Safety and efficacy of posterior approach for resection of spinal meningioma:Impact of dural attachment location

BACKGROUND Spinal meningiomas(SMs)are common benign tumors that are typically treated with surgical resection.The choice of surgical approach may vary depending on the location of dural attachment of the SM,with a posterior approach being the traditional preference.However,there is limited research available on the impact of dural attachment location on outcomes following posterior approach for SM resection.The average age of the included 34 patients’(10 males and 24 females)age was 62.09 years.Mean follow-up duration was 22.65 months.The location of SM was the thoracic spine in 32 cases,with only 2 in the cervical spine.On average,intraoperative blood loss was 520.59 mL,and operating time was 176.76 minutes.Thirty three cases had successful outcomes while only 1 experienced an unexpe-cted outcome.The tumor recurrence rate was 2.9%.After surgery,there were 3 cases of cerebral spinal fluid leakage,1 case of pneumonia,and 1 case of urinary tract infection.Dural attachments were predominantly found dorsal or dorso-lateral(13 cases),followed by ventral or ventrolateral(14 cases),and lateral(7 cases).The outcomes among these subgroups were similar.CONCLUSION The posterior approach for SM resection is safe and effective,yielding comparable surgical and neurological outcomes regardless of the dural attachment location.

Ruptured venous aneurysm associated with a dural arteriovenous fistula:Two case reports

BACKGROUND In general,venous aneurysm associated with dural arteriovenous fistula(dAVF)is considered to be developed under long standing venous hypertension and manifested as venous ectasia of draining vein itself.However,discrete saccular shaped venous aneurysm without angiographic evidence of venous hypertension arising from the draining vein,like cerebral arterial aneurysm,is quite rare and its pathomechanism remains unclear in patients with dAVF.CASE SUMMARY In this report,we present two cases of ruptured saccular venous aneurysms associated with dAVF without venous hypertension or venous ectasia.In both cases,significant curve or stenosis is observed in draining vein,which is located in just distal portion of the venous aneurysms.These aneurysms were successfully treated with a transarterial embolization.Underlying mechanism of venous aneurysms in these cases is discussed.CONCLUSION Although there is little doubt that hemodynamic stress has a critical role in the development of venous aneurysms in patients with dAVF,preceding venous hypertension or venous ectasia is not necessary for development and enlargement of venous aneurysms.Considering the significant risk of rupture,a careful review of draining vein features including tortuosity or stenosis is needed,especially in venous aneurysms without evidence of venous hypertension.

Intradural Metastases 硬脑膜转移瘤

Key Facts In adults, intradural <<extradural spinal metastases(Leptomeningeal>> cord metastases).In children, intradural> extradural metastases.Classic imaging appearance="carcinomatous meningitis"can be caused by spread from intracranial neoplasm ("drop mets") or non-CNS primary tumor.

A review on dural tail sign

"Dural tail sign" (DTS) which is a thickening of the dura adjacent to an intracranial pathology on contrast-enhanced T1 MR Images, was first thought to be pathognomonic of meningioma, however, many subsequent studies demonstrated this sign adjacent to various intra and extra-cranial pathologies and in spinal lesions. In this paper we outline the history, accompanying pathologies and the differentiation and probable pathophysiology of DTS. We also discuss whether we can predict tumoral involvement of the dural tail before surgery and whether the dural tail adjacent to a tumor should be resected.

Dural puncture epidural technique provides better anesthesia quality in repeat cesarean delivery than epidural technique:Randomized controlled study

BACKGROUND Repeat cesarean deliverys involve a longer surgery and more severe visceral traction than primary cesarean deliverys.The dural puncture epidural(DPE)technique provides faster and more effective analgesia for labor,but there is no sufficient evidence to indicate whether it is suitable for parturients undergoing repeat cesarean delivery.AIM To determine the efficacy and safety of the DPE anesthesia technique in patients undergoing repeat cesarean delivery.METHODS Patients undergoing repeat cesarean delivery were randomly divided into the DPE and epidural anesthesia(EA)groups.A 25-G spinal needle was used for dural puncture via a 19-G epidural needle.The patients in the two groups were injected with 5 mL of 2%lidocaine followed by 15 mL of a mixture of 1%lidocaine+0.5%ropivacaine as the epidural dosage.The primary outcome was the onset time of sensory block to the T6 dermatome level and the sensory and motor block degree.RESULTS A total of 115 women were included(EA:57,DPE:58).The mean time to sensory block to the T6 Level was significantly shorter in the DPE group than in the EA group(14.7 min vs 16.6 min;95%confidence interval,13.9 to 15.4 vs 15.8 to 17.4;P=0.001).The cranial sensory block level was significantly higher at 5,10,and 15 min after the initial dose in the DPE group than in the EA group(P<0.05).The sacral sensory block level was significantly higher and the modified bromage score was significantly lower in the DPE group at each time point(P<0.05).Adverse effects and neonatal outcomes were comparable between the two groups(P>0.05).CONCLUSION The DPE technique provided higher-quality anesthesia than the EA technique,with a rapid onset of surgical anesthesia,better cranial and sacral sensory block spread and a higher motor block degree,without increasing the incidence of maternal or fetal side effects in patients undergoing repeat cesarean delivery.

Application of hybrid operating rooms for treating spinal dural arteriovenous fistula

BACKGROUND A hybrid operating room(hybrid-OR)is a surgical space that combines a conventional operating room with advanced medical imaging devices.AIM To explore and summarize the technical features and effectiveness of the application of a hybrid-OR in dealing with spinal dural arteriovenous fistulas(SDAVFs).METHODS Eleven patients with SDAVFs were treated with the use of a hybrid-OR at the Department of Neurosurgery of our hospital between January 2015 and December 2018.The dual-marker localization technique was used in the hybrid-OR to locate the SDAVFs and skin incision,and the interoperative digital subtraction angiography(DSA)technique was used before and after microsurgical ligation of the fistulae in the hybrid-OR to verify the accuracy of obliteration.The patients were followed for an average of 2 years after the operation,and the preoperative American Spinal Cord Injury Association(ASIA)score and postoperative ASIA score at 6 mo after the operation were compared.RESULTS The location and skin incision of the SDAVFs were accurately obtained by using the dual-marker localization technique in the hybrid-OR in all patients,and there were no cases that required expansion of the range of the bone window in order to expose the lesions.Intraoperative error obliteration occurred and was identified in two patients by using the intraoperative DSA technique;therefore,the findings provided by the intraoperative DSA system significantly changed the surgical procedure in these two patients.With the assistance of the hybrid-OR,the feeding artery was correctly ligated in all cases,and the intraoperative error obliteration rate decreased from 18.2%(2/11)to 0%.All 11 patients were followed for an average of 2 years.The ASIA score at 6 mo after the operation was significantly improved compared with the preoperative ASIA score,and there were no patients with late recurrence during the follow-up.CONCLUSION Compared with intra-arterial embolization for the treatment of SDAVFs,hybrid-ORs can solve the problem of a higher incidence of initial failure and late recurrence.Compared with direct occlusion of SDAVFs in microsurgery,hybrid-ORs can take advantage of the intraoperative DSA system for locating the shunt and verifying the obliteration of fistulae in order to reduce the error obliteration rate.At this point,our experience suggests that the safety and ease of use make hybrid-ORs combined with microsurgery and intraoperative DSA systems an attractive modality for dealing with SDAVFs.

Tentorial dural arteriovenous fistula presenting as myelopathy: Case series and review of literature

Dural arteriovenous fistula(DAVF) is a rare type of cerebral arteriovenous malformation. Common presenting symptoms are related to hemorrhage. However, rarely these patients may present with myelopathy. We present two cases of DAVF presenting as rapidly progressive myelopathy. Two treatment options are available: microsurgical interruption of the fistula and endovascular embolization. These treatment options of DAVFs have improved significantly in the last decade. The optimal treatment of DAVFs remains controversial, and there is an ongoing debate as to whether primary endovascular or primary microsurgical treatment is the optimal management for these lesions. However, despite treatment a high percentage of patients are still left with severe disability. The potential for functional ambulation in patients with DAVF is related to the time of intervention. This emphasizes the important of early diagnosis and early intervention in DAVF. The eventual outcome may depend on several factors, such as the duration of symptoms, the degree of disability before treatment, and the success of the initial procedure to close the fistula. The usage of magnetic resonance imaging and selective angiography has significantly improved the ability to characterize DAVFs, however, these lesions remain inefficiently diagnosed. If intervention is delayed even prolonged time in rehabilitation does not change the grave prognosis. This review outlines the presentation, classication and management of DAVF as well as discussing patient outcomes.

Treatment of cavernous sinus dural arteriovenous fistula using different surgical approaches:Analysis of 32 consecutive cases

Objective:Transarterial and transvenous embolization methods are considered effective and safe approaches for the treatment of cavernous sinus dural arteriovenous fistula(CSDAVF).Here.,we report the angioarchitectural features and clinical outcomes of CSDAVF in patients treated with either the inferior arterial approach(IAA) or the inferior petrosal sinus approach(IPSA).Methods:The clinical data of 32 patients with CSDAVF treated at our institution from May 2008 to May 2014 were retrospectively analyzed.All patients underwent routine diagnostic digital subtraction angiography(DSA) before surgery.Embolization was performed using the IPSA through the internal jugular vein or IAA,based on angioarchitectural features.Results:Of the 32 patients with CSDAVF,24 underwent embolization treatment through the internal jugular veinIPSA and 8 patients underwent treatment through IAA.Nineteen patients in the IPSA group experienced mild headache,which improved after specific treatment.The immediate postembolization angiographic results revealed complete occlusion in 26 cases(18 IPSA and 8 IAA) and almost complete occlusion in 6 cases(IPSA).Complications that occurred during the procedure included abducens nerve palsy(n=1,IPSA) and prosopoplegia(n=1,IAA).One patient developed tinnitus,which was diagnosed as anterior cranial fossa new-onset dural arteriovenous fistula on DSA,whereas the symptoms of other patients all improved with no recurrence.Conclusions:On the basis of the angioarchitectural features of CSDAVF,IAA can be considered the primary treatment when the blood-supplying artery and fistula are relatively singular,and when the microcatheter can easily reach the fistula through the artery.The venous approach should be selected as the primary approach when the fistula is indistinguishable and blood is supplied by multiple arteries through small plexiform vessels.Choosing the optimal surgical approach may increase the success rate of intravascular CSDAVF surgery and may help avoid complications.

Esophageal squamous cell carcinoma with dural and bone marrow metastases

Patients with esophageal squamous cell carcinoma generally present at an advanced stage at the time of diagnosis.The most common sites of visceral metastasis are the lung,liver and bone,but brain and bone marrow involvement is exceedingly rare.Herein,we report a 62-year-old man with a 4-wk history of progressive low back pain with radiation to bilateral lower legs,dysphagia and body weight loss.Esophageal squamous cell carcinoma with regional lymph node,liver and bone metastases was diagnosed.He underwent concurrent chemoradiotherapy and got a partial response.Four months later,he complained of headache,diplopia and severe hearing impairment in the left ear.There was no evidence for bacterial,fungal,tuberculous infection or neoplastic infiltration.Magnetic resonance imaging of the brain demonstrated thickening and enhancement of bilateral pachymeninges and multiple enhancing masses in bilateral skull.Dural metastasis was diagnosed and he received whole brain irradiation.In addition,laboratory examination revealed severe thrombocytopenia and leucopenia,and bone marrow study confirmed the diagnosis of metastatic squamous cell carcinoma.This is the first described case of esophageal squamous cell carcinoma with dural and bone marrow metastases.We also discuss the pathogenesis of unusual metastatic diseases and differential diagnosis of pachymeningeal thickening.

Overview of multimodal MRI of intracranial Dural arteriovenous fistulas

Dural arteriovenous fistulas(DAVFs)include a wide range of pathological conditions that are associated with intracranial vessel abnormalities.While some types of DAVFs present with typical neuroimaging characteristics,others share overlapping pathological and neuroimaging features that can hinder accurate differentiation.Hence,misclassification of the various types of DAVFs is common.Thorough knowledge of DAVF imaging findings is essential to avoid such misinterpretations.Traditional digital subtraction angiography(DSA)is considered the gold standard for diagnosing and evaluating DAVFs.However,angiography cannot detect changes in a patient’s brain structure.Conventional magnetic resonance imaging(MRI)sequences,including MR angiography(MRA),allow the evaluation of DAVFs without ionizing radiation or invasiveness.Advanced MRI techniques,such as susceptibility-weighted imaging(SWI)and dynamic contrast-enhanced MRA,provide added value to real-time physio-pathological data regarding the hemodynamics of DAVFs.Beyond these techniques,new insights using high-resolution vascular wall MRI are incorporated for the noninvasive evaluation of DAVFs.This article reviews the pathophysiology of DAVFs,focusing on the specifics of MRI findings that facilitate their classification.The role of conventional and advanced MRI sequences for DAVFs was assessed using insights derived from the data provided by structured reports of multimodal MRIs to evaluate DAVFs.

Establishment of an animal model of dural venous sinus embolism

BACKGROUND： The pathological mechanism of secondary brain lesion following an embolism remains unclear. The establishment of an animal model that imitates the clinical pathophysiological processes is crucial to better study this disease during a certain time window. OBJECTIVE： To establish a new animal model of dural venous sinus embolism that is simple, has a high success rate, and emulates the pathophysiological course of clinical disease. DESIGN, TIME AND SETTING： A randomized block design trial was performed at the Department of Anatomy, Ningxia Medical College between March and December 2007. MATERIALS： Fifty-eight healthy, adult, Sprague Dawley rats were used in the present study. Plastic emboli, with a total length of 0.4 cm, were self-made. Each plastic embolus had a conical anterior segment; the largest diameter being 0.12 cm. The posterior segment became gradually thin and flat, with a width of 0.2 cm and length of 0.1 cm. METHODS： The fifty-eight rats were randomly divided into three groups： control （n = 6）, embolism （n = 26）, and sham-embolism （n = 26） groups. In the embolism group, a solid embolus was slowly inserted and fixed into the posterior part of the superior sagittal sinus against the flow of blood. The posterior segment was detained outside the superior sagittal sinus for fixing. In the sham-embolism group, rats were subjected only to sinus sagittalis superior exposure. In the control group, rats received no treatments. In both the embolism and the sham-embolism groups, the rat brains were resected at 6 hours, 1, 3, and 5 days post-surgery. MAIN OUTCOME MEASURES： （1） Brain surface appearance in the embolism and sham-embolism groups. （2） Thrombosis in the embolism group. （3） Cerebrospinal fluid content in the above-mentioned two groups. RESULTS： In the embolism group, the model success rate was 92% （24/26）. There was visible thrombosis in the superior sagittal sinus. Cerebral edema was noticeable under a microscope. These changes were visible at 6 hours after embolism and were most obvious at 1 day after surgery. In the embolism group, cerebrospinal fluid content reached a peak level at 6 hours post-surgery and was significantly increased compared with the sham-embolism and the control groups （P 〈 0.05）. At 1 day post-surgery, the amount of cerebrospinal fluid was still greater in the embolism group compared to the control group （P 〈 0.05） CONCLUSION： The method of inserting a solid embolus has many benefits, such as being able to directly observe, short cycle time, and minimal wound. The detained posterior segment prevents movement and perfusion of embolus, which results in a high success rate.

Clinical management of dural defects:A review

Dural defects are common in spinal and cranial neurosurgery.A series of complications,such as cerebrospinal fluid leakage,occur after rupture of the dura.Therefore,treatment strategies are necessary to reduce or avoid complications.This review comprehensively summarizes the common causes,risk factors,clinical complications,and repair methods of dural defects.The latest research progress on dural repair methods and materials is summarized,including direct sutures,grafts,biomaterials,non-biomaterial materials,and composites formed by different materials.The characteristics and efficacy of these dural substitutes are reviewed,and these materials and methods are systematically evaluated.Finally,the best methods for dural repair and the challenges and future prospects of new dural repair materials are discussed.

Acute Epidural Hematoma Compressing the Dominant Sigmoid Sinus as an Unusual Cause of Intracranial Hypertension: Case Report and Review of Literature

Post traumatic dural sinus vein stenosis has been rarely described in pediatric population. We present a case of a 9-year-old child that had sustained a head injury after a fall from height causing an acute epidural hematoma compressing the dominant sigmoid sinus. The patient had developed sub acutely signs and symptoms of increased intracranial pressure. Prophylactic treatment with anticoagulants was initiated despite the presence of an intracranial bleeding. Clinical and radiological improvements were achieved. We had also reviewed the literature regarding this uncommon entity and discussed other existing diagnostic and therapeutic alternatives. Further gathering of information is essential in order to form a therapeutic protocol.

Epidural analgesia followed by epidural hydroxyethyl starch prevented post-dural puncture headache:Twenty case reports and a review of the literature

BACKGROUND Accidental dural puncture(ADP)and subsequent post-dural puncture headache(PDPH)remain common complications of epidural procedures for obstetric anesthesia and analgesia.No clear consensus exists on the best way to prevent PDPH after ADP.CASE SUMMARY We report our findings in twenty parturients who underwent an incorporated strategy of epidural analgesia followed by epidural hydroxyethyl starch(HES)to prevent PDPH after ADP with a 16-gauge Tuohy needle during epidural procedures.ADP with a 16-gauge Tuohy needle occurred in nine parturients undergoing a cesarean section(CS)and in eleven parturients receiving labor analgesia.An epidural catheter was re-sited at the same or adjacent intervertebral space in all patients.After CS,the epidural catheter was used for postoperative pain relief over a 48-h period.After delivery in eleven cases,epidural infusion was maintained for 24 h.Thereafter,15 mL of 6%HES 130/0.4 was administered via the epidural catheter immediately prior to catheter removal.None of the parturients developed PDPH or neurologic deficits over a follow-up period of at least two months to up to one year postpartum.CONCLUSION An incorporated strategy of epidural analgesia followed by epidural hydroxyethyl starch may have great efficacy in preventing PDPH after ADP.

Standardizing Management of Post-Dural Puncture Headache in Obstetric Patients: A Literature Review

Post-dural puncture headache continues to be a significant cause of morbidity in parturients. Despite being a common complication faced by many anesthesiologists, there is a lack of consensus regarding its management. Many still use traditionally taught treatments such as strict bed rest and aggressive hydration despite lack of evidence for their usage. Few are using newly tested treatments such as gabapentin and ACTH despite being proven effective in randomized controlled trials. Furthermore, when and how the epidural blood patch should be used is contentious between different practitioners. This review aims at answering what is the best strategy to manage post-dural puncture headache and proposes an evidence-based practice guideline.

A Novel Combined Approach for Metastatic Breast Cancer with Dural and Leptomeningeal Disease with an Impressive Clinical Outcome: A Case Study

Concurrent dural and leptomeningeal metastatic carcinomatosis are very rare and have a poor prognosis. Here we present a woman with advanced estrogen receptor (ER) positive and progesterone receptor (PR) positive breast cancer who presented with leptomeningeal disease. Patient underwent multi targeted epigenetic therapies applied in a protocol called MTET. She continued to respond to the interval treatment, which consisted only of the nutraceutical agents. Here we discuss her case in detail and we believe that such an example might be applied to other patients in this situation resulting clinical improvement and less toxicity.

Post traumatic dural sinus thrombosis following epidural hematoma: Literature review and case report

Dural sinus thrombosis following a head trauma is a rare condition,described in literature along with the lack of consensus regarding diagnosis and management.We present a case of a fifty-year-old man with a head injury and combined supratentorial-subtentorial epidural hematoma who was treated conservatively through the administration of low molecular weight heparin.The diagnosis and management of this condition are discussed based on a literature review.The early diagnosis may prevent potentially treatable poor outcomes.

Dural lesions mimicking meningiomas:A pictorial essay

The purpose of this essay was to illustrate the radiological and pathological findings in a wide spectrum of dural lesions mimicking meningiomas.Familiarity with and knowledge of these findings will narrow the differential diagnosis and provide guidance for patient management.In this pictorial review,we describe the following entities:Solitary fibrous tumors,hemangiopericytoma,gliosarcoma,leiomyosarcoma,dural metastases,Hodgkin’s disease,plasmocytoma,Rosai-Dorfman disease,neurosarcoidosis,melanocytic neoplasms and plasma cell granuloma.

Late presentation of dural tears:Two case reports and review of literature

BACKGROUND The late presentation of dural tears(LPDT)has a low incidence rate and hidden symptoms and is easily ignored in clinical practice.If the disease is not treated in time,a series of complications may occur,including low intracranial pressure headache,infection,pseudodural cyst formation,and sinus formation.Here,we describe two cases of LPDT.CASE SUMMARY Two patients had sudden fever 1 wk after lumbar surgery.Physical examination showed obvious tenderness in the operation area.The patients were confirmed as having LPDT by lumbar magnetic resonance imaging and surgical exploration.One case was caused by continuous negative pressure suction and malnutrition,and the other was caused by decreased dural ductility and low postoperative nutritional status.The first symptom of both patients was fever,with occasional headache.Both patients underwent secondary surgery to treat the LPDT.Dural defects were observed and dural sealants were used to seal the dural defects,then drainage tubes were retained for drainage.After the operation,the patients were treated with antibiotics and the patients’surgical incisions healed well,without fever or incision tenderness.Both recovered and were discharged 1 wk after the operation.CONCLUSION LPDT is a rare complication of spinal surgery or neurosurgery that has hidden symptoms and can easily be overlooked.Since it may cause a series of complic-ations,LPDT needs to be actively addressed in clinical practice.

Transvenous embolization of dural arteriovenous fistula of cavernous region by multiple venous routes

Objective：To evaluate the safety and efficiency of transvenous embolization of dural arteriovenous fistula of cavernous region by multiple venous routes. Methods： Twenty seven patients with dural arteriovenous fistula of cavernous region were treated by transvenous embolization with micro-coils. The transvenous routes included inferior petrosal sinus, superior ophthalmic vein and facial vein. Results： Clinical cure was achieved in 23 cases and significant improvement of symptoms in 4 cases. Complete anglographic obliteration was documented in 22 patients （82%）. Residual shunting were left in 2 patients via pterygoid drainage and 1 case via inter-cavernous sinus, 2 cases via inferior petrosal sinus, disappeared one month later by manual compression carotid artery. Headache and vomiting were the most common symptoms after embolization. Three patients had diplopia and relieved within two months after embolization. There was no permanent procedure-related morbidity. The clinic follow up ranged from 5 months to 6 years, and there was not recurrence case. Conclusion： Transvenous embolization via different venous routes is a safe and efficient method for dural arteriovenous fistula of cavernous region treatment.