, MD; the DECIMAL investigators Background and Purpose-"Sinking skin flap" (SSF) syndrome is a rare complication after large craniectomy that may progress to "paradoxical" herniation as a consequence of atmospheric pressure exceeding intracranial pressure. The prevalence and characteristics of SSF syndrome after hemicraniectomy for malignant infarction of the middle cerebral artery are not well known. Methods-We analyzed a prospective cohort of 27 patients who underwent hemicraniectomy for malignant middle cerebral artery infarction. All had a clinical and brain imaging follow-up at 3 months and were followed until cranioplasty. Results-Three of 27 patients (11%) had, at 3 to 5 months posthemicraniectomy, SSF syndrome with severe orthostatic headache as the main symptom. Key Words: complications Ⅲ surgery Ⅲ hemicraniectomy Ⅲ malignant cerebral artery infarction Ⅲ herniation T he syndrome of the "trephined" or the "sinking skin flap" (SSF) syndrome is a rare complication after a large skull bone defect. 1 It consists of a sunken skin above the bone defect with neurological symptoms such as severe headaches, mental changes, focal deficits, or seizures. 1,2 The SSF may progress to "paradoxical herniation" as a consequence of the atmospheric pressure exceeding intracranial pressure and may eventually lead to coma and death.The objective of our study was to determine, in a prospective cohort of malignant infarction of the middle cerebral artery (MCA), the prevalence and characteristics of SSF syndrome and of any radiological sunken skin flap without symptoms after hemicraniectomy. Materials and Methods PatientsAll patients randomized in the surgical arm of DEcompressive Craniectomy In MALignant middle cerebral artery infarcts (DECIMAL), a trial that compared medical treatment and hemicraniectomy in malignant MCA infarction as well as all consecutive patients who had hemicraniectomy for a malignant MCA infarction in our stroke center after the end of DECIMAL inclusion but according to the same criteria, were considered. 3 All surviving patients had at the 3-month follow-up a clinical and brain imaging evaluation (axial and/or coronal fluid-attenuated inversion recovery MRI and/or axial and/or coronal CT scan) and were then followed every 3 months for 1 year. The timing and procedure of cranioplasty were left to the discretion of the neurosurgeon. The study was approved by an institutional ethics committee, and the patient or a close relative gave informed consent. Radiological EvaluationThe following measures were performed by the same neuroradiologist (J.-P.G.): (1) the maximum horizontal surface of the skull was estimated either on axial CT scan or axial fluid-attenuated inversion recovery MRI using the following formula: /4ϫAϫB in which "A" was the maximum distance from the anterior and posterior inner tables of the skull and "B/2" the half-depth to the inner skull surface opposite to the bone flap measured at the midpoint of "A"; (2) the whole surface of craniectomy was estimated either on coronal reformation and ...

BackgroundThere is no consensus regarding the best treatment option for unruptured aneurysms of the posterior communicating artery (PCom) presenting with oculomotor nerve palsy (ONP). We aimed to assess predictors of ONP recovery in a multicenter series of consecutive patients.Materials and methodsA retrospective review of prospective databases in three tertiary neurosurgical centers was carried out, selecting patients with ONP caused by unruptured PCom aneurysms, treated by surgical clipping or embolization, between January 2006 and December 2013. Patient files and imaging studies were used to extract ophthalmological assessments, treatment outcomes, and follow-up data. Predictors of ONP recovery during follow-up were explored using univariate and multivariate analyses.ResultsWe identified 55 patients with a median ONP duration before treatment of 11 days (IQR 4.5–18); the deficit was complete in 27 (49.1%) and incomplete in 28 (50.9%) cases. Median aneurysm size was 7 mm (IQR 5–9). Twenty-four (43.6%) patients underwent surgical clipping and 31 (56.4%) embolization as the primary treatment. Overall, ONP improved in 40 (72.7%) patients and persisted/recurred in 15 (27.3 %). Surgery, interval to complete treatment <4 weeks, aneurysm recurrence during follow-up, and retreatment during follow-up were significantly correlated with ONP outcome in the univariate analysis. In the multivariate analysis, independent predictors of ONP improvement were interval to complete treatment <4 weeks (OR 5.15, 95% CI 1.37 to 23.71, p=0.015) and aneurysm recurrence during follow-up (OR 0.1, 95% CI 0.02 to 0.47, p=0.003).ConclusionThere was no significant difference in ONP recovery between surgical clipping and embolization. The best predictor for ONP recovery was timely, complete, and durable aneurysm exclusion.

Intracranial dural arteriovenous fistulas (dAVFs) with perimedullary drainage represent a rare subtype of intracranial dAVF. Patients usually experience slowly progressive ascending myelopathy and/or lower brainstem signs. We present a case of foramen magnum dural arteriovenous fistula with an atypical clinical presentation. The patient initially presented with a generalised tonic-clonic seizure and no signs of myelopathy, followed one month later by rapidly progressive tetraplegia and respiratory insufficiency. The venous drainage of the fistula was directed both to the left temporal lobe and to the perimedullary veins (type III + V), causing venous congestion and oedema in these areas and explaining this unusual combination of symptoms. Rotational angiography and overlays with magnetic resonance imaging volumes were helpful in delineating the complex anatomy of the fistula. After endovascular embolisation, there was complete remission of venous congestion on imaging and significant clinical improvement. To our knowledge, this is the first report of a craniocervical junction fistula presenting with epilepsy.

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We present a case of a large unruptured basilar tip aneurysm with concomitant hydrocephalus. Complete thrombosis of the aneurysm was observed after ventriculoperitoneal shunting. Analyzing preoperative and postoperative MRI and DSA images, we identified reduced intracranial pressure and widening of the aneurysm-artery inclination angle as possible factors influencing spontaneous thrombosis. To the best of our knowledge, this is the first report of aneurysm thrombosis occurring after CSF diversion.