Laparoscopically assisted Adenomyomectomy Using the Double/Multiple-Flap Method with Temporary Occlusion of the Bilateral Uterine Artery and Utero-Ovarian Vessels in Comparison with the Double/Multiple-Flap Only Method

Introduction Adenomyomectomy is the most conservative surgical treatment for adenomyosis. However, the surgical efficacy of this treatment and the best approach to use are still debated. We aimed to evaluate the efficacy of laparoscopic adenomyomectomy using the double/multiple-flap method combined with temporary occlusion of the bilateral uterine artery and the utero-ovarian vessels to treat symptomatic adenomyosis. Patients We recruited 155 patients with symptomatic adenomyosis and divided them into group A (n = 76) and group B (n = 79), with each group treated using a different surgical approach. All eligible women were informed of the potential complications, benefits, and alternatives of each approach before they were assigned into one of the two groups. In group A, we performed laparoscopic adenomyomectomy with the double/multiple-flap method while in group B, we performed a double/multiple-flap adenomyomectomy combined with temporary occlusion of the bilateral uterine artery and utero-ovarian vessels. Over a 24-month follow-up period, we evaluated operating time, intraoperative blood loss, visual analog scale (VAS) scores, anti-Mullerian hormone levels, uterine volume, and relief of menorrhagia. Results There were no significant differences between groups A and B with respect to VAS scores, relief of menorrhagia and uterine volume at 3 months, 6 months, 12 months and 24 months after surgery (p > 0.05). Both groups showed significant improvement of these parameters after surgery compared with preoperative values (p < 0.05). Blood loss in group B was significantly lower than in group A (p < 0.001) while there was no significant difference in operating times (p > 0.05). Levels of AMH did not differ significantly between the groups throughout the follow-up period (p > 0.05). Conclusion Laparoscopic adenomyomectomy with temporary occlusion of the bilateral uterine artery and the utero-ovarian vessels offers a feasible surgical option to treat symptomatic adenomyoma.

Subtemporal, Transapical, and Transcavernous Approach to Clip Low-Lying Basilar Tip Aneurysm: 2-Dimensional Operative Video

Basilar tip aneurysm clipping is technically challenging because of the depth of operative corridor, rarity in presentation, and important perforators supplying deep, critical structures. Two major approaches to basilar tip aneurysms include (1) a frontotemporal (transorbital) trans-sylvian approach for most aneurysms and (2) a modified subtemporal approach for aneurysms with low-lying necks. A 53-yr-old woman presented to our institution with a large unruptured basilar tip aneurysm notable for a low, broad neck (6.4 mm). After discussion of risks and benefits of endovascular vs surgical options, the patient consented to operative intervention. She underwent a right frontotemporal craniotomy with zygomatic osteotomy, intradural petrous apicectomy, elective sectioning of the fourth cranial nerve (CN IV), and intracavernous removal of the dorsum sellae and posterior clinoid process to provide more space for aneurysm dissection. After temporary clipping of the basilar artery, the perforating arteries were dissected free from the aneurysm and the aneurysm occluded with 2 fenestrated clips. Important technical nuances of the approach include (1) achieving ample working room for temporary occlusion aneurysm dissection, (2) careful dissection of the perforators and contralateral P1, and (3) utilization of 2 fenestrated clips to accommodate and preserve the ipsilateral P1 segment. Postoperative angiogram showed complete aneur-ysmal occlusion. Postoperatively, the patient demonstrated mild cognitive impairment and a right CN IV palsy. At 6-wk follow-up, cognition recovered to normalcy. More recently, at 12-mo follow-up, the patient noted intermittent diplopia. Formal neuro-ophthalmologic assessment confirmed persistence of a CN IV palsy treated with prism lenses but no other neurological deficits.

Predictors of clinical outcomes for the treatment of complex intracranial aneurysms in the anterior circulation: a prospective randomised study; SCAT

<p><strong>Background.</strong> Large and giant aneurysms (&gt; 10 mm and &gt;25 mm, respectively), wide-necked (dome / neck ratio &gt; 1.5) and fusiform examples are challenging for both endovascular and microsurgical intervention. Currently, there is a lack of a universal approach in treating complex anterior circulatory aneurysms. Due to high morbidity and mortality rates and the absence of a common strategy, predictor analysis may have diagnostic relevance.</p><p><strong>Aim.</strong> We sought to identify predictors of unfavourable neurological outcomes for the treatment of complex intracranial aneurysms.</p><p><strong>Methods.</strong> The investigation of complex intracranial aneurysms (SCAT, NCT03269942) is a prospective randomised multicentre study. Unifactorial and multifactorial analyses of clinical outcomes were performed to identify predictors. According to our study protocol, we included 110 patients admitted to Meshalkin National Medical Research Center and the Federal Neurosurgical Center (Novosibirsk, Russian Federation) from March 2015 to June 2018, who met eligibility criteria (age &gt; 75 years, neck size &gt; 4 mm and dome/neck ratio &lt;1.5). Depending on the procedure, patients were divided into two groups using sealed envelope randomisation: 1) endovascular flow diversion (55 patients) and 2) microsurgical revascularisation (55 patients). Unfavourable outcomes were thought to be neurological deterioration with two or more mRS (modified Rankin scale) scores or ≥ mRS 4 decline.</p><p><strong>Results.</strong> Data analysis revealed significatly favourable outcomes in 94.5 % of the endovascular group, and 76.4 % of the microsurgical group at 12 months follow-up (p = 0.001). Morbidity and mortality rates were 5.5 and 1.8 % for the endovascular group, and 25.4 and 3.6 % for the microsurgical group, respectively. Log-rank criteria did not reveal any differences in mortality (p = 0.32). The overall complication rates were 29.1 % for the endovascular group, and 5.4 % for the microsurgical group (p = 0.001). We identified a significant difference in the frequency of ischaemic complications (p = 0.004), but haemorrhagic complication rates were similar (p = 0.297). Unifactorial analysis revealed predictors of unfavourable clinical outcomes: gender (male, ОR = 2.475, 95% CI: 1.005–6.094, p = 0.049), microsurgical intervention (OR = 5.618, 95% CI: 1.635–19.302, p = 0.006), giant aneurysm size (OR = 3.1, 95% CI: 1.22–7.88, p = 0,017), and temporary occlusion for &gt; 40 min (OR = 3.016, 95% CI: 1.13–8.04, p = 0.028). Giant aneurysm size is 6.1 times more increase the probability of unfavorable outcomes according multifactorial analysis.</p><p><strong>Conclusion.</strong> In spite of a high complete occlusion rate after microsurgical treatment with revascularisation, endovascular flow diversion demonstrated better clinical outcomes at short-term follow-up (12 months). Giant aneurysm size was a predictor of both ischaemic and haemorrhagic complications, with an approximate six-fold rise in unfavourable clinical outcomes. Other predictors included the microsurgical intervention itself, especially with increased temporary occlusion for &gt; 40 min, and the male gender.</p><p>Received 12 May 2020. Revised 11 November 2020. Accepted 12 November 2020.</p><p><strong>Funding:</strong> The study did not have sponsorship.</p><p><strong>Conflict of interest:</strong> Authors declare no conflict of interest.</p><p><strong>Author contributions</strong><br />Conception and design: K.Yu. Orlov, A.V. Dubovoy<br />Data collection and analysis: R.S. Kiselev<br />Statistical analysis: R.S. Kiselev<br />Drafting the article: R.S. Kiselev<br />Critical revision of the article: D.S. Kislitsin, A.V. Gorbatykh, A.V. Dubovoy, K.Yu. Orlov, V.V. Berestov, K.S. Ovsyannikov<br />Final approval of the version to be published: R.S. Kiselev, A.V. Dubovoy, D.S. Kislitsin, A.V. Gorbatykh, K.S. Ovsyannikov, V.V. Berestov, K.Yu. Orlov</p>

Catheterisation of the brachial artery in children: should we be so concerned?

To the Editor: Arterial catheterisation is often indicated for critical care patients to allow continuous haemodynamic monitoring and to facilitate blood sampling. However, it is associated with complications, with some considered minor (eg, bleeding, haematoma, local infection and temporary occlusion) and others considered major, requiring urgent limb- and/or life-saving treatment (eg, permanent occlusion, acute limb ischaemia, pseudoaneurysm and sepsis).

The influence of temporary occlusion of parent vessel on outcome of surgical treatment of ruptured cerebral aneurysms

Background/Aim. Aneurysm rupture followed by sub-arachnoid or intracerebral haemorrhage is always current topic and poses a great challenge to neurosurgeons. The aim of the study was to establish whether applying temporary occlusion before placing a final clip was justified. Methods. A prospective study was conducted on patients with aneurysm rupture, treated at Neurosurgical Clinic in Nis from January 2012 to December 2016. Patients belonging to I and II and 1, 2 and 3 grades according to the Hunt-Hess grading system and Fisher scale, respectively, were monitored. Results. In 85, out of total 182 bleeding aneurysms that were treated, a neurosurgeon decided to apply temporary clipping before placing the final clip. Temporary occlusion significantly influenced the presence of resulting neuro-logical deficit. Conclusion. The application of temporary occlusion facilitates placing the final clip but also affects the occurrence of neurological deficits. It is assumed that this is a consequence of caused vasospasm, considering that these are bleeding aneurysms.

In-Depth Analysis of Unmodulated Visible Light Positioning Using the Iterated Extended Kalman Filter

Indoor positioning with visible light has become increasingly important in recent years. Usually, light sources are modulated at high speeds in order to wirelessly transmit data from the fixtures to a receiver. The accuracy of such systems can range from a few decimeters to a few centimeters. However, additional modulation hardware is required for every light source, thereby increasing cost and system complexity. This paper investigates the use of unmodulated light for indoor positioning. Contrary to previous work, a Kalman filter is used instead of a particle filter to decrease the computational load. As a result, the update rate of position estimation can be higher. Additionally, more resources could be made available for other tasks (e.g., path planning for autonomous robots). We evaluated the performance of our proposed approach through simulations and experiments. The accuracy depends on a number of parameters, but is generally lower than 0.5 m. Moreover, temporary occlusion of the receiver can be compensated in most cases.

Final Results of the Prospective Multicenter Excimer Laser-Assisted High-Flow Bypass Study on the Treatment of Giant Anterior Circulation Aneurysms

BACKGROUND Both conventional bypass utilizing temporary recipient vessel occlusion and the excimer laser-assisted nonocclusive anastomosis (ELANA) bypass technique are possible strategies in the treatment of giant aneurysms. These treatments have only been studied in single institutional retrospective studies. The potential advantage of the ELANA technique is the absence of temporary occlusion of major arteries, decreasing the risk of intraoperative ischemia. OBJECTIVE To investigate the risks and potential benefits of high-flow bypass surgery for giant and complex aneurysms of the anterior cerebral circulation. In addition, the effectiveness of the ELANA bypass procedure in the treatment of these aneurysms is determined. METHODS A total of 37 patients were included in 8 vascular neurosurgical centers in the United States, Canada, and Europe. A 30-d postoperative bypass follow-up was studied by using digital subtraction angiography and/or magnetic resonance angiography and computed tomography angiography to assess patency as well as by clinical monitoring in all patients. RESULTS In 35 patients, an ELANA high-flow bypass was performed and the aneurysm treated. Four patients had remaining neurological deficits after 30 d caused by stroke (11.4%). These strokes were not related to the ELANA anastomosis device. CONCLUSION This study does not prove that the ELANA technique has an advantage over conventional bypass techniques, but it appears to be an acceptable alternative to conventional transplanted high-flow bypass in this very-difficult-to-treat patient group, especially in select patients whom cannot be bypassed using conventional means in which temporary occlusion is considered to be not recommended.