Current status and future prospect of endovascular neurosurgery

Revitalizing neurosurgical frontiers: The EANS frontiers in neurosurgery committee's strategic framework

Introduction

The field of neurosurgery faces challenges with the increasing involvement of other medical specialties in areas traditionally led by neurosurgeons. This paper examines the implications of this development for neurosurgical practice and patient care, with a focus on specialized areas like pain management, peripheral nerve surgery, and stereotactic radiosurgery.

Research question

To assess the implications of the expanded scope of other specialties for neurosurgical practice and to consider the response of the EANS Frontiers in Neurosurgery Committee to these challenges.

Materials and methods

Analysis of recent trends in neurosurgery, including the shift in various procedures to other specialties, demographic challenges, and the emergence of minimally invasive techniques. This analysis draws on relevant literature and the initiatives of the Frontiers in Neurosurgery Committee.

Results

We explore a possible decrease in neurosurgical involvement in certain areas, which may have implications for patient care and access to specialized neurosurgical interventions. The Frontiers in Neurosurgery Committee's role in addressing these concerns is highlighted, particularly in terms of training, education, research, and networking for neurosurgeons, especially those early in their careers.

Discussion and conclusion

The potential decrease in neurosurgical involvement in certain specialties warrants attention. This paper emphasizes the importance of carefully considered responses by neurosurgical societies, such as the EANS, to ensure neurosurgeons continue to play a vital role in managing neurological diseases. Emphasis on ongoing education, integration of minimally invasive techniques, and multidisciplinary collaboration is essential for maintaining the field's competence and quality in patient care.

Cerebral Perfusion Unveiled: A Comprehensive Review of Blood Pressure Management in Neurosurgical and Endovascular Aneurysm Interventions

This comprehensive review delves into the intricate dynamics of cerebral perfusion and blood pressure management within the context of neurosurgical and endovascular aneurysm interventions. The review highlights the critical role of maintaining a delicate hemodynamic balance, given the brain's susceptibility to fluctuations in blood pressure. Emphasizing the regulatory mechanisms of cerebral perfusion, particularly autoregulation, the study advocates for a nuanced and personalized approach to blood pressure control. Key findings underscore the significance of adhering to tailored blood pressure targets to mitigate the risks of ischemic and hemorrhagic complications in both neurosurgical and endovascular procedures. The implications for clinical practice are profound, calling for heightened awareness and precision in hemodynamic management. The review concludes with recommendations for future research, urging exploration into optimal blood pressure targets, advancements in monitoring technologies, investigations into long-term outcomes, and the development of personalized approaches. By consolidating current knowledge and charting a path for future investigations, this review aims to contribute to the continual enhancement of patient outcomes in the dynamic field of neurovascular interventions.

Intravenous recording of intracranial, broadband EEG

The most direct evaluation of human brain activity has been obtained from intracranial electrodes placed either on the surface of the brain or inserted into the brain to record from deep brain structures. Currently, the placement of intracranial electrodes implies transcranial surgery, either through a burr hole or a craniotomy, but the high degree of invasiveness and potential for morbidity of such major surgical procedures limits the applicability of intracranial recording. The vascular system provides a natural avenue to reach many brain regions that currently are reached by transcranial approaches, along with deep brain structures that cannot be reached via a transcranial approach without significant risk. To determine the applicability of intravascular approaches to high-frequency intracranial monitoring, a catheter containing multiple macro- and micro-electrodes was placed into the superior sagittal sinus of anesthetized pigs in parallel with clinical, subdural electrode grids to record epileptiform activity induced by direct, cortical injection of penicillin and to record responses to electrical stimulation. Intravascular electrodes recorded epileptiform spikes with similar magnitudes and waveshapes to those obtained by surface electrodes, both for macroelectrodes and microelectrodes, including the spatiotemporal evolution of epileptiform activity, suggesting that intravascular electrodes might provide localizing information regarding seizure foci. Sinusoidal electrical stimulation showed that intravascular electrodes provide sufficient broadband fidelity to record high-frequency, physiological events that may also prove useful in localizing seizure onset zones. As intravascular techniques have transformed cardiology, so intravascular neurophysiology may transform intracranial monitoring, in general, and the treatment of epilepsy, in particular.

Endovascular neurosurgery in Europe and in Italy: what is in the future?

BACKGROUND

The cerebrovascular discipline has undergone dramatic changes in recent years. This has been made possible by the work of pioneers in the fields of neurosurgery and neuroradiology.

METHODS

In this article we review the evolution and fundamental stages that led to the birth of endovascular treatment and discuss why, also in Europe, this treatment must be included in neurosurgery, encouraging the training of endovascular neurosurgeons who can collaborate with their interventional neuroradiology colleagues in order to form unbiased surgeons who understand the disease from both the endovascular as well as the surgical prospective. We examine how the new generation of European cerebrovascular specialists, including neurosurgeons, neuroradiologists, and some neurologists, will attain their requisite endovascular training. Finally, we briefly review the current state of endovascular neurosurgery in Europe and in Italy and speculate about what its role will be in the near and distant future.

CONCLUSIONS

To remain at the forefront of evaluating, caring for, and treating patients with cerebrovascular disease, vascular neurosurgery must evolve toward a specialty, mastering the knife as well as the catheter. We think it is time for European neurosurgeons to start training residents in endovascular neurosurgery in the same way we train neurosurgeons in every other neurosurgical discipline. • Peer-Review Report.

Clinical Problem-Solving: Aneurysm or Spinal Arteriovenous Fistula—Bait and Switch

OBJECTIVE:

The authors use an instructive case to review the challenges of diagnosis in subarachnoid hemorrhage (SAH) and to reinforce the nuances of clinical management.

IMPORTANCE:

The presented case highlights critical issues in patient selection and challenges in the diagnosis of SAH and the management of both aneurysmal and arteriovenous fistula-related SAH. The critical points in decision making and diagnosis are discussed, and the case is accompanied by a brief review of the literature on the issues being faced.

CLINICAL PRESENTATION:

The present case is a patient presenting with SAH who was found to have an anterior communicating artery aneurysm. However, clues in the presentation and workup point to another etiology.

CONCLUSION:

A strong history of sudden neck pain before headache and abundance of SAH along the brainstem mandates a need to thoroughly evaluate the source of hemorrhage from cervical vessels through an angiogram.

Extravasation during Aneurysm Embolization without Neurologic Consequences. Lessons learned from Complications of Pseudoaneurysm Coiling. Report of 2 Cases

Although endovascular intervention is the first-line treatment of intracranial aneurysm, intraprocedural rupture or extravasation is still an endangering event. We describe two interesting cases of extravasation during embolotherapy for ruptured peripheral cerebral pseudoaneurysms. Two male patients were admitted after development of sudden headache with presentation of intracerebral and subarachnoid hemorrhage, respectively. Initial angiographic assessment failed to uncover any aneurysmal dilatation in both patients. Two weeks afterwards, catheter angiography revealed aneurysms each in the peripheral middle cerebral artery and anterior inferior cerebellar artery. Under a general anesthesia, endovascular embolization was attempted without systemic heparinization. In each case, sudden extravasation was noted around the aneurysm during manual injection of contrast after microcatheter navigation. Immediate computed tomographic scan showed a large amount of contrast collection within the brain, but they tolerated and made an unremarkable recovery thereafter. Intraprocedural extravasation is an endangering event and needs prompt management, however proximal plugging with coil deployment can be sufficient alternative, if one confronts with peripheral pseudoaneurysm. Peculiar angiographic features are deemed attributable to extremely fragile, porous vascular wall of the pseudoaneurysm. Accordingly, it should be noted that extreme caution being needed to handle such a friable vascular lesion.