Introduction Pure arterial malformations (PAMs) are rare vascular abnormalities defined as dilated, tortuous arterial loops without any associated venous compartment. PAMs are thought to be benign developmental anomalies that can be safely managed conservatively. Methods We present a case of life-threatening hemorrhage in a patient with a PAM associated with two aneurysms and review the literature describing hemorrhages associated with PAMs. Results A 65-year-old female presented with subarachnoid and intraventricular hemorrhage. A digital subtraction angiography revealed a posterior inferior cerebellar artery PAM associated with two saccular aneurysms, which were subsequently microsurgically clipped. At the 1-year follow-up, the patient was neurologically intact. In our literature review, we identified 21 papers describing a total of 37 PAMs. Patients were predominantly female (64.9%) and their median age was 35 years. Almost half (48.6%) of PAMs were associated with aneurysms. In the group of PAMs that were not associated with an aneurysm, the intracranial hemorrhage rate was 15.8%, while in cases of coexisting PAM and aneurysm it was 44.4% (p = .0789). Conclusions PAM natural history remains unknown, particularly in cases of coexistence with aneurysms. Patients so affected require careful observation. The description of PAMs as benign vascular malformations should be revised. Surgical management of hemorrhagic PAMs coexisting with aneurysms is possible and should be considered.

IntroductionThe ongoing need for dural tenting sutures in a contemporary neurosurgical practice has been questioned in the literature for over two decades. In the past, these sutures were supposed to prevent blood collecting in the potential space between the skull and the dura by elevating the latter. Theoretically, with modern haemostasis and proper postoperative care, this technique should not be necessary and the surgery time can be shortened. Unfortunately, there is no evidence-based proof to either support or reject this hypothesis.Methods and analysisThe systematic review will be performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) statement and The Cochrane Handbook for Systematic Reviews of Interventions. Eight electronic databases of peer-reviewed journals will be searched, as well as other sources. Eligible articles will be assessed against inclusion criteria. The intervention is not tenting the dura and this will be compared with the usual dural tenting sutures. Where possible, ‘summary of findings’ tables will be generated.Ethics and disseminationEthical committee approval is not required for a systematic review protocol. Findings will be presented at international neurosurgical conferences and published in a peer-reviewed medical journal.PROSPERO registration numberCRD42018097089.

ObjectiveWe retrospectively evaluated the oncological and functional effectiveness of revision surgery for recurrent or remnant vestibular schwannoma (rVS).MethodsWe included 29 consecutive patients with unilateral hearing loss (16 women; mean age: 42.2 years) that underwent surgery for rVS. Previous surgeries included gross total resections (GTRs, n=11) or subtotal resections (n=18); mean times to recurrence were 9.45 and 4.15 years, respectively. House–Brackmann (HB) grading of facial nerve (FN) weakness (grades II-IV) indicated that 22 (75.9%) patients had deep, long-lasting FN paresis (HB grades: IV-VI). The mean recurrent tumor size was 23.3 mm (range: 6 to 51). Seven patients had neurofibromatosis type 2.ResultsAll patients received revision GTRs. Fourteen small- to medium-sized tumors located at the bottom of the internal acoustic canal required the translabyrinthine approach (TLA); 12 large and small tumors, predominantly in the cerebellopontine angle, required the retrosigmoid approach (RSA); and 2 required both TLA and RSA. One tumor that progressed to the petrous apex required the middle fossa approach. Fifteen patients underwent facial neurorrhaphy. Of these, 11 received hemihypoglossal–facial neurorrhaphies (HHFNs); nine with simultaneous revision surgery. In follow-up, 10 patients (34.48%) experienced persistent deep FN paresis (HB grades IV-VI). After HHFN, all patients improved from HB grade VI to III (n=10) or IV (n=1). No tumors recurred during follow-up (mean, 3.46 years).ConclusionsAggressive microsurgical rVS treatment combined with FN reconstruction provided durable oncological and neurological effects. Surgery was a reasonable alternative to radiosurgery, particularly in facial neurorrhaphy, where it provided a one-step treatment.

Background In 2011, a civil war started in Syria, which is on-going and has reached a death toll of over 400,000 people. Humanitarian organizations, including Aid to The Church in Need (ACN), have strived to provide help and medical support to the civilian victims. Methods We performed a retrospective analysis of data gathered in ACN projects in Syria in 2019. The datasets included descriptions of diseases, treatments, costs, cities, and hospitals. For each patient, we assigned the following additional categories: type of help (treatment, diagnosis, or nonmedical), type of treatment (medical or surgical), medical specialty, gross anatomic region, and presence of trauma. Results A total of 3835 patients benefited from ACN support in Syria in 2019. The majority of financial support went towards treatment (78.4%), while other support went towards nonmedical help (15.7%) or providing a diagnosis (5.9%). Among treatments, 66.6% were medical and 33.4% surgical. The most common medical specialty was internal medicine (48.4%), followed by public health (13.7%) and surgery (7.3%). Anatomic region was undefined in 68.3% of cases and, when defined, was most commonly the abdominal cavity and pelvis (13%). The vast majority of cases 95.1%) were not associated with trauma. Procedural costs were highest in the Valley of Christians region, and lowest in Tartous. Network graphs were used to visualize the three most common diagnoses and treatments for each medical specialty. Conclusions The present report describes the treatment of war victims in Syria in 2019. The patients lacked the most basic medical or surgical healthcare. Charity organizations, like ACN, constitute a valuable source of information about the healthcare of war victims. Unfortunately, the methods of describing medical treatment provided to civilian victims remain underdeveloped. Future studies will require the cooperation of healthcare providers, humanists, and social workers. The present findings can help to optimize the provision of humanitarian help by charity organizations, by tailoring projects to the specific needs of Syrian war victims.

Spinal dural arteriovenous fistula (SDAVF) is the most common vascular malformation of the spine in adults. However, the coincidence of tethered cord syndrome, lipoma, and SDAVF on the sacral level is exceptionally rare. We describe two patients, probably the fifth and sixth ever reported. The first was a 33 year-old female who underwent surgical cord de-tethering. Surprisingly, a sacral SDAVF was discovered intraoperatively, despite negative digital subtraction angiography (DSA). The second patient was a 30 year-old male with similar pathologies. After three failed embolizations, the fistula was surgically disconnected. Both patients recovered well. A review of patients with sacral SDAVF coexisting with spinal dysraphism, with an emphasis on the basis of symptoms was done. As a rule, in these coincident disorders, the SDAVF was the direct cause of increasing symptoms. Previous reports and our findings reveal that surgery might be superior to endovascular embolization for treating sacral SDAVFs with coexisting entities, because surgery offers a one-step treatment.