AIM: To examine the outcomes of microsurgery only versus combined microsurgery and embolization in treating cerebral arteriovenous malformations (AVM). MATERIAL and METHODS: A total of 62 patients (34 male and 28 female) with Spetzler-Martin grade 3 (n=44) and grade 4 (n=18) AVMs were examined. Thirty-seven patients were treated with a combination of microsurgery + embolization, whereas 25 patients were treated with microsurgery alone. The clinical characteristics of the treatment groups were compared (ruptured/unruptured, eloquent/non-eloquent, modified Rankin scores, duration of surgery, preoperative and postoperative hemoglobin levels, and use of blood products). RESULTS: The number of patients with ruptured or eloquently localized AVMs was more in combination of microsurgery + embolization. On the other hand, the duration, preoperative versus postoperative hemoglobin levels, and usage of blood products did not differ between treatment groups. CONCLUSION: The results of the study showed no superiority of the combined treatment in managing AVMs in parallel to recent meta-analyses. However, a patient-tailored approach is recommended while making the treatment decision for such challenging intracerebral AVM cases.

AIM: To present our experience of 225 clipped aneurysms in 196 patients to compare indocyanine green video angiography (ICG-VA), micro-Doppler ultrasonography (MDUSG), and postoperative digital subtraction angiography (DSA) in terms of determining aneurysm obliteration, neck remnants, and parent artery patency. MATERIAL and METHODS: This retrospective study included 196 patients (108 female and 88 male patients) treated between 2013 and 2016. In all cases, aneurysm neck remnants and vessel patency were assessed using ICG-VA and 16-Hz MDUSG. DSA was performed in every case postoperatively within the first 5 days. RESULTS: The mean patient age was 55.8 years (range, 31-80 years), and the mean follow-up duration was 25 months (range, 2-48 months). Of the 225 clipped aneurysms, 86 were located in the anterior cerebral artery and its branches, 103 in the bifurcation of the middle cerebral artery (MCA) and the branches of the MCA, 34 in the internal cerebral artery and its branches, 1 in the posterior inferior cerebellar artery, and 1 at the basilar apex. We observed 2 neck remnants (0.8%), 2 parent/perforating artery occlusions (0.8%), and 2 residual aneurysm fillings (0.8%). There were no striking differences among the assessed methods. CONCLUSION: ICG-VA, MDUSG, and dome puncturing are all useful techniques in aneurysm surgery for assessing complete obliteration of the aneurysm. In our experience, all the 3 tools are complementary to each other, and none of them is superior to the others. We recommend the use of all 3 tools to obtain a favorable outcome.

Internal carotid artery (ICA) injury is a catastrophic complication of endoscopic endonasal surgery (EES). However, its standard management, emergent endovascular treatment, may not always be available, and the transnasal approach may be insufficient to achieve hemostasis.A 44-year-old woman with pituitary adenoma underwent EES complicated with the ICA cavernous segment injury (CSI). In urgent intraoperative angiogram, a good collateral flow from the contralateral carotid circulation was observed. Due to the unavailability of intraoperative embolization, emergent surgical trapping was performed by combined transcranial and cervical approach. The patient recovered but later developed a giant cavernous pseudoaneurysm. During the pseudoaneurysm embolization, ICA was directly accessed via a 1.7-F puncture hole using a bare microcatheter technique. Then, both the aneurysm and parent artery were obliterated with coils. At the 4-year follow-up, the patient was asymptomatic without a residual tumor. To our knowledge, this is the first case of ICA–CSI during EES successfully treated with ICA trapping as a lifesaving urgent surgery that achieved a complete recovery after a pseudoaneurysm embolization. Although several studies reported that EES-related ICA–CSIs with percutaneous carotid artery access, neither our surgical salvage technique nor our carotid access and tract embolization techniques were previously described.

In this case series, we aimed to report our clinical experience with hybrid positron emission tomography (PET) and magnetic resonance imaging (MRI) navigation in the management of recurrent glial brain tumors. Consecutive recurrent neuroglial brain tumor patients who underwent PET/MRI at preoperative or intraoperative periods were included, whereas patients with non-glial intracranial tumors including metastasis, lymphoma and meningioma were excluded from the study. A total of eight patients (mean age 50.1 ± 11.0 years) with suspicion of recurrent glioma tumor were evaluated. Gross total tumor resection of the PET/MRI-positive area was achieved in seven patients, whereas one patient was diagnosed with radiation necrosis, and surgery was avoided. All patients survived at 1-year follow-up. Five (71.4%) of the recurrent patients remained free of recurrence for the entire follow-up period. Two patients with glioblastoma had tumor recurrence at the postoperative sixth and eighth months. According to our results, hybrid PET/MRI provides reliable and accurate information to distinguish recurrent glial tumor from radiation necrosis. With the help of this differential diagnosis, hybrid imaging may provide the gross total resection of recurrent tumors without harming eloquent brain areas.