World Neurosurg
-
The introduction of carotid stenting (CAS) has led to numerous comparative trials with carotid endarterectomy (CEA). ⋯ Mortality has improved, but routine discharge has decreased following both CEA and CAS, congruent with increasing patient comorbidity. Trends in volumes, outcomes, and complication rates continue to favor CEA in real-world practice.
-
Tentorial dural arteriovenous fistulas (AVFs) are bridging vein shunts, and are therefore sometimes supplied by the pial artery as well as the dural artery. Recently, intraprocedural hemorrhage from the pial artery was reported, and we experienced 2 tentorial dural AVFs with the same complication. Pure pial artery has a glomus-like structure and forms direct shunts along the draining vein, and is likely to bleed after restriction of the draining vein caused by the transarterial embolization. This study investigated the characteristics of the pial arterial supply as a cause of hemorrhage. ⋯ To prevent intraprocedural hemorrhage, differentiation of the pure pial supply from the dural branch of the pial artery is important. The infratentorial artery will supply supratentorial fistula as the dural branch after passing through the tentorium. In contrast, the supratentorial artery can supply supratentorial fistula not only as a dural branch but also as a pure pial feeder. Therefore, attribution of the fistula and the pial supply, supratentorial or infratentorial, is useful in identifying pure pial supply.
-
Spinal surgery is undergoing a major transformation toward a minimally invasive paradigm. This shift is being driven by multiple factors, including the need to address spinal problems in an older and sicker population, as well as changes in patient preferences and reimbursement patterns. Increasingly, minimally invasive surgical techniques are being used in place of traditional open approaches due to significant advancements and implementation of intraoperative imaging and navigation technologies. ⋯ Numerous algorithms have been described, and additional efforts are underway to better optimize patient selection for minimally invasive spinal surgery (MISS) procedures in order to achieve optimal outcomes. Numerous unique MISS approaches and techniques have been described, and several have become fundamental. Investigators are evaluating combinations of MISS techniques to further enhance the surgical workflow, patient safety, and efficiency.
-
Syringomyelia is often resistant to various treatment modalities.1 Chiari I malformations are associated with syringomyelia in approximately 69% of operative cases.2 Failure to resolve syringomyelia after Chiari decompression is common.3 The pathophysiology of Chiari-associated syringomyelia has been well studied, with Oldfield emphasizing the water-hammer mechanism, with treatment limited to bony decompression and duraplasty.4 On the other hand, capacious fourth ventricular drainage is thought to be essential for syrinx resolution. Persistence or progression of the syrinx after decompression is an indication for reoperation. ⋯ In revisions to treat progressive syringomyelia after failed decompression, we undertake the following steps: 1) adequate lateral bony decompression,11-13 2) lysis of scar/adhesions around the cisterna magna, 3) opening the fourth ventricle outlet by releasing any web/adhesions, 4) insertion of a shunt from the fourth ventricle to the cervical subarachnoid space, and 5) bipolar coagulation of the lateral tonsillar pia to maintain patency of cerebrospinal fluid pathways.8 We favor autologous fascia or pericranium for expansile duraplasty, as the use of nonautologous materials may cause excessive scarring.14-16 In this video, we demonstrate these tenets in 3 cases of Chiari-associated syringomyelia, 2 revisions and 1 primary case, with excellent resolution of the syrinx (Video 1). The patients consented to surgery and publication of images.