From the realms of the depths of neurosurgery Ahmed Ansari Asian Journal of Neurosurgery 2019 14(4):1057-1057

Flow diversion for the treatment of petrous internal carotid artery aneurysms Michael George Zaki Ghali, Mandy Binning Asian Journal of Neurosurgery 2019 14(4):1058-1062 Petrous internal carotid artery (ICA) aneurysms are rare and pose a unique management dilemma. They are most commonly fusiform. They are difficult to treat surgically and typically not amenable to selective aneurysmal obliteration. The advent of flow diverters, such as the Pipeline endovascular device, has offered a new approach to these historically challenging lesions. The unique utility of flow diversion in treatment of petrous ICA aneurysms is reviewed and discussed.

Posteroinferior cerebellar artery aneurysms: Influence of angioanatomy on the safety of flow diversion treatment Michael George Zaki Ghali, Yi Jonathan Zhang, Peter Kan, Gavin W Britz Asian Journal of Neurosurgery 2019 14(4):1063-1067 Several anatomical variables critically influence therapeutic strategies for posteroinferior cerebellar artery (PICA) aneurysms and, specifically, the safety of flow diversion for these lesions. We review the microsurgical anatomy of the PICA, discussing and detailing these considerations in the treatment of aneurysms of this vessel from a theoretical perspective and in light of our previously published clinical results.

Occurrence of trigger finger following carpal tunnel release Masatoshi Yunoki, Ryoji Imoto, Nobuhiko Kawai, Atsushi Matsumoto, Koji Hirashita, Kimihiro Yoshino Asian Journal of Neurosurgery 2019 14(4):1068-1073 Surgical treatment of carpal tunnel syndrome (CTS) was recently started in our department, and we noticed that the development of trigger finger (TF), with which neurosurgeons are generally unfamiliar, is not rare after such treatment. We summarized the clinical and pathogenetic aspects of TF and retrospectively analyzed the medical records of all 39 patients who underwent CTR in our department to investigate the occurrence of TF. In 39 patients with CTS, 46 surgical interventions were performed in our department. All surgical procedures were carried out by open release of the transverse carpal ligament under local anesthesia infiltration, but the distal forearm fascia was not released. The mean postoperative follow-up period was 21.1 ± 16.8 months. TF after CTR occurred in nine hands of eight patients (9 of 46 hands, 19.6%). The mean interval between CTR and TF onset was 5.3 ± 2.8 months. TF after surgical treatment of CTS is not rare; therefore, surgeons who treat CTS should understand the clinical features of TF and carefully assess affected patients, particulary at presentation and within 6 months postoperatively.

Expert consensus on the management of brain arteriovenous malformations Yoko Kato, Van He Dong, Feres Chaddad, Katsumi Takizawa, Tsuyoshi Izumo, Hitoshi Fukuda, Takayuki Hara, Kenichiro Kikuta, Yasunobu Nakai, Toshiki Endo, Hiroki Kurita, Bin Xu, Vladimír Beneš, Raftopoulos Christian, Giacomo Pavesi, Mojgan Hodaie, Rajan Kumar Sharma, Harshal Agarwal, Krishna Mohan, Boon Seng Liew Asian Journal of Neurosurgery 2019 14(4):1074-1081 Brain arteriovenous malformations (bAVMs) are complex, heterogeneous, and uncommon intracranial lesions. They can be treated by one or a combination of the following treatment modalities, namely embolization, radiosurgery, or microsurgical resection. In Spetzler-Martin Grade 4 and 5 arteriovenous malformations (AVMs), conservative management may be the best option. A group of experts in the management of AVMs of different disciplines gathered in January 2019 in Hanoi to compile the “Expert Consensus on the Management of Brain Arteriovenous Malformations”.

Do asians have higher carotid bifurcation? A computed tomographic angiogram study of the common carotid artery bifurcation and external carotid artery branching patterns Ekkapot Jitpun, Yodkhwan Wattanasen, Wuttipong Tirakotai Asian Journal of Neurosurgery 2019 14(4):1082-1088 Introduction: Carotid endarterectomy is a major treatment modality for high-grade carotid stenosis. Preoperative identification of the level of the carotid bifurcation and its branching pattern is important in planning for adequate exposure and cross-clamping to achieve hemostasis during the procedure. Most of the previous studies on carotid arteries were performed in cadavers. Methods: We studied levels of carotid bifurcation compared relatively with the level of the vertebral body and ipsilateral angle of the mandible and its branching pattern using computed tomographic angiogram (CTA) carotid with multiplanar reconstruction and three-dimensional imaging in 100 CTA studies. Results: Most of the carotid bifurcations were located at the level of C3–C4 vertebral body and 12% were considered to be high bifurcation. Carotid bifurcations were located below the angle of the mandible in 83.5%. The superior thyroid, facial, and lingual arteries arose from separate branches of external carotid arteries in 67.7% of samples. Facial arteries arose in common trunk with lingual arteries in 29.2%, much more common than previous cadaveric studies. The lingual arteries arose with superior thyroid arteries in 2%, while occipital arteries had high variations in their branching patterns. Conclusions: CTA is an effective and reliable modality for preoperative evaluation of the carotid system in patients undergoing carotid endarterectomy and other carotid procedures. Higher percentage of high carotid bifurcation was found in our study, concordant with other Asian cadaveric studies. We assumed that carotid bifurcation of Asian tends to be located slightly higher than those of the Caucasian population.

Outcomes of the endoscopic transsphenoidal surgery for resection of pituitary adenomas utilizing extracapsular dissection technique with a cotton swab Janissardhar Skulsampaopol, Ake Hansasuta Asian Journal of Neurosurgery 2019 14(4):1089-1094 Purpose: The purpose of this study was to determine the effectiveness and safety of a cotton swab for extracapsular dissection in endoscopic transsphenoidal surgery (ETSS) for pituitary adenoma (PA). Materials and Methods: A retrospective review of patients undergoing ETSS for PA from 2014 to 2017 was undertaken. Only patients with extracapsular dissection by cotton swab with the intent to completely remove the tumor were included. Assessment of the prospectively recorded clinical, laboratory, and radiographic presentation as well as the intra- and postoperative data was carried out. Factors influencing the extent of resection were analyzed. Results: Of the 222 patients, one hundred cases met the inclusion criteria. The cohort consisted of 81 nonfunctioning and 19 functioning PAs. Fifty patients presented with visual disturbance and 34 patients had prior surgical treatment. The majority of PAs was macroadenoma (97%) with 73% modified Hardy Stage C and 38% Knosp Grade 4. Intraoperative cerebrospinal fluid (CSF) leakage was the most frequently noted complication (78%). Meningitis occurred in three cases and repeat ETSS for CSF leakage repair was necessary in three patients. No death or vascular injury was observed. At 12 months after ETSS, magnetic resonance imaging scan confirmed 43% complete tumor resection. Previous surgery and Knosp Grade 4 were the strong factors for incomplete PA removal by multivariate logistic regression analysis. For functioning PAs, thirteen patients (68.42%) achieved biochemical remission. Conclusion: Cotton swab for extracapsular dissection proved its clinical effectiveness and safety. In spite of the technique, negative predictors for complete PA resection were parasellar extension and previous surgery.

Effect of anesthetic agents on cognitive function and peripheral inflammatory biomarkers in young patients undergoing surgery for spine disorders Asish Kumar Sahoo, Nidhi Panda, Pranshuta Sabharwal, Ankur Luthra, Mukilan Balu, Rajeev Chauhan, Hemant Bhagat Asian Journal of Neurosurgery 2019 14(4):1095-1105 Background: Exposure to anesthesia has been postulated to affect the cognitive function by inciting central nervous system inflammation. Hence, we planned to compare the psychometrical effects of anesthetic agents propofol, desflurane, or sevoflurane on postoperative cognitive function and also measure the change in concentration of serum S-100β, interleukin (IL)-6, and tumor necrosis factor (TNF)-α to look for the contribution of systemic inflammation. Methods: This was a prospective, double-blind, randomized controlled trial. Intuitional ethical committee approval and consent from patients were obtained. We enrolled 66 patients, allocated into three equal groups to receive either sevoflurane (n = 22), desflurane (n = 22), or propofol (n = 22). Standard anesthesia protocol was followed titrated to a bispectral index of 40–60. Patients with preoperative mini-mental state examination ≤23 were excluded. Each patient was assessed thrice with battery of cognitive tests in preoperative period (baseline), after 72 h (early postoperative cognitive dysfunction [POCD]), after 3 months (delayed POCD) of surgery. Serum levels of IL-6, TNF-α, and S-100β were measured preoperatively and 72 h after surgery. Results: Mean scores of various psychometric tests improved slightly in early postoperative period which was not statistically significant (P > 0.5). In delayed postoperative period, there was significant improvement in scores as compared to baseline (P < 0.5) in all the groups. There was nonsignificant change in the levels of biomarkers S-100β, TNF-α, and IL-6 between baseline and postoperative period in all the groups. Conclusion: In young patients, there is no effect of anesthesia on postoperative cognitive functions. There is no association of inflammatory markers with respect to the patient's cognitive status.

Histopathological profile of brain tumors: A 12-year retrospective study from Madinah, Saudi Arabia Albasri Abdulkader Mohammed, Almuhamdi Nawal Hamdan, Alqaidi Sara Homoud Asian Journal of Neurosurgery 2019 14(4):1106-1111 Objectives: The objective of this study is to characterize the histopathological types and basic demographic parameters of brain tumors in the Madinah region of Saudi Arabia and to analyze and compare the findings with previously published literature. Materials and Methods: This retrospective study was conducted in the Department of Pathology, King Fahad Hospital, Madinah, Saudi Arabia, and comprised cases of brain tumors during 12 years (from January 2006 to December 2017). Basic demographic data, tumor site, and histopathological patterns were obtained from the medical records and further analyzed and graded according to the World Health Organization (WHO) 2007 classification. Results: A total of 227 brain tumors in 122 (53.7%) males and 105 (46.3%) female patients were recorded. Pediatric and adult patients accounted for 10.6% and 89.4% of the cases, respectively. The predominant age group affected was between 40 and 49 years (23.5%). The most common histopathological diagnosis in the present study was meningioma (30.8%), followed by astrocytic tumors (29.1%), metastatic tumors (7.7%), and embryonal tumors (6.6%). The meningothelial meningioma was the most common type of meningioma (48.5%). The majority of astrocytic tumors (52%) fell under the WHO Grade IV. Conclusion: This retrospective study established a baseline profile of brain tumors based primarily on the histopathological experience at a tertiary care hospital in the Madinah, Saudi Arabia, and provides an initiating platform to workup for future population targeted studies on brain tumors.

Endoscopic surgery for thalamic hemorrhage with intraventricular hemorrhage: Effects of combining evacuation of a thalamic hematoma to external ventricular drainage Yu Shimizu, Katsuhiro Tsuchiya, Hironori Fujisawa Asian Journal of Neurosurgery 2019 14(4):1112-1115 Objectives: Intraventricular hemorrhage (IVH) caused by thalamic hemorrhage leads to hydrocephalus, increased intracranial pressure, and reduced levels of consciousness. The aim of this study was to investigate the efficacy and compare the results of endoscopic surgery for the evacuation of a thalamic and intraventricular hematoma against those of external ventricular drainage (EVD) surgery. Materials and Methods: From January 2010 to December 2018, 68 patients with IVH caused by thalamic hemorrhage were treated in our department. Our study was approved by the Institutional Ethics Committee. The included patients were randomly divided into an EVD group and an endoscopic surgery group. The outcome was measured after 3 months using a 30-day mortality rate, pneumonia onset rate, ventriculoperitoneal (VP) shunt dependency rate, and Glasgow Outcome Scale (GOS) score. Results: Thirty-eight of the 68 patients were randomly assigned to the endoscopic surgery group and 30 were assigned to the EVD group. Patients treated with endoscopic surgery had significantly less drainage dependency on day 30 (P = 0.00014 < 0.00005) in comparison to those treated with EVD. The difference in the functional outcomes between the two groups of patients was mainly dependent on the onset of pneumonia and the consciousness level at the time of admission. The onset rate of aspiration-related pneumonia until day 30 was 11% in the endoscopic surgery group and 45% in the EVD group. The VP shunt rates were 27.8% in the endoscopic surgery group and 60% in the EVD group. The endoscopic surgery group had a significantly lower VP shunt rate compared with the EVD group. Intracerebral hemorrhage evacuation late was found to be associated with shunt-dependent rate and hospitalization. Conclusions: Endoscopic surgery was found to be associated with a lower GOS score and lower onset rates for shunt-dependent hydrocephalus and aspiration-related pneumonia in comparison to EVD. High evacuation rate was associated with lower shunt-dependent rate and short hospitalization.