang CH, Xu JG, Li H, You C. Surgical treatment for large spontaneous basal ganglia hemorrhage: retrospective analysis of 253 cases. Br J Neurosurg. 2013 Oct;27(5):617-21. doi: 10.3109/02688697.2013.765938. Epub 2013 Feb 14. PMID: 23406426.
2)

Yuan Z, Wei Q, Chen Z, Xing H, Zhang T, Li Z. Laser navigation combined with XperCT technology-assisted puncture of basal ganglia intracerebral hemorrhage. Neurosurg Rev. 2023 May 5;46(1):104. doi: 10.1007/s10143-023-02015-2. PMID: 37145343.
3)

khallaf, M., Abdelrahman, M. Surgical management for large hypertensive basal ganglionic hemorrhage: single center experience. Egypt J Neurosurg 34, 19 (2019). https://doi.org/10.1186/s41984-019-0044-9

Burr hole trephination for chronic subdural hematoma

Burr hole trephination for chronic subdural hematoma

Double burr hole trepanation combined with a subperiostal passive closed-drainage system is a technically easy, highly effective, safe, and cost-efficient treatment strategy for symptomatic chronic subdural hematomas. The absence of a drain in direct contact with the hematoma capsule may moderate the risk of postoperative seizure and limit the secondary spread of infection to intracranial compartments 1).


The main aim of surgery should be a complete removal of the aggressive liquid. In case of many membranes that separate the hematoma into chambers like honeycomb an open procedure cannot be avoided. Nevertheless, the preferred operative therapy for most of CSDH is a burr hole craniostomy with a closed drainage system 2) 3).

Preferably under general anesthesia the surgical approach should be over the thickest part of the hematoma and the patients positioned in a way that the burr hole comes to the highest point to avoid pneumocephalus.

Therefore, the head is rotated and the ipsilateral shoulder is usually padded.

The supine position is used with the patient‘s head rotated for temporal access. Extremes of head rotation can obstruct the jugular venous drainage, and a shoulder roll can combat this problem or lateral positioning (park bench position).

Sites of predilection are frontal about 1 cm anterior to the coronal suture or parietal posterior to the parietal eminence. The area around Kocher’s point offers a safe entry without injury of branches of the middle meningeal artery or the motor strip. Additionally, the skin incision should be brought, if possible, into alignment with an eventual future skin flap for craniotomy. A curved flap avoids a burr hole position directly under the skin cut and a possible impaired wound-healing as a consequence. Further, the base of the C-shaped incision should be opposite of the planned direction of the drain tip. Obviously, a kinking of the drain is obviated 4).

A performed burr hole with a diameter of 14 mm enables a sufficient angulation of the drain tip and allows an insertion of the drainage close to the calvaria.


Diren and Ozdemir found that an increase in the width of burr hole craniotomy (BHC), especially the posterior BHC, contributed to the improvement in midline shift 5).

The dura mater is coagulated and cut in a stellate fashion.

Under direct vision, the external membrane is perforated by the tips of the bipolar forceps. In general, there are the open or the closed ways of evacuation of the hematoma after the drain is inserted 6)

The open variant should be chosen only if irrigation is desired: the dura and external membrane are opened widely so that the fluid of the hematoma and irrigation can drip out beside the drain during rinsing. Removal of the fluid enriched with inflammatory mediators is considered obviously as an advantage, although a remaining pneumocephalus is seen as an approved factor of recurrence 7) 8).

In the closed way the aim is that no air enters the subdural space. Before the dural opening the drain is tunneled beneath the galea in the direction towards the middle of the base of the skin flap. A distance from the burr hole to the drain’s exit point of at least 5 cm prevents infection 9).

Then the dura and external membrane are incised. This opening should have the same diameter as the drain to allow for a watertight and airtight drain introduction. The hematoma can therefore be evacuated only through the drain: the more fluid that is going to be collected, the more negative pressure that will be built up, which helps the brain to unfold again.

The dura is covered with a small piece of a gelatin sponge and the burr hole is filled and with bone chips collected at the beginning.

The last steps are to connect the drain to a closed collecting system and secure the connection and the exit point from the skin with sutures.


Drain insertion after CSDH drainage is important, but position (subgaleal or subdural) and duration did not appear to influence recurrence rate or clinical outcomes. Similarly, drain location did not influence recurrence rate nor outcomes where both parietal and frontal burr holes were made. Further prospective cohort studies or randomized controlled trials could provide further clarification 10).


1)

Zumofen D, Regli L, Levivier M, Krayenbühl N. Chronic subdural hematomas treated by burr hole trepanation and a subperiostal drainage system. Neurosurgery. 2009 Jun;64(6):1116-21; discussion 1121-2. doi: 10.1227/01.NEU.0000345633.45961.BB. PubMed PMID: 19487891.
2)

Santarius T, Kirkpatrick PJ, Ganesan D, Chia HL, Jalloh I, Smielewski P, Richards HK, Marcus H, Parker RA, Price SJ, Kirollos RW, Pickard JD, Hutchinson PJ (2009) Use of drains versus no drains after burr-hole evacuation of chronic subdural haematoma: a randomised controlled trial. Lancet 374:1067–1073
3)

Weigel R, Schmiedek P, Krauss JK (2003) Outcome of contemporary surgery for chronic subdural haematoma: evidence based review. J Neurol Neurosurg Psychiatry 74:937–943
4)

Emich S, Dollenz M, Winkler PA. Burr hole is not burr hole: technical considerations to the evacuation of chronic subdural hematomas. Acta Neurochir (Wien). 2015 Jan 13. [Epub ahead of print] PubMed PMID: 25578345.
5)

Diren F, Ozdemir O. The effectiveness of Burr-hole sizes on midline shift and hematoma thickness in the treatment of chronic subdural hematoma. World Neurosurg. 2023 Apr 20:S1878-8750(23)00546-6. doi: 10.1016/j.wneu.2023.04.062. Epub ahead of print. PMID: 37087033.
6)

Tosaka M, Sakamoto K, Watanabe S, Yodonawa M, Kunimine H, Aishima K, Fujii T, Yoshimoto Y (2013) Critical classification of craniostomy for chronic subdural hematoma; safer technique for hematoma aspiration. Neurol Med Chir (Tokyo) 53:273–278
7)

Mori K, Maeda M (2001) Surgical treatment of chronic subdural hematoma in 500 consecutive cases: clinical characteristics, surgical outcome, complications, and recurrence rate. Neurol Med Chir (Tokyo) 41:371–381
8)

Stanišić M, Hald J, Rasmussen IA, Pripp AH, Ivanović J, Kolstad F, Sundseth J, Züchner M, Lindegaard KF (2013) Volume and densities of chronic subdural haematoma obtained from CT imaging as predictors of postoperative recurrence: a prospective study of 107 operated patients. Acta Neurochir 155:323–333
9)

Berghauser Pont LM, Dammers R, Schouten JW, Lingsma HF, Dirven CM (2012) Clinical factors associated with outcome in chronic subdural haematoma: a retrospective cohort study of patients on preoperative corticosteroid therapy. Neurosurgery 70:873–880
10)

Glancz LJ, Poon MTC, Coulter IC, Hutchinson PJ, Kolias AG, Brennan PM. Does Drain Position and Duration Influence Outcomes in Patients Undergoing Burr-Hole Evacuation of Chronic Subdural Hematoma? Lessons from a UK Multicenter Prospective Cohort Study. Neurosurgery. 2019 Oct 1;85(4):486-493. doi: 10.1093/neuros/nyy366. PubMed PMID: 30169738.

Superficial temporal artery to middle cerebral artery bypass for moyamoya disease

Superficial temporal artery to middle cerebral artery bypass for moyamoya disease

Collateral artery formation from the extracranial carotid artery to ischemic brain tissue determines the clinical success of superficial temporal artery (STA) to middle cerebral artery (MCA) bypass surgery in adult patients with moyamoya disease, but postoperative collateral formation (PCF) after STA-MCA bypass surgery is unpredictable. Accurate preoperative prediction of acceptable PCF could improve patient selection. Sun et al. aim to develop a prediction nomogram model for PCF in this patient population.

Adult patients with moyamoya disease undergoing the STA-MCA bypass surgery between January 2013 and December 2020 at a single institution were retrospectively or prospectively enrolled in this observational study. Data including potential clinical and radiological predictors were obtained from hospital records. A nomogram was generated based on a multivariate logistic regression analysis, to identify potential predictors associated with good PCF. The performance of the nomogram was evaluated for discrimination, calibration, and clinical utility.

Data from 243 patients with moyamoya disease who underwent the STA-MCA bypass surgery were analyzed to build the nomogram. After 1-year follow-up, 162 (66.7%) hemispheres had good PCF and 81 (33.3%) had poor PCF. Good PCF is associated with 3 preoperative factors: age at operation, the diameter of the donor branch of STA, and the preinfarction period stage. Incorporating these 3 factors, the model achieved a concordance index of 0.88 (95% CI, 0.84-0.92) and had a well-fitted calibration curve and good clinical application value. A cutoff value of 100 was determined to predict good PCF via this nomogram.

The nomogram exhibits high accuracy in predicting good PCF after the STA-MCA bypass surgery in adult patients with moyamoya disease and may allow surgeons to better evaluate preoperatively candidacy for successful bypass surgery 3).

Data for consecutive patients who underwent STA-MCA MVB from 2000-2019 due to moyamoya/moyamoya-like disease, complex intracranial aneurysms, or intractable brain ischemia due to internal carotid artery or middle cerebral artery occlusive disease with repeated ischemic events were retrospectively analyzed under a waiver of informed consent. Key surgical steps and the important role of neuroendovascular interventions are presented. Surgical results and late outcomes were analyzed.

The study was comprised of 32 patients (17 women [53%], 15 men [47%]), mean age 42.94 years (range 16-66). Patients underwent 37 STA-MCA MVB procedures during the study period; 22 with moyamoya/moyamoya-like disease (69%) underwent 27 surgeries (five bilateral); 7 with complex aneurysms (22%) and 3 with vascular occlusive disease (9%) underwent unilateral bypass. Five of seven aneurysms were treated with coiling or flow-diverter stent implant prior to bypass surgery; two were clipped during the bypass procedure. There were no surgical complications, no perioperative mortality, and no death from complications related to neurovascular disease at late follow-up. Transient neurological deficits following 8/37 (21%) resolved with no permanent neurologic sequelae. Transient ischemic attacks occurred only in the immediate postoperative period in four patients (11%).

In specific cases, STA-MCA MVB is a feasible and clinically effective procedure. It is important to preserve this technique in surgical armamentarium 4).


From October 2005 to November 2009, Xu et al. from the Department of Neurosurgery, Fudan University, Shanghai, China performed a combined revascularization procedure in 111 patients with different types and stages of moyamoya disease. The superficial temporal arterymiddle meningeal artery and the deep temporal artery were evaluated for individualized surgical planning in these cases. The integrity of the deep temporal artery and the middle meningeal artery network, and the pre-existing spontaneous anastomoses of the distal branches of the external carotid artery with the cortical arteries were well preserved. The mean follow-up time was 72.5 months, all clinical and radiological data were retrospectively reviewed.

A total of 198 stomas were performed in 122 hemispheres, all remaining patent until the last follow-up. The encephalo-duro-myo-synangiosis resulted in extensive anastomoses of the deep temporal artery (100%), the middle meningeal artery (90.9%), and the sphenopalatine artery (39.8%) with the cortical arteries, respectively. The superficial temporal artery, deep temporal artery, and the middle meningeal artery were significantly thickened in 88 patients as determined by digital subtraction angiography at follow-up. The relative cerebral blood flow increased significantly within one week after the operation. At 6 months post the operation, the relative cerebral blood flow was further increased by 15.5% from the gradual formation of anastomoses as a result of indirect revascularization. Transient ischemic attacks were effectively reduced or totally arrested. The neurological deficits significantly improved in 37 patients, with the National Institutes of Health Stroke Scale scores lowered by 2-8. There was no rehemorrhage in hemorrhagic moyamoya disease patients.

This study showed that the superficial temporal artery-middle cerebral artery bypass combined with encephalo-duro-myo-synangiosis can achieve good therapeutic effect in the moyamoya disease treatment 5).


1)

Wen Y, Gou Y, Wang B, Wang Z, Chen S, Zhang S, Zhang G, Li M, Feng W, Qi S, Wang G. Is STA really a low-flow graft? A quantitative ultrasonographic study of the flow of STA for cerebral revascularization in MMD patients. CNS Neurosci Ther. 2023 Apr 1. doi: 10.1111/cns.14197. Epub ahead of print. PMID: 37002791.
2)

Gao F, Chen S, Gu J, Wang Z, Wang Z. Clinical Efficacy of Superficial Temporal Artery-middle Cerebral Artery Bypass Grafting Surgery Combined With Temporal Muscle Patch on Patients With Moyamoya Disease. J Craniofac Surg. 2022 Sep 6. doi: 10.1097/SCS.0000000000008992. Epub ahead of print. PMID: 36731073.
3)

Sun H, Li Y, Xiao A, Li W, Xia C, You C, Ma L, Liu Y, Xia C. Nomogram to Predict Good Collateral Formation After the STA-MCA Bypass Surgery in Adult Patients With Moyamoya Disease. Stroke. 2023 Feb 7. doi: 10.1161/STROKEAHA.122.039975. Epub ahead of print. PMID: 36748463.
4)

Kahanov L, Cohen JE, Fraifeld S, Mizrahi C, Leker RR, Moscovici S, Spektor S. Superficial Temporal Artery-Middle Cerebral Artery Microvascular Bypass: Its Role in Treatment of Patients with Moyamoya Disease, Cerebral Aneurysms, and Vascular Occlusive Disease. Isr Med Assoc J. 2021 May;23(5):306-311. PMID: 34024048.
5)

Xu B, Song DL, Mao Y, Gu YX, Xu H, Liao YJ, Liu CH, Zhou LF. Superficial temporal artery-middle cerebral artery bypass combined with encephalo-duro-myo-synangiosis in treating moyamoya disease: surgical techniques, indications and midterm follow-up results. Chin Med J (Engl). 2012 Dec;125(24):4398-405. PMID: 23253709.

Trigeminal neuralgia

Trigeminal neuralgia

Typical trigeminal neuralgia caused by microvascular compression of the trigeminal nerve root in the posterior fossa may become transformed over time into atypical trigeminal neuralgia, if left untreated. This transformation involves change in the character of pain and development of sensory impairment. Two representative cases are presented to support this theory.

If the theory of progressive change in character of pain and degree of sensory impairment in the course of otherwise typical trigeminal neuralgia is correct, trigeminal neuralgia, atypical neuralgia, and trigeminal neuropathic pain may represent different degrees of injury to the trigeminal nerve, therefore comprising a continuous spectrum rather than discrete diagnoses 2).

Barrow Neurological Institute Pain Scale.

Barrow Neurological Facial Numbness Scale.

Slavin KV. Commentary: Development and Evaluation of a Preoperative Trigeminal Neuralgia Scoring System to Predict Long-Term Outcome Following Microvascular Decompression. Neurosurgery. 2019 Dec 9. pii: nyz540. doi: 10.1093/neuros/nyz540. [Epub ahead of print] PubMed PMID: 31813971.


1)

Lewy FH: The first authentic case of major trigeminal neuralgia and some comments on the history of this disease. Ann Med Hist 10:247–250, 1938.
2)

Burchiel KJ, Slavin KV. On the natural history of trigeminal neuralgia. Neurosurgery. 2000 Jan;46(1):152-4; discussion 154-5. Review. PubMed PMID: 10626945.

Flow Diverter Stent for Middle Cerebral Artery Aneurysm

Flow Diverter Stent for Middle Cerebral Artery Aneurysm



Middle cerebral artery aneurysms tend to be complex, with integrated branches and potentially wide necks. Pipeline embolization device stents are safe and effective in the middle cerebral artery aneurysm, and the patency of the side and jailed branches is preserved in most cases. Higher occlusion and lower in-stent stenosis rates are seen with longer follow-up durations 1).

However, compared to published series on the open surgical treatment of this subset of aneurysms, flow diversion has inferior outcomes and is associated with a higher rate of complications 2).

Flow diverter for middle cerebral artery aneurysm treatment should be considered an alternative when traditional treatment methods are not feasible 3).

When performed in a select treatment group, high rates of aneurysm occlusion and protection against re-rupture can be achieved 4).

Longer angiographic follow-ups are needed to assess the morphologic outcome; immediate subtotal occlusions do not seem to be related to rupture 5).

Findings suggest that complete occlusion after endovascular treatment with FDD can be delayed (>6 months). Ischemic complications may occur as early or delayed, particularly at clopidogrel interruption 6).

The Pipeline Embolization Device provides a safe and effective treatment alternative for wide-neck MCA aneurysms that give rise to a bifurcating or distal branch when other endovascular techniques are thought to be unfeasible or more risky 7).

WEB flow disruption seems to be a promising technique for the treatment of complex MCA aneurysms, particularly those with a wide neck or unfavorable dome-to-neck ratio 8).

For Caroff et al. compared with other available therapeutic options, the flow-diverter stent does not appear to be a suitable solution for the treatment of saccular MCA bifurcation aneurysms 9).

Unsatisfactory occlusion rate in bifurcation aneurysms likely results from residual filling of the aneurysms in cases in which the jailed side branch remains patent 10).

A systematic search of PubMed, MEDLINE, and Embase was performed for studies published from 2008 to May 2017.

According to the Preferred Reporting Items for Systematic Reviews and MetaAnalyses, Cagnazzo et al. selected studies with >5 patients describing angiographic and clinical outcomes after flow-diversion treatment of MCA aneurysms.

Random effects metaanalysis was used to pool the following outcomes: aneurysm occlusion rate, procedure-related complications, rupture rate of treated aneurysms, and occlusion of the jailed branches.

Twelve studies evaluating 244 MCA aneurysms were included in this meta-analysis. Complete/near-complete occlusion was obtained in 78.7% (95% CI, 67.8%-89.7%) of aneurysms. The rupture rate of treated aneurysms during follow-up was 0.4% per aneurysm year. The rate of treatment-related complications was 20.7% (95% CI, 14%-27.5%), and approximately 10% of complications were permanent. The mortality rate was close to 2%. Nearly 10% (95% CI, 4.7%-15.5%) of jailed arteries were occluded during follow-up, whereas 26% (95% CI, 14.4%-37.6%) had slow flow. Rates of symptoms related to occlusion and slow flow were close to 5%.

Small and retrospective series could affect the strength of the reported results.

Given the not negligible rate of treatment-related complications, flow diversion for MCA aneurysms should be considered an alternative treatment when traditional treatment methods are not feasible. However, when performed in this select treatment group, high rates of aneurysm occlusion and protection against re-rupture can be achieved 11).

Burrows et al. present the case of an adolescent with a middle cerebral artery (MCA) fusiform aneurysm which recurred following clip reconstruction and bypass. The aneurysm was successfully treated with endovascular flow diversion 12).


1)

Soydemir E, Gündoğmuş CA, Türeli D, Andaç Baltacıoğlu N, Bayri Y, Baltacıoğlu F. Safety and efficacy of flow diverter stents in the treatment of middle cerebral artery aneurysms: a single-center experience and follow-up data. Diagn Interv Radiol. 2023 Mar 29;29(2):350-358. doi: 10.4274/dir.2022.211050. Epub 2023 Feb 1. PMID: 36988000.
2)

Diestro JDB, Adeeb N, Dibas M, Boisseau W, Harker P, Brinjikji W, Xiang S, Joyce E, Shapiro M, Raz E, Parra-Farinas C, Pickett G, Alotaibi NM, Regenhardt RW, Bernstock JD, Spears J, Griessenauer CJ, Burkhardt JK, Hafeez MU, Kan P, Grandhi R, Taussky P, Nossek E, Hong T, Zhang H, Rinaldo L, Lanzino G, Stapleton CJ, Rabinov JD, Patel AB, Marotta TR, Roy D, Dmytriw AA. Flow Diversion for Middle Cerebral Artery Aneurysms: An International Cohort Study. Neurosurgery. 2021 Nov 18;89(6):1112-1121. doi: 10.1093/neuros/nyab365. PMID: 34624100.
3)

Bhogal P, AlMatter M, Bäzner H, Ganslandt O, Henkes H, Aguilar Pérez M. Flow Diversion for the Treatment of MCA Bifurcation Aneurysms-A Single Centre Experience. Front Neurol. 2017 Feb 2;8:20. doi: 10.3389/fneur.2017.00020. eCollection 2017. PubMed PMID: 28210239; PubMed Central PMCID: PMC5288345.
4) , 11)

Cagnazzo F, Mantilla D, Lefevre PH, Dargazanli C, Gascou G, Costalat V. Treatment of Middle Cerebral Artery Aneurysms with Flow-Diverter Stents: A Systematic Review and Meta-Analysis. AJNR Am J Neuroradiol. 2017 Oct 5. doi: 10.3174/ajnr.A5388. [Epub ahead of print] PubMed PMID: 28982785.
5)

Iosif C, Mounayer C, Yavuz K, Saleme S, Geyik S, Cekirge HS, Saatci I. Middle Cerebral Artery Bifurcation Aneurysms Treated by Extrasaccular Flow Diverters: Midterm Angiographic Evolution and Clinical Outcome. AJNR Am J Neuroradiol. 2017 Feb;38(2):310-316. doi: 10.3174/ajnr.A5022. Epub 2016 Dec 15. PubMed PMID: 27979794.
6)

Briganti F, Delehaye L, Leone G, Sicignano C, Buono G, Marseglia M, Caranci F, Tortora F, Maiuri F. Flow diverter device for the treatment of small middle cerebral artery aneurysms. J Neurointerv Surg. 2016 Mar;8(3):287-94. doi: 10.1136/neurintsurg-2014-011460. Epub 2015 Jan 20. PubMed PMID: 25603808.
7)

Yavuz K, Geyik S, Saatci I, Cekirge HS. Endovascular treatment of middle cerebral artery aneurysms with flow modification with the use of the pipeline embolization device. AJNR Am J Neuroradiol. 2014 Mar;35(3):529-35. doi: 10.3174/ajnr.A3692. Epub 2013 Sep 26. PubMed PMID: 24072620.
8)

Pierot L, Klisch J, Cognard C, Szikora I, Mine B, Kadziolka K, Sychra V, Gubucz I, Januel AC, Lubicz B. Endovascular WEB flow disruption in middle cerebral artery aneurysms: preliminary feasibility, clinical, and anatomical results in a multicenter study. Neurosurgery. 2013 Jul;73(1):27-34; discussion 34-5. doi: 10.1227/01.neu.0000429860.04276.c1. PubMed PMID: 23615104.
9)

Caroff J, Neki H, Mihalea C, D’Argento F, Abdel Khalek H, Ikka L, Moret J, Spelle L. Flow-Diverter Stents for the Treatment of Saccular Middle Cerebral Artery Bifurcation Aneurysms. AJNR Am J Neuroradiol. 2016 Feb;37(2):279-84. doi: 10.3174/ajnr.A4540. Epub 2015 Sep 24. PubMed PMID: 26405085.
10)

Topcuoglu OM, Akgul E, Daglioglu E, Topcuoglu ED, Peker A, Akmangit I, Belen D, Arat A. Flow Diversion in Middle Cerebral Artery Aneurysms: Is It Really an All-Purpose Treatment? World Neurosurg. 2016 Mar;87:317-27. doi: 10.1016/j.wneu.2015.11.073. Epub 2015 Dec 23. PubMed PMID: 26723288.
12)

Burrows AM, Zipfel G, Lanzino G. Treatment of a pediatric recurrent fusiform middle cerebral artery (MCA) aneurysm with a flow diverter. J Neurointerv Surg. 2013 Nov;5(6):e47. doi: 10.1136/neurintsurg-2012-010478.rep. Epub 2012 Nov 27. PubMed PMID: 23188788.

Microvascular Decompression Complications

Microvascular Decompression Complications

Latest Pubmed Related Articles



Microvascular decompression (MVD) has a satisfactory safety, and it is the only surgical treatment for neurovascular compression diseases, such as hemifacial spasmtrigeminal neuralgia, and glossopharyngeal neuralgia, from the perspective of etiology.


Microvascular decompression (MVD) is a surgical procedure used to relieve pressure on a nerve root in the brainstem. While the procedure has a high success rate, like all surgeries, it does carry some risks and potential complications.

Some possible complications of microvascular decompression include:

Bleeding: Bleeding can occur during or after the surgery, which may require additional medical intervention.

Infection: Infection can occur at the site of the surgery or in the brain, which can lead to serious complications.

Nerve damage: Nerve damage can occur during the surgery, which may lead to a range of symptoms, including weakness, numbness, and paralysis.

Hearing loss: MVD can lead to hearing loss in some cases, particularly if the acoustic nerve is damaged during the procedure.

Balance problems: MVD can cause balance problems or vertigo, which may persist for several weeks or months after the surgery.

Cerebrospinal fluid leak: In rare cases, MVD can cause a cerebrospinal fluid leak, which may require further medical intervention.

It’s important to note that while these complications are possible, they are relatively rare.


Bilateral dilated and fixed pupils have long been regarded as a sign of life threatening, which is common in patients with brain herniation due to intracranial hypertension. However, transient dilated pupils after MVD have not been previously reported.

Wang et al. presented 2 patients with bilateral transient dilated and fixed pupils after MVD and discussed the possible etiologies through the literature review. Physical examination of both patients showed bilateral pupils were normal and without a medical history of pupil dilation. They underwent MVD under general anesthesia and used propofol and sevoflurane. In both cases, the vertebral artery was displaced, and Teflon pads were inserted between the vertebral artery and the brain stem. Postoperation, we found transient bilateral mydriasis without light reflection in both patients. The emergency head computed tomography revealed no obvious signs of hemorrhage and cerebral herniation. About 1 hour later, this phenomenon disappeared. Therefore, the authors think if MVD is successfully carried out, bilateral transient mydriasis may not necessarily indicate brain stem hemorrhage, cerebral herniation, and other emergency conditions, which can be recovered within a short time. The causes could be related to stimulation of the sympathetic pathway in the brain stem during MVD and side effects of anesthetics 1).


1)

Wang L, Fan H, Xu X, Su S, Feng W, Wu C, Chen Y. Bilateral Transient Dilated and Fixed Pupils After Microvascular Decompression: Rare Clinical Experience. J Craniofac Surg. 2023 Mar 21. doi: 10.1097/SCS.0000000000009293. Epub ahead of print. PMID: 36941233.

Olfactory groove meningioma

Olfactory groove meningioma



Olfactory groove meningiomas (OGMs) are arachnoid cell neoplasms of the frontoethmoidal suture and lamina cribrosa1) and may involve any part of the area from the crista galli to the planum sphenoidale 2) 3) 4).

The Meningiomas Arising from the Olfactory Groove and Their Removal by the Aid of Electro-surgery By Harvey Cushing · 1927


Cushing H, Eisenhardt L (1938) The olfactory meningiomas with primary anosmia. In: Cushing H, Eisenhardt L (eds) Meningiomas: their classification, regional behavior, life history, and surgical results. Charles C Thomas, Springfield, pp 250–282


Ojemann RG (1991) Olfactory groove meningiomas. In: Al-Mefty O (ed) Meningiomas. Raven Press, New York, pp 383–393


Al-Mefty O (1993) Tuberculum sellae and olfactory groove meningioma. In: Sekhar LN, Janecka IP (eds) Surgery of cranial base tumors. Raven Press, New York, pp 507–519


Surgery of Skull Base Meningiomas: With a Chapter Madjid Samii, ‎Mario Ammirati · 2012


Meningiomas of the Skull Base Treatment Nuances in Contemporary Neurosurgery 2018

A systematic review was performed to identify studies that compared outcomes following EEA and TCA for OGMs. Data extracted from each study included gross total resection (GTR), the incidence of cerebrospinal fluid (CSF) leaks, and post-operative complications including anosmia. The results of the search yielded 5 studies that met the criteria for inclusion and analysis. All studies compared TCA (n = 922) with EEA (n = 141) outcomes for OGMs. Overall, the rate of gross total resection (GTR) was lower among the endoscopic group (70.9%) relative to the transcranial group (91.5%). The rate of postoperative CSF leak was 6.3% vs. 25.5% for the transcranial and endoscopic groups, respectively. Post-operative anosmia was higher for patients undergoing EEA (95.9%) compared with patients in the transcranial group (37.4%). In this analysis, EEA was associated with a lower rate of GTR and higher incidences of CSF leaks and post-operative anosmia. However, with increasing surgeon familiarity with the endoscopic anatomy and technique for managing ASB pathologies, a nuanced approach may be used to minimize patient morbidity and widen the spectrum of skull base surgery 5).


Electronic databases were searched from inception until December 2019 for studies delineating TCAs for OGM patients. Patient demographics, pre-operative symptoms, surgical outcomes, and complications were evaluated and analyzed with a meta-analysis of proportions. Results: A total of 27 observational case series comparing 554 unilateral vs. 451 bilateral TCA patients were eligible for review. The weighted pooled incidence of gross total resection is 94.6% (95% CI, 90.7-97.5%; I 2 = 59.0%; p = 0.001) for unilateral and 90.9% (95% CI, 85.6-95.4%; I 2 = 58.1%; p = 0.003) for bilateral cohorts. Similarly, the incidence of OGM recurrence is 2.6% (95% CI, 0.4-6.0%; I 2 = 53.1%; p = 0.012) and 4.7% (95% CI, 1.4-9.2%; I 2 = 55.3%; p = 0.006), respectively. Differences in oncologic outcomes were not found to be statistically significant (p = 0.21 and 0.35, respectively). Statistically significant differences in complication rates in bilateral vs. unilateral TCA cohorts include meningitis (1.0 vs. 0.0%; p = 0.022) and mortality (3.2 vs. 0.2%; p = 0.007). Conclusions: While both cohorts have similar oncologic outcomes, bilateral TCA patients exhibit higher postoperative complication rates. This may be explained by underlying tumor characteristics necessitating more radical resection but may also indicate increased morbidity with bilateral approaches. However, evidence from more controlled, comparative studies is warranted to further support these findings 6).


A PubMed search of the recent literature (2011-2016) was performed to examine outcomes following EEA and TCA for OGM. The extent of resection, visual outcome, postoperative complications, and recurrence rates were analyzed using percentages and proportions, the Fischer exact test, and the Student’s t-test using GraphPad PRISM 7.0Aa (San Diego, CA) software.

Results: There were 444 patients in the TCA group with a mean diameter of 4.61 (±1.17) cm and 101 patients in the EEA group with a mean diameter of 3.55 (± 0.58) cm (p = 0.0589). GTR was achieved in 90.9% (404/444) in the TCA group and 70.2% (71/101) in the EEA group (p < 0.0001). Of the patients with preoperative visual disturbances, 80.7% (21/26) of patients in the EEA cohort had an improvement in vision compared to 12.83%(29/226) in the TCA group (p < 0.0001). Olfaction was lost in 61% of TCA and in 100% of EEA patients. CSF leaks and meningitis occurred in 25.7% and 4.95% of EEA patients and 6.3% and 1.12% of TCA patients, respectively (p < 0.0001; p = 0.023).

The updated literature review demonstrates that despite more experience with endoscopic resection and skull base reconstruction, the literature still supports TCA over EEA with respect to the extent of resection and complications. EEA may be an option in selected cases where visual improvement is the main goal of surgery and postoperative anosmia is acceptable to the patient or in medium-sized tumors with existing preoperative anosmia. Nevertheless, based on our results, it seems more prudent at this time to use TCA for the majority of OGMs 7).


1)

Guinto G. Olfactory Groove Meningiomaas. World Neurosurg. 2015 Jun;83(6):1046-7. doi: 10.1016/j.wneu.2014.12.044. Epub 2015 Jan 14. PMID: 25596435.
2)

Hentschel SJ, DeMonte F, Olfactory groove meningiomas. DeMonte F, McDermott MW, Al-Mefty O: Al-Mefty’s Meningiomas 2New York, Thieme, 2011. 196–205
3)

Nakamura M, Struck M, Roser F, Vorkapic P, Samii M: Olfactory groove meningiomas: clinical outcome and recurrence rates after tumor removal through the frontolateral and bifrontal approach. Neurosurgery 62:6 Suppl 31224–1232, 2008
4)

Pepper J, Hecht SL, Gebarski SS, Lin EM, Sullivan SE, Marentette LJ. Olfactory groove meningioma: discussion of clinical presentation and surgical outcomes following excision via the subcranial approach. Laryngoscope. 2011;121:2282–2289.
5)

Purohit A, Jha R, Khalafallah AM, Price C, Rowan NR, Mukherjee D. Endoscopic endonasal versus transcranial approach to resection of olfactory groove meningiomas: a systematic review. Neurosurg Rev. 2020 Dec;43(6):1465-1471. doi: 10.1007/s10143-019-01193-2. Epub 2019 Nov 10. PMID: 31709465.
6)

Feng AY, Wong S, Saluja S, Jin MC, Thai A, Pendharkar AV, Ho AL, Reddy P, Efron AD. Resection of Olfactory Groove Meningiomas Through Unilateral vs. Bilateral Approaches: A Systematic Review and Meta-Analysis. Front Oncol. 2020 Oct 22;10:560706. doi: 10.3389/fonc.2020.560706. PMID: 33194626; PMCID: PMC7642686.
7)

Shetty SR, Ruiz-Treviño AS, Omay SB, Almeida JP, Liang B, Chen YN, Singh H, Schwartz TH. Limitations of the endonasal endoscopic approach in treating olfactory groove meningiomas. A systematic review. Acta Neurochir (Wien). 2017 Oct;159(10):1875-1885. doi: 10.1007/s00701-017-3303-0. Epub 2017 Aug 22. PMID: 28831590.

3D Exoscope for Vascular neurosurgery

3D Exoscope for Vascular neurosurgery

In aneurysm clipping, three-dimensional exoscopes are noninferior to operating microscopes in terms of surgery duration, safety, and outcomes, based on limited series. Progressive experience enables the surgeon to perform significantly more device adjustments within the same amount of surgical time 1)


Visualization and Maneuverability Features of a Robotic Arm Three-Dimensional Exoscope and Operating Microscope for Clipping an Unruptured Intracranial Aneurysm: Video Comparison and Technical Evaluation 2).


A case of a 11-year-old male with Alagille syndrome, pancytopenia, and peripheral pulmonary stenosis found to have a 12 × 13 × 7 mm distal left M1 aneurysm arising from the inferior M1/M2 junction. The patient was neurologically intact without evidence of rupture. In order to prevent catastrophic rupture, the decision was made to treat the lesion. Due to the patients underlying medical conditions including baseline coagulopathy, surgical management was felt to be superior to an endovascular reconstruction, which would require long-term antiplatelet therapy. Thus the patient underwent a left-sided pterional craniotomy with exoscopic 3D ICG-VA. As demonstrated in Video 1, ICG-VA was performed before definitive clip placement in order to understand flow dynamics with particular emphasis on understanding the middle cerebral artery outflow. Postoperatively, the patient remained at his neurologic baseline and subsequent imaging demonstrated complete obliteration of the aneurysm without any neck remnant. The patient continues to follow and remains asymptomatic and neurologically intact without radiographic evidence of residual or recurrence 3)

The Kinevo 900 exoscope was used in 3 patients with cerebral (2) and spinal (1) vascular pathology, we evaluated the image quality, equipment management, ergonomics, educational utility, 3D glasses, we recorded the characteristics of the cases. and we show a review of the experience of other authors.

Results: 3 patients underwent surgery: one occipital cavernoma, one cerebral dural fistula, and 1 spinal dural fistula. Excellent 3D visualization with Zeiss Kinevo 900 exoscope (Carl Zeiss, Germany), surgical comfort, and educational utility is shown. There were no complications.

The experience and that of other authors suggests that the 3D exoscope shows excellent visualization, better ergonomics, and an innovative educational experience. Vascular microsurgery can be performed safely and effectively 4).


1)

Rossmann T, Veldeman M, Nurminen V, Huhtakangas J, Niemelä M, Lehecka M. 3D Exoscopes are Noninferior to Operating Microscopes in Aneurysm Surgery: Comparative Single-Surgeon Series of 52 Consecutive Cases. World Neurosurg. 2023 Feb;170:e200-e213. doi: 10.1016/j.wneu.2022.10.106. Epub 2022 Nov 9. PMID: 36334715.
2)

Haeren R, Hafez A, Lehecka M. Visualization and Maneuverability Features of a Robotic Arm Three-Dimensional Exoscope and Operating Microscope for Clipping an Unruptured Intracranial Aneurysm: Video Comparison and Technical Evaluation. Oper Neurosurg (Hagerstown). 2022 Jan 1;22(1):28-34. doi: 10.1227/ONS.0000000000000060. Erratum in: Oper Neurosurg (Hagerstown). 2022 Aug 1;23(2):e157. PMID: 34982902.
3)

Wali AR, Kang KM, Rennert R, Santiago-Dieppa D, Khalessi AA, Levy M. First-in-Human Clinical Experience Using High-Definition Exoscope with Intraoperative Indocyanine Green for Clip Reconstruction of Unruptured Large Pediatric Aneurysm. World Neurosurg. 2021 Jul;151:52. doi: 10.1016/j.wneu.2021.04.019. Epub 2021 Apr 17. PMID: 33872836.
4)

Acha JL, Contreras L, Lopez K, Azurin M, Cueva M, Bellido A, Contreras S, Santos O. Neurovascular microsurgical experience through 3D exoscopy. Case report and literature review. World Neurosurg. 2023 Mar 3:S1878-8750(23)00270-X. doi: 10.1016/j.wneu.2023.02.120. Epub ahead of print. PMID: 36871654.

Parkinson’s disease

Parkinson’s disease

Parkinson’s disease is a progressive neurological disorder characterized by the preferential loss of dopaminergic neurons in the substantia nigra, which project to the striatum.

Parkinson’s disease (PD) is a neurodegenerative disease involving the basal ganglia, resulting in motor and extra-motor deficits. These extra-motor deficits may be reflective of a self-regulatory deficit impacting patients’ ability to regulate cognitive processes, thoughts, behaviors, and emotions.

With advances in knowledge disease, boundaries may change. Occasionally, these changes are of such a magnitude that they require redefinition of the disease. In recognition of the profound changes in our understanding of Parkinson’s disease (PD), the International Parkinson and Movement Disorders Society (MDS) commissioned a task force to consider a redefinition of PD.

Several critical issues were identified that challenge current PD definitions. First, new findings challenge the central role of the classical pathologic criteria as the arbiter of diagnosis, notably genetic cases without synuclein deposition, the high prevalence of incidental Lewy body (LB) deposition, and the nonmotor prodrome of PD. It remains unclear, however, whether these challenges merit a change in the pathologic gold standard, especially considering the limitations of alternate gold standards. Second, the increasing recognition of dementia in PD challenges the distinction between diffuse LB disease and PD. Consideration might be given to removing dementia as an exclusion criterion for PD diagnosis. Third, there is increasing recognition of disease heterogeneity, suggesting that PD subtypes should be formally identified; however, current subtype classifications may not be sufficiently robust to warrant formal delineation. Fourth, the recognition of a nonmotor prodrome of PD requires that new diagnostic criteria for early-stage and prodromal PD should be created; here, essential features of these criteria are proposed. Finally, there is a need to create new MDS diagnostic criteria that take these changes in disease definition into consideration 1).

see Parkinson’s Disease Dementia

Idiopathic Parkinson’s disease

Current subtype classifications may not be sufficiently robust to warrant formal delineation.

see also Tremor predominant Parkinson’s disease.

Sporadic Parkinson’s disease and some genetic forms such as GBA1-associated parkinsonism, LRRK2-associated Parkinson’s disease

The natural history of PD may follow a more benign motor-predominant course in some patients, while in others the disabling non-motor features predominate. The underlying basis of the clinical heterogeneity is poorly understood, but it is becoming clear that this is, at least in part, due to genetic factors 2) 3) 4). One of these genetic risk factors is mutation in the GBA1 gene, which has emerged numerically as the most important genetic abnormality associated with PD 5) 6), being found in about 5% of patients with the so-called sporadic PD

The main neuropathological finding is Alpha-synuclein-containing Lewy bodies and loss of dopaminergic neurons in the substantia nigra, manifesting as reduced facilitation of voluntary movements. With progression of PD, Lewy body pathology spreads to neocortical and cortical regions. Several environmental factors are associated with increased risk of PD. Autopsy studies show that the clinical diagnosis of PD is not confirmed at autopsy in a significant proportion of patients. Revised diagnostic criteria are expected to improve the clinician´s accuracy in diagnosing PD. Increasing knowledge on genetic and environmental risk factors of PD will probably elucidate the cause of this disease within the near future 7)

Open science and collaboration are necessary to facilitate the advancement of Parkinson’s disease (PD) research. Hackathons are collaborative events that bring together people with different skill sets and backgrounds to generate resources and creative solutions to problems. These events can be used as training and networking opportunities, thus we coordinated a virtual 3-day hackathon event, during which 49 early-career scientists from 12 countries built tools and pipelines with a focus on PD. Resources were created with the goal of helping scientists accelerate their own research by having access to the necessary code and tools. Each team was allocated one of nine different projects, each with a different goal. These included developing post-genome-wide association studies (GWAS) analysis pipelines, downstream analysis of genetic variation pipelines, and various visualization tools. Hackathons are a valuable approach to inspire creative thinking, supplement training in data science, and foster collaborative scientific relationships, which are foundational practices for early-career researchers. The resources generated can be used to accelerate research on the genetics of PD 8).

meta-analysis investigated the effectiveness of short pulse width DBS (spDBS) versus conventional DBS (cDBS) in patients with Parkinson’s disease.

Four databases (PubMed, Cochrane, Web of Science, and Embase) were independently searched until October 2021 by two reviewers. They utilized the following scales and items: therapeutic windows (TW), efficacy threshold, side effect threshold, Movement Disorder Society-Sponsored Revision Unified Parkinson’s Disease Rating Scale (MDS-UPDRS) part III off-medication score, Speech Intelligence Test (SIT), and Freezing of Gait Questionnaire (FOG-Q).

The analysis included seven studies with a total of 87 patients. The results indicated that spDBS significantly widened the therapeutic windows (0.99, 95% CI = 0.61 to 1.38) while increasing the threshold amplitudes of side effects (2.25, 95% CI = 1.69 to 2.81) and threshold amplitudes of effects (1.60, 95% CI = 0.84 to 2.36). There was no statistically significant difference in UPDRS part III, SIT, and FOG-Q scores between spDBS and cDBS groups, suggesting that treatment with both cDBS and spDBS may result in similar effects of improved dysarthria and gait disorders.

Compared with cDBS, spDBS is effective in expanding therapeutic windows (TW). Both types of deep brain stimulation resulted in improved gait disorders and speech intelligibility 9)


1)

Berg D, Postuma RB, Bloem B, Chan P, Dubois B, Gasser T, Goetz CG, Halliday GM, Hardy J, Lang AE, Litvan I, Marek K, Obeso J, Oertel W, Olanow CW, Poewe W, Stern M, Deuschl G. Time to redefine PD? Introductory statement of the MDS Task Force on the definition of Parkinson’s disease. Mov Disord. 2014 Apr;29(4):454-62. doi: 10.1002/mds.25844. Epub 2014 Mar 11. PubMed PMID: 24619848.
2)

Kalia LV, Lang AE. Parkinson’s disease. Lancet. 2015;386(9996):896–912.
3)

Nalls MA, Pankratz N, Lill CM, Do CB, Hernandez DG, Saad M, et al. Large-scale meta-analysis of genome-wide association data identifies six new risk loci for Parkinson’s disease. Nat Genet. 2014;46(9):989–93.
4)

Williams-Gray CH, Goris A, Saiki M, Foltynie T, Compston DA, Sawcer SJ, et al. Apolipoprotein E genotype as a risk factor for susceptibility to and dementia in Parkinson’s disease. J Neurol. 2009;256(3):493–8.
5)

Gan-Or Z, Giladi N, Rozovski U, Shifrin C, Rosner S, Gurevich T, et al. Genotype-phenotype correlations between GBA mutations and Parkinson’s disease risk and onset. Neurology. 2008;70(24):2277–83.
6)

Migdalska-Richards A, Schapira AH. The relationship between glucocerebrosidase mutations and Parkinson’s disease. J Neurochem. 2016 Oct;1(139 Suppl):77–90.
7)

Tysnes OB, Storstein A. Epidemiology of Parkinson’s disease. J Neural Transm (Vienna). 2017 Aug;124(8):901-905. doi: 10.1007/s00702-017-1686-y. Epub 2017 Feb 1. PMID: 28150045.
8)

Leonard HL, Murtadha R, Martinez-Carrasco A, Jama A, Müller-Nedebock AC, Gil-Martinez AL, Illarionova A, Moore A, Bustos BI, Jadhav B, Huxford B, Storm C, Towns C, Vitale D, Chetty D, Yu E, Grenn FP, Salazar G, Rateau G, Iwaki H, Elsayed I, Foote IF, Jansen van Rensburg Z, Kim JJ, Yuan J, Lake J, Brolin K, Senkevich K, Wu L, Tan MMX, Periñán MT, Makarious MB, Ta M, Pillay NS, Betancor OL, Reyes-Pérez PR, Alvarez Jerez P, Saini P, Al-Ouran R, Sivakumar R, Real R, Reynolds RH, Hu R, Abrahams S, Rao SC, Antar T, Leal TP, Iankova V, Scotton WJ, Song Y, Singleton A, Nalls MA, Dey S, Bandres-Ciga S, Blauwendraat C, Noyce AJ; International Parkinson Disease Genomics Consortium (IPDGC) and The Global Parkinson’s Genetics Program (GP2). The IPDGC/GP2 Hackathon – an open science event for training in data science, genomics, and collaboration using Parkinson’s disease data. NPJ Parkinsons Dis. 2023 Mar 4;9(1):33. doi: 10.1038/s41531-023-00472-6. PMID: 36871034.
9)

Zou X, Shi Y, Wu X, Ye Q, Lin F, Cai G. Efficacy of short pulse and conventional deep brain stimulation in Parkinson’s disease: a systematic review and meta-analysis. Neurol Sci. 2022 Nov 16. doi: 10.1007/s10072-022-06484-z. Epub ahead of print. PMID: 36383263.