Occipital transtentorial approach for pineal region lesions: Addressing the controversies in conventional teaching

Background: The occipital transtentorial (OT) approach is well-established approach for pineal region tumors and can be of choice for the lesions located around the suboccipital part of tentorium such as the quadrigeminal plate, posterior part of thalamus, tentorial surface of cerebellum, splenial region, posterior falx, and lesions around the tentorial incisura. However, it is not very much extensively used in the above-mentioned locations other than the pineal region. Methods: Thirty-one patients of pineal region lesions were operated by OT approach, the role of conventional preoperative evaluation of the anatomy of the venous sinuses, deep venous system, and tentorial angle was investigated. Results: A variety of lesions were operated using this approach achieving gross and near total resection in majority of the cases (76.6%), with acceptable postoperative mean modified Rankin scales (1.8). Conclusion: The OT is a preferable approach for pineal region lesions for patients of all ages and can be tailored for achieving high resectability rates irrespective of the status of the deep venous system and tentorial angle, with reasonable postoperative surgical outcome.

Endovascular management of anterior falcotentorial dural arteriovenous fistulas: importance of functionality of deep venous system and existence of accompanying choroidal arteriovenous malformation

BackgroundAnterior falcotentorial junction dural arteriovenous fistulas (AFDAVFs) are the most deeply located and most complex type of tentorial fistula due to their location and vascular anatomy. We aimed to make new angiographic definitions of AFDAVF nidus and functionality of the deep venous system of the brain and thereby provide a safer approach for endovascular treatment.MethodsWe retrospectively examined 18 patients with AFDAVF who received endovascular treatment at our neuroradiology department between June 2002 and May 2019. Pre- and post-treatment clinical assessments were performed using the modified Rankin Scale. AFDAVF niduses were defined as mixed-type or pure-dural-type on the basis of whether choroidal arteriovenous malformation was coexisting or not, respectively. The deep venous system was denoted as functional or nonfunctional.ResultsWe included 13 men and 5 women (mean (range) age, 47.2 (31–62) years). We evaluated 15 patients with pure-dural-type AFDAVFs and three with mixed-type AFDAVFs. Complete occlusion of the fistula was achieved in 15/18 patients. Three patients had transient neurologic symptoms. In two patients these were due to mild thalamic ischemia and in the third patient was due to tectal venous ischemia, all in mixed-type AFDAVF. One patient also developed Parinaud syndrome due to compression of the tectal plate by a thrombosed large vein of Galen. No patients died or developed permanent morbidity.ConclusionEvaluating AFDAVFs as described here using our new subtyping model will help improve analysis of the malformation and development of a safer endovascular strategy, and hence may prevent periprocedural complications and improve treatment safety.

Clinical outcomes and overview of dedicated venous stents for management of chronic iliocaval and femoral deep venous disease

Objectives Venous stenting of the lower extremities has grown in popularity and is now considered a key component of the primary treatment strategy for the management of pathologically obstructive or stenotic lesions of the deep venous system. This review aims to provide an overview of the role of venous stenting in the management of chronic conditions affecting the deep venous system of the lower limbs. Methods An overview of venous stents design and current role of stenting procedure in individuals presenting with Chronic Venous Insufficiency (CVI) and presenting the current trials of dedicated venous stenting in management of chronic deep venous lesions. This review provides a focused insight on venous stent design, physical properties and the available dedicated venous stents selected studies with their related patency outcome based on selective literature search of the PubMed database and Cochrane library. Conclusions Dedicated venous stent technology is advancing at a rapid pace alongside the increased undertaking of endovascular deep venous stent reconstruction in the management of iliocaval vein pathologies. The ideal design(s) for venous stents remain unknown, although it is hoped that the presence of new dedicated venous stents in clinical practice will allow the generation of experience and data to advance our understanding in this area.

Endovascular management of torcular dural sinus malformations in children: the role of straight sinus occlusion

BackgroundTorcular dural sinus malformations (tDSMs) with arteriovenous shunts are rare congenital intracranial vascular malformations that carry a high rate of neurologic impairment and death in the neonatal, infant and young pediatric population. Their impact on brain venous drainage, especially the deep venous system, is one of the key factors in the clinical prognosis and natural history of the disease. We describe our therapeutic strategy for tDSMs, disconnecting the reflux into the deep venous system by performing an endovascular straight sinus occlusion.MethodsAmong all children with dural sinus malformations seen between 2002 and 2020, we retrospectively reviewed those with tDSM in whom straight sinus occlusion had been performed.ResultsOur databank included nine patients with tDSM that were embolized. Mean age at the clinical onset was 8.9±9.6 months (min–max=0–31). Five patients presented a significant reflux in the straight sinus on digital subtraction angiography. Those patients were initially clinically worse (mean modified Rankin Scale (mRS) 3.8) than those who did not present with reflux (mean mRS 2.25), this reflux being responsible for intraventricular hemorrhage in three patients. The reflux was suppressed by transarterial embolization in one patient and by transvenous straight sinus occlusion in four patients. Staged endovascular treatment resulted in a complete cure in six patients without complications, and clinical improvement in all patients.ConclusionStraight sinus occlusion is a feasible technique that needs to be considered in the treatment strategy for tDSM with deep venous reflux in order to avoid or minimize brain damage.

PATHOPHYSIOLOGICAL AND PATHOMORPHOLOGICAL ASPECTS OF RELAPSE OF VARICOSE VEINS AFTER ENDOVASCULAR LASER VEIN COAGULATION

The aim: With the help of biochemical and morphological methods of investigation to identify the causes of a false postoperative recurrence of varicose veins after the EVLC. Materials and methods: In 173 patients with varicose veins of the lower extremities, the level of markers of endothelial dysfunction was determined: P-selectin, E-selectin, tissue plasminogen activator, endothelin-1, adhesion molecules of type 1 vascular endothelium (sVCAM-1-soluble vascularcellularmolecula), circulating endothelial cells (CEC) before surgery (EVLC), on the 10th and 60th day of the postoperative period.At the same time, a morphological and electron microscopic examination of the state of the deep venous system in 31 patients with varicose vein disease of the lower extremities who died from acute heart failure, was performed. Results: Increased values of markers of endothelial dysfunction in patients with varicose veins of the lower extremitiesbefore surgery of EVLC were established. We found that, despite the operation, the parameters of endothelial dysfunction decrease, but in the remote postoperative period do not come to the norm. Morphological and electron microscopic studies of the deep vein wall revealed pathomorphological changes in all of their layers, especially the endothelial layer. At the heart of the development of endothelial dysfunction in the postoperative period, the leading role belongs to changes in mitochondria. Conclusions: 1. Based on our research, we can state that there are significant pathomorphological and pathophysiological changes in the deep venous system of the lower extremities in conditions of varicose vein disease. 2. The initiator of postoperative relapse of varicose veins are structural changes in the wall of deep veins with a violation of the integrity of the endothelial lining, contributing to the absorption of plasma and leukocyte contents from the blood stream in the interstitium, with the following pathological changes in the layers of deep veins.Such changes are the basis for the manifestations of endothelial dysfunction in the postoperative period.

STMO-14 SURGICAL MANAGEMENT OF DEEP-SEATED GLIOMA AROUND THALAMUS

BACKGROUND Higher extent of resection contributes to better prognosis of the patients with glioma. However, resection of deep-seated glioma represents a surgical challenge not only because of the depth but because of adjacent eloquent structures such as pyramidal tract, deep venous system, and brainstem. METHODS We performed a retrospective review of patients with deep-seated glioma around thalamus who underwent surgery between March 2014 and February 2019. The tumors were removed with use of neuronavigation, DTI tractography, electrophysiological monitoring and photo dynamics diagnosis using aminolevulinic acid via interhemispheric or transcortical approach. Volumetric analysis of preoperative tumor volume as well as postoperative residual volumes was performed. RESULTS A total of 17 patients, ages ranged from 13–79 years (median; 51) were eligible. Twelve patients underwent radical resection and 5 underwent biopsy (2 with craniotomy, 2 with endoscopy, and 1 stereotactic biopsy). Pathological diagnosis consisted of glioblastoma (GBM) in 10, diffuse midline glioma (DMG) in 3, anaplastic astrocytoma in 3, and diffuse astrocytoma in 1. Extent of resection of the patients attempted radical resection was 96.7%±6.4%. Postoperatively, 12 patients developed hemianopsia, 2 had hemiparesis because of corticospinal tract injury, 2 sensory disturbance, and 3 cognitive dysfunction. At 1 month after surgery, Karnofsky performance status (KPS) worsened in 5 GBM patients and 1 DMG patient, while improved or stable in the rest 11 patients. CONCLUSION Resection of deep-seated glioma around thalamus accompanies a high risk of neurological deficits. Nevertheless, radical resection without KPS decline can be achieved by preserving the corticospinal tract, deep venous system, and brainstem and minimizing damages of surrounding brain.