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  • Author or Editor: Giuseppe Esposito x
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Three-dimensional computed tomography angiography in presurgical planning for treatment of infratentorial dural arteriovenous fistulas

Technical note

Sergio Paolini, Giuseppe Lanzino, Claudio Colonnese, Eugenio Venditti, Giampaolo Cantore, and Vincenzo Esposito

Dural arteriovenous fistulas (DAVFs) with pure leptomeningeal drainage may be cured by simple interruption of their venous side. This report illustrates the cases of 3 patients undergoing surgery for fistulas classified as Borden Type III, involving the posterior cranial fossa. Preoperatively, the surgical anatomy of these lesions was investigated with 3D reformatting of multislice CT angiography, in addition to conventional angiography. Reformatted images clarified the surgical anatomy of the malformation. Reconstructing both the osseous and the vascular structures and simulating the surgical orientation allowed localization of the dural takeoff point of the DAVF's drainage, showing its relationship with osseous landmarks. Precise localization of the DAVF's drainage may help in choosing the most direct and effective approach to treat the malformation. The reported cases could be treated with a standard retrosigmoid exposure, avoiding the need for more complex cranial base approaches.

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Flow augmentation STA-MCA bypass evaluation for patients with acute stroke and unilateral large vessel occlusion: a proposal for an urgent bypass flowchart

Martina Sebök, Giuseppe Esposito, Christiaan Hendrik Bas van Niftrik, Jorn Fierstra, Tilman Schubert, Susanne Wegener, Jeremia Held, Zsolt Kulcsár, Andreas R. Luft, and Luca Regli

OBJECTIVE

Endovascular recanalization trials have shown a positive impact on the preservation of ischemic penumbra in patients with acute large vessel occlusion (LVO). The concept of penumbra salvation can be extended to surgical revascularization with bypass in highly selected patients. For selecting these patients, the authors propose a flowchart based on multimodal MRI.

METHODS

All patients with acute stroke and persisting internal carotid artery (ICA) or M1 occlusion after intravenous lysis or mechanical thrombectomy undergo advanced neuroimaging in a time window of 72 hours after stroke onset including perfusion MRI, blood oxygenation level–dependent functional MRI to evaluate cerebrovascular reactivity (BOLD-CVR), and noninvasive optimal vessel analysis (NOVA) quantitative MRA to assess collateral circulation.

RESULTS

Symptomatic patients exhibiting persistent hemodynamic impairment and insufficient collateral circulation could benefit from bypass surgery. According to the flowchart, a bypass is considered for patients 1) with low or moderate neurological impairment (National Institutes of Health Stroke Scale score 1–15, modified Rankin Scale score ≤ 3), 2) without large or malignant stroke, 3) without intracranial hemorrhage, 4) with MR perfusion/diffusion mismatch > 120%, 5) with paradoxical BOLD-CVR in the occluded vascular territory, and 6) with insufficient collateral circulation.

CONCLUSIONS

The proposed flowchart is based on the patient’s clinical condition and multimodal MR neuroimaging and aims to select patients with acute stroke due to LVO and persistent inadequate collateral flow, who could benefit from urgent bypass.

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Longitudinal neuropsychological assessment after aneurysmal subarachnoid hemorrhage and its relationship with delayed cerebral ischemia: a prospective Swiss multicenter study

Martin N. Stienen, Menno R. Germans, Olivia Zindel-Geisseler, Noemi Dannecker, Yannick Rothacher, Ladina Schlosser, Julia Velz, Martina Sebök, Noemi Eggenberger, Adrien May, Julien Haemmerli, Philippe Bijlenga, Karl Schaller, Ursula Guerra-Lopez, Rodolfo Maduri, Valérie Beaud, Khalid Al-Taha, Roy Thomas Daniel, Alessio Chiappini, Stefania Rossi, Thomas Robert, Sara Bonasia, Johannes Goldberg, Christian Fung, David Bervini, Marie Elise Maradan-Gachet, Klemens Gutbrod, Nicolai Maldaner, Marian C. Neidert, Severin Früh, Marc Schwind, Oliver Bozinov, Peter Brugger, Emanuela Keller, Angelina Marr, Sébastien Roux, Luca Regli, and on behalf of the MoCA-DCI Study Group

OBJECTIVE

While prior retrospective studies have suggested that delayed cerebral ischemia (DCI) is a predictor of neuropsychological deficits after aneurysmal subarachnoid hemorrhage (aSAH), all studies to date have shown a high risk of bias. This study was designed to determine the impact of DCI on the longitudinal neuropsychological outcome after aSAH, and importantly, it includes a baseline examination after aSAH but before DCI onset to reduce the risk of bias.

METHODS

In a prospective, multicenter study (8 Swiss centers), 112 consecutive alert patients underwent serial neuropsychological assessments (Montreal Cognitive Assessment [MoCA]) before and after the DCI period (first assessment, < 72 hours after aSAH; second, 14 days after aSAH; third, 3 months after aSAH). The authors compared standardized MoCA scores and determined the likelihood for a clinically meaningful decline of ≥ 2 points from baseline in patients with DCI versus those without.

RESULTS

The authors screened 519 patients, enrolled 128, and obtained complete data in 112 (87.5%; mean [± SD] age 53.9 ± 13.9 years; 66.1% female; 73% World Federation of Neurosurgical Societies [WFNS] grade I, 17% WFNS grade II, 10% WFNS grades III–V), of whom 30 (26.8%) developed DCI. MoCA z-scores were worse in the DCI group at baseline (−2.6 vs −1.4, p = 0.013) and 14 days (−3.4 vs −0.9, p < 0.001), and 3 months (−0.8 vs 0.0, p = 0.037) after aSAH. Patients with DCI were more likely to experience a decline of ≥ 2 points in MoCA score at 14 days after aSAH (adjusted OR [aOR] 3.02, 95% CI 1.07–8.54; p = 0.037), but the likelihood was similar to that in patients without DCI at 3 months after aSAH (aOR 1.58, 95% CI 0.28–8.89; p = 0.606).

CONCLUSIONS

Aneurysmal SAH patients experiencing DCI have worse neuropsychological function before and until 3 months after the DCI period. DCI itself is responsible for a temporary and clinically meaningful decline in neuropsychological function, but its effect on the MoCA score could not be measured at the time of the 3-month follow-up in patients with low-grade aSAH with little or no impairment of consciousness. Whether these findings can be extrapolated to patients with high-grade aSAH remains unclear.

Clinical trial registration no.: NCT03032471 (ClinicalTrials.gov)