Intracranial Procedures Research Articles

Heparin Flush Use in Transfemoral Cerebral Angiography Survey

The drug concentration of heparinized saline used for transfemoral catheter angiography flush during different types of cerebral angiogram procedures varies among providers and centers worldwide. Although heparin is recommended for use during cerebral angiograms to minimize the risk of thromboembolic events associated with the utilization of multiple endovascular devices and lengthy procedures, there is a paucity of information available regarding protocols for administration of heparin and heparinized saline. Higher concentrations of heparinized saline flush may benefit patients undergoing elective nonruptured intracranial aneurysm embolization procedures by decreasing the risk of thromboembolism. However, it could potentially place patients undergoing revascularization procedures for acute ischemic stroke at higher risk of symptomatic intracerebral hemorrhage, particularly if they received intravenous tissue plasminogen activator immediately before endovascular thrombectomy. After obtaining permission from the Association for Radiologic and Imaging Nursing (ARIN) Board of Directors, a survey was presented in English and electronically distributed by the ARIN to all current and past ARIN members with valid e-mail addresses. The survey was preceded by an introductory letter explaining the study purpose and its voluntary nature. Response to the survey was identified as consent to participate. Subjects were asked to participate if they were currently involved in the management of patients undergoing cerebral angiography with a variety of interventions including management of acute ischemic and hemorrhagic stroke. There is a paucity of evidence supporting use of a specific concentration of heparinized saline solution. It ranges from no heparin added to concentrations exceeding 5 units/mL for transfemoral flush. The most frequently used concentration is 2 units/mL (32.8–34.8% of respondents depending on endovascular intervention), and the least frequently utilized concentrations are 3 units/mL and higher than 5 units/mL (4.3–5.7% of respondents depending on endovascular intervention). Mixing and labeling bags with heparinized saline flush was noted to be the responsibility of interventional radiology registered nurse (39%, n = 46), pharmacy (26.3%, n = 31), or the angiography technologist (8.5%, n = 10). More than quarter (26.5%) of respondents noted not having readily available premixed heparinized saline flush. Twenty-four (20.3%) of survey participants claimed using only premixed bags of heparinized saline solution. Despite the Institute for Healthcare Improvement, Institute for Safe Medication Practices and Joint Commission recommendations, there are no standard protocols across stroke centers identifying optimal heparinized saline flush solution concentration, preparation, and documentation. Replication of this survey among members of the American Society of Neuroradiology is recommended to validate the findings from the present study. If confirmed, a consensus on safety of heparinized saline flush use during neuroradiology interventions is strongly advised.

Safety and Efficacy of Tirofiban in Rescue Treatment for Acute Intracranial Intraprocedural Stent Thrombosis.

Background and Purpose: The incidence of acute intraprocedural stent thrombosis (AIST) during stenting of intracranial atherosclerotic stenosis (ICAS) has seldom been reported and evidence regarding the treatment of AIST is lacking. We aim to investigate the incidence of AIST during stenting of ICAS in our institute, assess the preliminary efficacy and safety of rescue treatment of tirofiban for these patients.Methods: From September 2016 to May 2019, all symptomatic ICAS patients who underwent intracranial stenting in our institute were prospectively registered into this study, of which patients with AIST were retrospectively reviewed to extract baseline characteristics, perioperative management, procedural details, angiographic, and clinical outcomes. Rescue treatment of tirofiban for AIST was assessed by recanalization of the culprit vessel and periprocedural death, hemorrhage, and ischemic stroke.Results: Acute intraprocedural stent thrombosis developed in 12 (6.2%) patients within 30 min after stent placement of 194 patients. All 12 cases were successfully recanalized with modified Treatment in Cerebral Ischemia (mTICI) 3 and Arterial Occlusive Lesion (AOL) 3 after rescue treatment of tirofiban alone. There was no perioperative death or any hemorrhagic complication. Three patients suffered perioperative ischemic stroke.Conclusions: We observed a non-negligible rate of AIST during intracranial stenting procedures for ICAS. Intra-arterial bolus followed by intravenous tirofiban infusion seems to be efficacious and safe for AIST during stent placement for ICAS, without increasing the rate of hemorrhagic complications and death.

A pilot study of optical neuronavigation-guided brain biopsy in the horse using anatomic landmarks and fiducial arrays for patient registration.

BackgroundOptical neuronavigation‐guided intracranial surgery has become increasingly common in veterinary medicine, but its use has not yet been described in horses.ObjectivesTo determine the feasibility of optical neuronavigation‐guided intracranial biopsy procedures in the horse, compare the use of the standard fiducial array and anatomic landmarks for patient registration, and evaluate surgeon experience.AnimalsSix equine cadaver heads.MethodsComputed tomography images of each specimen were acquired, with the fiducial array rigidly secured to the frontal bone. Six targets were selected in each specimen. Patient registration was performed separately for 3 targets using the fiducial array, and for 3 targets using anatomic landmarks. In lieu of biopsy, 1 mm diameter wire seeds were placed at each target. Postoperative images were coregistered with the planning scan to calculate Euclidian distance from the tip of the seed to the target.ResultsNo statistical difference between registration techniques was identified. The impact of surgeon experience was examined for each technique using a Mann‐Whitney U test. The experienced surgeon was significantly closer to the intended target (median = 2.52 mm) than were the novice surgeons (median = 6.55 mm) using the fiducial array (P = .001). Although not statistically significant (P = .31), for the experienced surgeon the median distance to target was similar when registering with the fiducial array (2.47 mm) and anatomic landmarks (2.58 mm).Conclusions and Clinical ImportanceRegistration using both fiducial arrays and anatomic landmarks for brain biopsy using optical neuronavigation in horses is feasible.

Thiel\u2019s embalming method with additional intra-cerebral ventricular formalin injection (TEIF) for cadaver training of head and brain surgery

Thiel’s embalming method provides natural coloration, flexibility, and tissue plasticity, and is used widely to prepare specimens for cadaver surgical training. However, this method causes brain softening, thereby restricting the cadaver surgical training of intra-cranial procedures. In this study, three cadavers were embalmed using formalin fixation, Thiel’s embalming method, and Thiel’s embalming method with additional intra-cerebral ventricular formalin injection, respectively. We also established rat models of the three embalming methods to develop and determine the best method for retaining adequate brain elasticity. The intra-ventricular formalin injection in the cadaver was performed through the Kocher’s point, as in the classical external ventricular drain procedure. Both, the cadaver brains and rat models yielded consistent shear wave measurements and brain surface stiffness data. Notably, the Thiel’s embalming method with additional intra-cerebral ventricular formalin injection yielded suitable elasticity for brain cadaver surgical training in terms of brain mobilization and surgical field deployment, and also discharged formaldehyde in undetectable quantities. To our knowledge, this is the first report in which a fixed quality, namely, brain elasticity for the performance of head and brain cadaver surgical training, has been evaluated in a cadaver subjected to the Thiel’s embalming method with immersion fixation in the cerebrospinal fluid space. We conclude that the Thiel’s embalming method with additional intra-cerebral ventricular formalin injection can maintain the brain elasticity, and may therefore improve the quality of head and brain cadaver surgical training safely and easily.

Outcomes of Intracranial Versus Subcranial Approaches to the Frontofacial Skeleton

An intracranial approach to the craniomaxillofacial skeleton can be effective for correcting complex craniofacial dystoses such as frontofacial hypoplasia, hypertelorism, and orbital dystopia. However, the significant morbidity resulting from the high complication rates has limited intracranial use. Given the need for intracranial approaches for certain clinical indications, the present study reevaluated intracranial frontofacial procedures to determine their safety and outcomes. A retrospective review was performed of all frontofacial procedures completed between 2007 and 2017 at a single institution. Patients who had undergone monobloc distraction alone or with facial bipartition, facial bipartition alone, or box osteotomy were included in the intracranial cohort. Those who had undergone Le Fort III distraction, advancement, or a combination with Le Fort I were included in the subcranial cohort. The recorded data included demographics, previous craniofacial surgery, and operative events. The complications rates were compared between the 2 cohorts. The present study included 65 patients-35 subcranial and 30 intracranial. The rates of previous craniomaxillofacial (P=.193) and intracranial (P=.340) surgery were equivalent between the 2 cohorts. Of the 30 intracranial and 35 subcranial patients, 26.7% and 34.3% experienced complications (P=.218). The intracranial patients experienced more dural tears (53.3 vs 5.7%; P<.0001); however, no significant differences were observed in cerebrospinal fluid leakage. Reintubations (n=3; 4.5%) occurred exclusively in the subcranial group. No significant differences in the major and minor complication rates were observed between the 2 cohorts. Intracranial and subcranial frontofacial procedures are associated with an equal riskof major and minor complications. Given the lack of an increase in risk, intracranial frontofacial procedures should be considered for the management of complex craniofacial dystoses.

Patterns in Pain and Opiate Use after Endoscopic Sinus Surgery.

To evaluate postoperative opiate use and patients' opinions regarding pain management after endoscopic sinus surgery (ESS). Case series with planned data collection. Tertiary referral medical center. We prospectively evaluated postoperative opiate utilization in adults undergoing ESS over a 2-year period at an academic medical facility. Exclusion criteria included use of nasal packing, intracranial or orbital procedures, tumor surgery, and any use of endoscopic drills. All patients underwent bilateral maxillary antrostomy, total ethmoidectomy, sphenoidotomy, and frontal sinusotomy with or without septoplasty. Patients were discharged with 30 oxycodone-acetaminophen (5-325 mg) and a survey assessing pain and narcotic/nonnarcotic use on postoperative days 0 to 7. A total of 64 patients completed surveys. Mean ± SD narcotic use over the 7-day postoperative period was 7.7 ± 7.6 pills. Patients with high narcotic use (>6 pills total) had no differences in demographic or surgical factors from those with low use (≤6 pills) but did report a higher level of postoperative day 1 pain (4.8 ± 1.1 vs 2.0 ± 1.4, P < .001). Narcotic use declined during this period, with <30% of patients requiring narcotics by postoperative day 3. Our results support reduced opiate prescription and encouragement of nonnarcotic use after ESS without compromising effective pain management.

Risk Factors and Mechanisms of Postoperative Delirium After Intracranial Neurosurgical Procedures

Postoperative delirium (POD) is a condition characterized by cerebral dysfunction or failure and associated with high morbidity and mortality, prolonged intensive care unit and hospital stay, increased costs and long-term disability. The risk factors can be divided into three categories: preoperative, intraoperative, and postoperative. POD is underrecognized, underdiagnosed, and undertreated condition which can also lead to potentially life-threatening conditions. Prevention and treatment of POD include adequate perioperative pain control, maintenance of optimal blood pressure, water-electrolyte balance, hypo- and hyperglycemia, sleep hygiene. Despite POD has been extensively studied in various types of surgery, there is not enough evidence on POD in intracranial neurosurgery. Patients undergoing open craniotomy might be at particular risk because on top of the above-mentioned factors, they also might have a direct neurosurgical brain injury. Future research on the POD in neurosurgical patients after intracranial interventions is needed. A bibliographic search was performed in the MEDLINE and PubMed virtual library. The following descriptors were used: POD, neurosurgery, anesthesia, and POD, postoperative pain management and POD, water and electrolyte imbalance and POD, neurochemistry of POD. We included in this review original and review articles in the English language. Majority of non-neurosurgical patients have multiple risk factors for POD (preoperative, intraoperative, and postoperative); patients undergoing intracranial neurosurgery on top of that might have additional risks associated with neurosurgical pathology (brain tumor, cerebral hemorrhage, and severe traumatic injury) as well as neurosurgery-induced brain injury can also appear to be a contributing factor.

The Clinical and Imaging Profile of Skew Deviation: A Study of 157 Cases.

Skew deviation, a vertical misalignment of the eyes caused by a lesion in the vestibulo-ocular pathway, is a common manifestation of brainstem dysfunction, yet comprehensive information about its clinical profile is lacking. The aim of this study was to document presenting symptoms, causes, ocular alignment features, accompanying neurologic signs, pertinent brain imaging abnormalities, and measures used to relieve diplopia. We searched the electronic medical records text from 2000 to 2018 for "skew" or "skew deviation" at a tertiary care academic center, including only patients diagnosed under supervision of faculty neuro-ophthalmologists. After excluding patients with features suggesting an imitator of skew deviation, we collected data useful in answering the selected clinical issues. In a cohort of 157 patients, vertical misalignment ranged between 1 and 30 prism diopters (PD) (median 5 PD) and was comitant in 100 (64%) patients. Diplopia was reported by 87% and blurred vision by 11% of patients. Blurred vision was more common when vertical misalignment was less than 3 PD. At least one accompanying neurologic sign was present in 133 (85%) patients, most often nystagmus, followed by gaze paresis, ataxia, saccadic pursuit, and internuclear ophthalmoplegia. Stroke affecting the thalamus, brainstem, or cerebellum accounted for 82 (52%) of cases. Stroke was usually ischemic, mostly unprovoked, but also occurring after intracranial or extracranial surgical procedures. Brainstem tumor and operative injury caused most of the remaining cases. A subgroup of 17 (11%) patients had skew deviation as the only new clinical sign and had no pertinent brain imaging abnormalities. Resolution of skew deviation, documented in 58 (42%) of 137 patients who had at least one follow-up visit, usually occurred within 3 months, but sometimes not until after 12 months. Of 110 patients who still had diplopia on follow-up examinations, the diplopia was successfully relieved with prism spectacles in 68 (62%). The cause of the skew deviation, amount of vertical misalignment, and degree of incomitance did not predict the success in relieving diplopia. Accompanying neurologic signs, including ataxia, endured in 44% of patients and were often more debilitating than the diplopia of skew deviation. The amplitude of misalignment in skew deviation varies widely but is generally 5 PD or less. When misalignment is 3 PD or less, patients report blurred vision rather than diplopia. Skew deviation is usually accompanied by other neurologic signs reflecting brainstem dysfunction. Yet there is a small subgroup in which vertical misalignment is an isolated sign, and there are no supporting brain imaging abnormalities. The main cause of skew deviation is ischemic stroke, which affects not only the brainstem but also the thalamus. Diplopia from skew deviation frequently persists, in which case prism spectacles may be successful in palliating it. Accompanying neurologic signs, especially ataxia, may outlast skew deviation and be more debilitating.

Blood Conservation for Complex Spine and Intracranial Procedures

Neurological surgery, which includes intracranial and spine surgery, is associated with a significant risk of major perioperative bleeding. This review highlights the various blood conservation techniques currently in practice for major, complex spine and intracranial surgery. Several techniques have been described to reduce blood loss and transfusion requirements perioperatively. These include preoperative risk identification and stratification and use of different blood conservation strategies perioperatively. The efficacy and safety of tranexamic acid has been demonstrated in major spine surgery, and its role has expanded in traumatic brain injury based on the CRASH-3 study. Permissive hypotension should be avoided based on recent high-quality observational data on the negative effects of cumulative hypotension on end-organ injury. The use of viscoelastic blood coagulation management is increasingly used as a theragnostic approach to blood conservation strategies. The ability to minimize blood loss and reduce exposure to allogeneic blood transfusions, which can greatly increase perioperative morbidity and mortality, is paramount. Our review provides a framework for evidence-based blood conservation strategies for neurological surgery.

Association of intracranial arteriovenous malformation embolization with more rapid rate of perfusion in the peri-nidal region on color-coded quantitative digital subtraction angiography

BackgroundHemodynamic alterations post-embolization of intracranial arteriovenous malformations (AVMs) may cause delayed edema/hemorrhage in brain parenchyma adjacent to the lesion.ObjectiveTo quantify and compare cerebral perfusion changes in the peri-AVM territory pre-...

Does Postoperative Cognitive Decline Result in New Disability After Surgery?

Establish whether POCD is associated with new disability after surgery, which would inform whether POCD impacts patient-centered outcomes. POCD is a decline in neuropsychiatric tests scores from presurgical baseline which occurs in approximately 15% of older patients 3 months after surgery. POCD is a research construct meant to investigate patient and family reports of older adults who were "never the same after surgery." However, many patients with POCD do not perceive difficulty with thinking and memory, and the question remains whether POCD impacts patient function. We performed a prospective cohort study of 167 older adults undergoing major noncardiac surgery (requiring at least a 2-day hospital stay). Exclusion criteria were: history of dementia, cardiac or intracranial procedure, inability to consent for themselves, or emergency surgery. We administered formal neuropsychiatric testing (Alzheimer Disease Research Center UDS battery), basic and instrumental activities of daily living (Alzheimer Disease Research Center IADLs), pain (geriatric pain measure), and depression screening (hospital depression and anxiety scale) before and 3 months after surgery. We recorded all patient refined diagnostic related groups codes, blood pressure, anesthetics and narcotics administered, surgical and anesthesia duration, and measured complications and severity, length of stay, and readmissions. Patients with POCD (21/167, 14.1%) had twice the proportion of new impairment in IADL as compared to those without POCD (57% vs 27%, P = .01). The most common areas of decline were social activities, ability to find items around the house, remember appointments, shop and pay for items, do laundry, drive a car/use public transport, and do housework. Predictors of IADL change after surgery included POCD, presurgical cognition, presurgical function, postoperative depression, and the development of postoperative complications. Patients with POCD experience a much higher incidence of new disability after surgery. Baseline cognitive or functional limitations are also risk factors for new disability. Many patients are not aware of their limitations before surgery. Future study is needed to identify practical ways to routinely screen patients and reduce risk. Patients need to be informed of their risk for new disability after surgery to inform their medical decision making.

Risk Factors and Mechanisms of Postoperative Delirium After Intracranial Neurosurgical Procedures.

Postoperative delirium (POD) is a condition characterized by cerebral dysfunction or failure and associated with high morbidity and mortality, prolonged intensive care unit and hospital stay, increased costs and long-term disability. The risk factors can be divided into three categories: preoperative, intraoperative, and postoperative. POD is underrecognized, underdiagnosed, and undertreated condition which can lead to potentially life-threatening conditions. Prevention and treatment of POD include adequate perioperative pain control, maintenance of optimal blood pressure, water-electrolyte balance, hypoglycemia, hyperglycemia, sleep hygiene. Despite POD has been extensively studied in various types of surgery, there is not enough evidence on POD in intracranial neurosurgery. Patients undergoing open craniotomy might be at particular risk because on top of the above-mentioned factors, they also can have a direct neurosurgical brain injury. Future research on the POD in neurosurgical patients after intracranial interventions is needed. A bibliographic search was performed in the MEDLINE and PubMed virtual library. The following descriptors were used: POD, neurosurgery, anesthesia and POD, postoperative pain management and POD, water and electrolyte imbalance and POD, neurochemistry of POD. We included in this review original and review articles in the English language. Majority of non-neurosurgical patients have multiple risk factors for POD (preoperative, intraoperative, and postoperative); patients undergoing intracranial neurosurgery might have additional risks associated with neurosurgical pathology (brain tumor, cerebral hemorrhage, and severe traumatic brain injury) as well as neurosurgery-induced brain injury can also appear to be a contributing factor.

A dedicated cerebrovascular anesthesia team is a critical component of a comprehensive stroke center

There has been a long-standing debate regarding the optimal approach to the anesthetic management of patients undergoing mechanical thrombectomy. While the vast majority of intracranial neurointerventional procedures are performed under...

International survey of neurosurgical anesthesia (iSonata) : An international survey of current practices in neurosurgical anesthesia.

No standardized recommendations have been currently defined for anesthesia management of patients undergoing elective intracranial surgery. It can therefore be assumed that international clinical institutions have diverging approaches or standard operating procedures (SOP) which determine the type of general anesthesia, hemodynamic management, neuromuscular blockade, implementation of hypothermia and postoperative patient care. This international survey aimed to assess perioperative patient management during elective intracranial procedures. This survey was performed from February to October 2018 and 311 neurosurgical, maximum care centers across 19European countries were contacted. The aim was to evaluate the anesthesia management to provide relevant data of neuroanesthesia practices across European centers. The survey differentiated between vascular and non-vascular as well as supratentorial and infratentorial procedures. Atotal of 109 (35.0%) completed questionnaires from 15European countries were analyzed. The results illustrated that total intravenous anesthesia was most commonly implemented during elective intracranial procedures (83.8%). All centers performed endotracheal intubation prior to major intracranial surgery (100%). Central venous lines were placed in 63.3% of cases. Moderate intraoperative hypothermia was carried out in 12.8% of the procedures, especially during vascular supratentorial and infratentorial surgery. Aneuromuscular blockade during surgery was implemented in 74.1% of patients. Assessment of the neuromuscular junction was performed in 59.2% of cases, 76.7% of patients were immediately extubated in the operating room. 84.7% of these patients were directly transferred to amonitoring ward or an intensive care unit (ICU) and 55.1% of ventilated patients were transferred directly to an ICU. The data demonstrate that many aspects of anesthesia management during elective intracranial surgery vary between European institutions. The data also suggest that abroad consensus exists regarding the implementation of total intravenous anesthesia, airway management (endotracheal intubation), the implementation of urinary catheters, large bore peripheral venous lines and the broad availability of cross-matched red blood cell concentrates. Nevertheless, anesthesia management (e.g. central venous catheterization, moderate hypothermia, neuromuscular monitoring) is still handled differently across many European institutions. Alack of standardized guidelines defining anesthetic management in patients undergoing intracranial procedures could explain this variability. Further studies could help establish optimal anesthesia management for these patients. This in turn could help in the development of national and international guidelines and SOPs which could define optimal management strategies for intracranial procedures.

Distal versus proximal pulsed radiofrequency for treating trigeminal neuralgia

Aims The aim of this study was to evaluate and compare percutaneous distal pulsed radiofrequency (DPRF) and proximal pulsed radiofrequency (PPRF) for the trigeminal nerve in the management of trigeminal neuralgia (TN). Patients and methods We conducted a prospective clinical trial including 20 patients with recent TN (3–6 months). The patients were randomized into two groups: DPRF (n=10) and PPRF (n=10). Patients were clinically followed up for 1 year and pain intensity was assessed at 3, 6, 9, and 12 months after the procedure using the visual analog scale (VAS). Results The percentages of patients with satisfactory pain relief (50–80% pain relief) were 30% at 3 months, 40% at 6 months, and 40% at 12 months in DPRF group. However, in PPRF group, the percentages of patients who showed excellent pain relief (≥80% pain relief) at 3, 6, and 12 months were 50, 50, and 40%, respectively, whereas the percentages of patients with satisfactory pain relief (50–80% pain relief) at 3, 6, and 12 months were 40, 30, and 60%, respectively. Comparing the VAS score at 1, 3, 6, and 12 months did not show any significant difference between the two groups. In both groups, there was a significant decrease in VAS score after 1, 3, 6, 9, and 12 months compared with the preprocedure score (P Conclusion PRF treatment is a safe, effective, well-controlled procedure for the treatment of TN. There was no significant difference between DPRF and PPRF procedures. DPRF is a simple, safe, and effective procedure before the attempt to do the intracranial procedure.

Assessing the motivational effects of ethanol in mice using a discrete-trial current-intensity intracranial self-stimulation procedure

BackgroundAlcohol (ethanol) produces both rewarding and aversive effects, and sensitivity to these effects is associated with risk for an alcohol use disorder (AUD). Measurement of these motivational effects in animal models is an important but challenging aspect of preclinical research into the neurobiology of AUD. Here, we evaluated whether a discrete-trial current-intensity intracranial self-stimulation (ICSS) procedure can be used to assess both reward-enhancing and aversive responses to ethanol in mice. MethodsMale and female C57BL/6J mice were surgically implanted with bipolar stimulating electrodes targeting the medial forebrain bundle and trained on a discrete-trial current-intensity ICSS procedure. Mice were tested for changes in response thresholds after various doses of ethanol (0.5 g/kg-1.75 g/kg; n = 5–7 per dose), using a Latin square design. ResultsA 1 g/kg dose of ethanol produced a significant reward-enhancement (i.e., lowered response thresholds), whereas a 1.75 g/kg dose produced an aversive effect (elevated response thresholds). Ethanol doses from 1 to 1.75 g/kg increased response latencies as compared to saline treatment. ConclusionsThe discrete-trial current-intensity ICSS procedure is an effective assay for measuring both reward-enhancing responses to ethanol as well as aversive responses in the same animal. This should prove to be a useful tool for assessing the effects of experimental manipulations on the motivational effects of ethanol in mice.

In Hospital Outcome of CEA And CAS in the German National Carotid Registry 2014-2015

Introduction - The German National Quality Assurance Registry includes the datasets of all procedures (CEA and CAS) performed in German hospitals. The in-hospital outcome is reported by a questionnaire and finally evaluated and monitored by a federal institution (IQTIG) with the assistance of a clinical advisory board. It is the aim of this presentation to report the outcome of CEA vs. CAS as well as of simultaneous procedures combined with cardiac surgery or intracranial endovascular procedures. Methods - Data were collected at discharge on a electronic basis and primarily transferred to local state agencies (n=11) for plausibility check and monitoring. The data sets from 11 agencies were then anonymously compiled and evaluated by a federal institute (IQTIG). The quality of the registry is checked on a yearly basis by random sample analysis of individual charts. Data collection is linked to reimbursement of the procedure. The reports from 2014 and 2015 include the data sets from n= 64.868patients. 12.156 CAS (18,7%) and n=52.712 CEA (81,3%) were performed. 2,3% of CEA and 8,4% of the CAS procedures were special indications, including interventions prior to intracranial interventional procedures or other indications. Emergency procedures were included in the registry (7,44% CEA, 16,98% CAS). Results - 654[KM1] hospitals performed CEA and/or CAS in 2014 and with 648 in 2015). 282 (2015) / 297 (2014)hospitals reported <20 cases CEAs[KM2] per year (51,9% (2015) / 53,1% (2014)). 293 (2015) /280 (2014) hospitals reported < 20 CAS procedures 87,2% (2015) / 85,9% (2014)) The rates of preoperative neurological examination was 68,6% ( CEA) and 79,3% ( CAS, the postoperative rates were 58,2% (CEA) and 71,7% ( CAS). The results for stroke and death were below the AHA limit of 3% for asymptomatic carotid stenosis in both groups, with stroke/death rates of 1.76[KM3] % (2014) and 1.58% (2015) for CAS and 1.12% resp. 1.45% for CEA. In the case of contralateral stenosis the results were: 1.40% resp. 2.77% for CAS and 2.64% resp. 1.61% for CEA. In symptomatic stenosis, stroke/death rates for CAS were 3,5% (2014) and 3.91% (2015). CEA resulted in stroke/death rates of 2.35% resp.2.55%. The ratio observed/expected for severe stroke and death rose from 1.00 to 1.41 in the case of CAS, with values for 1.0 and 1.03 for CEA (2014 vs. 2015). Conclusion - The percentage of CAS (18% ) in the population did not change in the last two years. Both methods resulted in acceptable results for treatment of asymptomatic stenosis on a national scale. Risk adjustement was done to make individual hospitals comparable. There were differences in indications: CAS was more often used in acute stroke and in combination with intracranial procedures. CEA was also performed in combination with ACBG; the results of simultaneous ACBG and CEA were poor and reached unacceptable high stroke/death rates. The interpretation of these registry data is somewhat limited due to missing follow-up data as well as due to the fact the the data sets were pooled, and therefore a detailed statistical comparison was not possible.

German Carotid National Registry – Value and Limitations

Introduction: The mandatory data collection for extracranial carotid desobliteration (CEA/CAS) was introduced over 10 years ago in Germany. The mandatory data collection for carotid desobliteration (CEA) has been introduced over 10 years ago. Available cumulative data sets are available in the period 2009-2014 (AQUA). After that time period, data were reported by the IQTIG Federal Insitute (2015-2018). CAS recording was begun in 2012. The yearly number of recorded cases exceeds 32.000 cases per year, reported by > 600 hospitals. The completeness of data sets is >98,5% Cumulative data sets were available for secondary evaluation in the period 2009-2014 (AQUA). After that time period, date were reported by the IQTIG Federal Insitute (2015-2018). CAS procedures were collected since 2012. The yearly number of recorded cases exceeds 32.000 cases per year, reported by > 600 hospitals. The completeness of data sets is >98,5% Methods: The yearly data sets were collected by 11 local authorities and evaluated by a central federal government autority (IQTIG). 16 quality indicators are used, 4 of which are used to initiated a structured dialoge. A rate of observed to expected ( O:E) is calculated for risk adjustement. The data of 2017 are reported ( 2018 will be available at the time of presentation). Results: n=33597 procedures were recorded, among those n=25.740 CEA and n= 6747 CAS.Conversion from CAS to CEA was reported in n=24 cases. in n=1086 procedures, CAS was performed to gain access for an intracranial procedures. In CEA,41,8% of patients were at the age of 70-79 years, and 17,8% over 80 years of age. Female patients were treated in 32,48% of cases. In Case the rates were 37,1% resp. 14.28%, female patients in 31.7%. For CEA, ,the O/E ratio for stroke and death rates in symptomtic stenoses were 1,10 for S/D, and 1.17 for major S/D. in CAS the rates were 1.00 resp.1.05. Only 3% of the 663 hospitals were considered to have a quality problem, which needed to be corrected. Secondary data analysis of the years 2009-2014 showed no differences in outcome for gender, but increasing complications rates with higher age in both CEA and CAS. The use of preopertative/preinterventional thrombocyte inhibition was of advantage and resulted in lower stroke rates. Time of surgery after an index event was not a significant factor for outcome. Conclusion: This registry is limited due to the lack of follow-up data after hospital discharge. However, it is the largest national registry with 99,5% complete data sets reflecting a real-world setting. CEA and CAS cannot be directly compared due to cumulated data analysis. However, in the CAS group, more stroke patients and combined procedures were recorded, which was considered in the risk adjustment. Further data analysis of the registry combined with routine data sets from hospital data will improve the safety of CEA/CAS and help to identify risk factors other than those known from RCT's. Disclosure: Nothing to disclose

The using of endoscopic technology in transcranial neurosurgery of tumors chiasmosellar region and arterial anterior ring aneurysm

Objective – to study the experience and technical possibilities of the optimal using of the endoscopic assistance during different stages of intracranial surgical procedures in patients with chiasmal–sellar tumors (CST) and arterial aneurysms (AA) of the anterior circulation (AC).Materials and methods. The results of initial series of 59 patients with CST and 14 patients with AA of the AC who were operated at Romodanov Neurosurgery Institute NAMS of Ukraine between 2012 to August 2017, with the using of endoscopic assistance at the different stages of procedure were analyzed. There were used following methods: clinical and neurological exams, laboratory measurements, instrumental evaluation, neuroimaging (brain Computer Tomography (CT), CT Angiography, brain Magnetic Resonance Imaging (MRA), Magnetic Resonance Angiography (MRA), Digital Subtraction Angiography (DSA) of cerebral vessels), functional (Doppler Ultrasound (DU) of the head and neck vessels), morphological evaluation, electroencephalography, statistical analysis.Results. The choice of surgical tactics and approach for CST was performed considering the localization and expansion of CST on the seller region (ante, retro, para, endosellar) and three-dimensional virtual and material modeling. According to the histological type, distribution of CST was follow: tuberculum and diaphragm sellar meningioma – 22 (37.2%) cases, craniopharyngioma – 15 (25.5%), pituitary adenomas – 14 (23.8%), epidermoid and dermoid cysts – 5 (8.5%), optic nerve gliomas – 3 (5.1%). Craniotomy approaches was follow: supraorbital – in 25 (42.4%) patients, pterional – in 18 (30.5%), modified orbitozygomatic- in 16 (27.1%). In 48 (81.3%) cases, initial removal was done, and in 11 (18.7 %) – repeated surgical interventions (regrowth and residual growth of the pituitary adenoma – 7 (63.6%) cases, craniopharyngioma – 4 (36.4%). Microscopic tumor removal were considered as radical in 46 among 56 patients (82.1%). Postoperative mortality was 2.49% (1 patient). The new onset of diabetes insipidus occurred in 3 (5.1%) observations, transient functional disorders, including cosmetic – in 38 (64.4%). Thirty-two (54.3%) patients showed an improvement of visual function (expansion of vision fields, regression of scotomas and / or increased of visual acuity according to Kadasheva scale assessment). Patients with AA of the AC underwent microsurgical procedure under endoscopic assistance and measuring the depth of the wound and the angles of the surgical field during pterional approach – in 9 (64.3%), orbitozygomatic – in 1 (7.1%), pterional with anterior clinoidectomy – in 2 (14.3%), infratemporal – in 2 (14.3%) cases.The evaluation of results included an assessment of AA clipping: Simple clip – 6 (42.9%), Multiple clips – 8 (57.1%). Following intraoperative complication was seen – AA rupture in 1 (7.1%) case, and secondary postoperative ischemic complication in 1 (7.1%) case. The grade of AA exclusion from the blood flow after clipping was done according to Raymond scale: class I – 13 (92.9%) cases, class II – 1 (7.1%). The quality of life of the surgical treated patients was evaluated using Extended Glasgow Outcome Scale. Full and good recovery was observed in 6 (42.9%) patients, mild dependence in 4 (28.6%), moderate dependence in 4 (28.6%).Conclusions. Endoscopic assistant should be used during tumor inspection, its dissection and for control of radical removal considering the size of the bone window, parameters of surgical approach and quality of microscopic visualization. Extreme importance has the utilization of endoscopic assistance for controlling of tumor removal, since its remaining may be inaccessible for microscopic examination, which is situated in «blind» spots. Endoscopic assistance during different stages of clipping of AA of the AC is accessory technique that improves intraoperative visualization during separation of the affected aneurysmal arterial segment of the AC, determining the anatomical location of the perforating arteries, AA neck regions, assessment of the clip / clips position on the AA neck or AA body without additional traction on the wound margins, and for inaccessible regions for microscope examination.

Delayed heamatoma after melanoma metastasis resection upon restart of Immunotherapy: Case Report and Review of the Literature

Abstract Background Supratentorial Metastatic Melanomas are common and increasingly treated with immunotherapy. While improving the outcome, the immunotherapy potentially increases the risks of the intracranial surgical procedures, particularly bleeding. However, scarce reports address this complications. Case Description A 52-year old male with a history of right upper limb excised skin lesion resected with wide local excision 6 months prior to admission, who presented with a three weeks history of progressive headaches, vomiting, odd behaviours, forgetfulness, and left lower sided weakness. Brain imaging showed a right frontal lesion with evidence of haemorrhage within it with midline shift and mass effect. He underwent craniotomy and resection of the lesion with no post-operative complication, resolution of left sided hemiparesis and post-operative imaging documenting complete resection and no post-operative complications. The histopathology confirmed metastatic melanoma and he received adjuvant immunotherapy (Nivolumab), however he represented 4 weeks post operatively with sudden onset headache with vomiting with no neurological deficit, brain imaging showed a delayed hematoma in the surgical site. Conclusions This case report highlights the risk of post-operative bleeding with the immunotherapy and paves the way for further studies with regards to the safety of immunotherapy after intracranial procedures