Microsurgical clipping versus newer endovascular techniques in treatment of unruptured anterior communicating artery-complex aneurysms: a meta-analysis and systematic review

The aim of this study is to compare occlusion rate, complication rate, and clinical outcome of microsurgical clipping (MC) and advanced endovascular techniques (EVT) in unruptured anterior communicating artery-complex aneurysms (ACoCAs). We reviewed the scientific literature reporting occlusion rate, time of occlusion assessment, and clinical outcome of MC and EVT in patients with unruptured ACoCAs, from January 2009 to December 2019. We included in our analysis 25 studies and 872 patients with unruptured ACoCAs (434 treated with endovascular techniques and 438 with MC). Ninety-three (10.7%), 320 (36.7%), 21 (2.4%), and 438 (50.2%) were treated with flow diverter (FD), stent-assisted coiling (SAC), endosaccular devices (ES), and microsurgical clipping (MC) respectively. FD, SAC, ES, and MC subgroups presented minor complications in 11.8%, 3.8%, 14.3%, and 7.1% of cases (p=.016), and major complications in 3.2%, 4.4%, 0%, and 7.1% (p=.136) of patients. A total occlusion rate post-treatment has been achieved in 4.3%, 87.1%, 47.6%, and 98.2% of cases (p=.000), while at 12 months' follow-up in 50%, 66%, 83.3%, and 80% of patients (p=.001). FD, SAC, ES, and MC subgroups had a good clinical outcome at 12 months in 93.5%, 90.5%, 100%, and 67.8% of cases. MC is associated with higher post-treatment total occlusion rate, but higher complication and lower good clinical outcome rates. EVT are promising in treating unruptured anterior cerebral artery aneurysms with high margin of safety and good clinical outcome, despite the lower total occlusion rate.

Subacute combined degeneration without nutritional anemia

Subacute combined degeneration (SCD) is a rare neurological complication of cobalamin deficiency, characterized by demyelination of the dorsal and lateral spinal cord. The diagnosis and treatment of SCD can be delayed if a patient does not present with clear clinical and laboratory signs of nutritional anemia, which has a marked effect on neurological recovery. We report a 62-year-old man with SCD with a history of gastric cancer and chronic alcoholism who presented with ataxia, gait disturbance, urinary incontinence, and limb weakness, but without other clinical or laboratory signs of cobalamin deficiency. The SCD diagnosis was confirmed by 3-Tesla MRI, which showed intramedullary signal alteration in the posterior columns of the entire spinal cord.

Does recurrent laryngeal nerve anatomy condition the choice of the side for approaching the anterior cervical spine?

AIM

The anterior cervical presternocleidomastoid approach is a safe and standardized procedure. Nevertheless, in all the largest series presented in literature, a certain risk of injury to the recurrent laryngeal nerves (RLNs) is reported and the choice of the side of the approach seems to influence such risk. Our aim was to study the surgical anatomy of the RLNs and to understand whether the side of the approach can be a risk factor for their surgical damage.

METHODS

We performed an anatomical dissection of 6 fresh cadavers, studying the origin and the course of both the RLNs, to assess their vulnerability in the anterior presternocleidomastoid approach to the cervical spine.

RESULTS

The origin of the right RLN was at C7 in 2 cases and at T1 in 4 cases. In all cases it arose where vagus nerve crossed the subclavian artery and it was directed superiorly and transversely to the esophagotracheal groove.

CONCLUSIONS

The right and left RLNs have different origin and course. Although the discussion about the best side for the anterior cervical approach is debated, in our opinion, both anatomical and surgical considerations, concerning RLNs, lead to the evidences that the left side approach, when possible, should be preferred below the level of C4.

Ghost lesions in patient with cerebral-isolated neurosarcoidosis. A case report

We present a case of isolated cerebral neurosarcoidosis with remitting nodular lesions resembling intraventricular neoplasms. The patient, admitted at our Department for surgical treatment of a magnetic resonance imaging (MRI) demonstrated fourth ventricle lesion, presented acute intracranial hypertension. A second MRI performed before the scheduled operation showed the disappearance of the fourth ventricle lesion and a tetra-ventricular hydrocephalus. The patient has been treated with a third-ventriculostomy, followed, after 15 days, by ventriculoperitoneal shunt. High doses of steroids have been administered. Cerebrospinal fluid analysis has been conducted and a high concentration of ACE, specific marker of neurosarcoidosis, has been found. No biopsy was performed to avoid surgical complications. A systemic chemotherapy with azathioprine has been started, but the patient died six months later for worsening of the clinical conditions. The autopsy confirmed the diagnosis of neurosarcoidosis. This is the first MRI documented case of neurosarcoidosis with remitting lesions. Diagnosis of isolated neurosarcoidosis is difficult and it is based on clinical and radiological exclusion of other entities. CSF examination is useful for diagnosis, for the reported specificity and sensibility of ACE. Medical treatment is based on corticosteroids and chemotherapic agents. Neurosurgical intervention can be related to treat hydrocephalus due to ependymal and arachnoidal involvement or to remove large lesions. In our opinion biopsy should be limited only to ACE negative patients and to those who do not respond to chemotherapy.

Surgical approaches to the cervico-thoracic junction

The cervico-thoracic junction (CTJ) extends between the 7th cervical and the 4th thoracic vertebrae and comprehends the inferior portion of the brachial plexus and the parenchymatous, vascular and nervous structures of the upper mediastinum. The posterior surgical approaches, as the laminectomy or the arthro-pediclectomy, fail to expose the anterior spinal elements. Thus, further surgical approaches have been proposed: postero-lateral, antero-lateral (thoracotomies) and purely anterior. The aim of this study was to discuss indications, key anatomical landmarks and risks of the main surgical approaches to the CTJ. Ten fresh cadavers from the Anatomical Laboratory of the University of Nantes (France) were used for the surgical dissection of the CTJ. The postero-lateral and the antero-lateral approaches were performed in 4 cadavers each and the anterior approaches were studied in 2. The postero-lateral extrapleural approach (PLEA) permits an excellent antero-lateral exposure of the T2-T4 segment, preserving the parascapular musculature integrity. The thoracotomies allow the exposure of the antero-lateral portion of the junctional vertebrae, with the limits of the intrapleural approaches. The anterior approaches, including the presternocleidomastoid cervicotomy eventually associated to the sterno-claviculotomy, expose the anterior portion of the cervical and the upper thoracic vertebrae up to T4. We believe that the PLEA performs the greater surgical exposure with minimal risk of vasculo-nervous damage. Among the anterior approaches, the simple cervicotomy is the most indicated procedure in case of patients with certain anatomical conditions.

The role of constitutive nitric oxide synthase in pathogenesis of secondary lesion after spinal cord injury. Preliminary results

BACKGROUND

Secondary lesion (SL) is an early phenomenon of cellular death following spinal cord injury (SCI). Nitric oxide (NO) could be involved in its pathogenesis. NO is a gaseous metabolite produced by 2 constitutive isoforms of NO synthase (cNOS), constantly active, and by 1 inducible isoform (iNOS), synthesized during inflammation and able to produce large amount of NO. High concentrated NO is toxic for cells; therefore, NO concentration is strictly and finely regulated. We suppose that major inhibitory effect on the iNOS expression is represented by the same physiological concentration of NO, synthesized by cNOS. The aim of this study is to assess the role of the 2 cNOS in pathogenesis of SL after SCI in rat.

METHODS

A dorsal SCI has been performed on rats (n=5) by a vascular clip (50 g/mm(2) for 15"). Fifteen minutes after trauma, activity of nNOS and eNOS has been measured (U/mg) in the cervical, dorsal and lumbar segments of spinal cord. Uninjured rats (n=5) served as control group. m-RNA for iNOS in untreated rats (n=2) has been also investigated by Northern blotting.

RESULTS

In injured rats nNOS activity has shown a reduction in dorsal and lumbar segments, compared to the control group. eNOS activity, highly variable in the control group, has not been detectable in injured spinal cord. i-NOS mRNA has not been found in spinal cord of uninjured rats.

CONCLUSIONS

These results would be in line with our hypothesis and provide the bases for other investigations. New therapeutic strategies for SL prevention, based on the modulation of cNOS, will be evaluated.