Successful Mechanical Thrombectomy for Subocclusive Thrombus at the Origin of Lenticulostriate Artery.

Optimal treatment of patients with intracranial subocclusive thrombus remains unclear. Such a rare case successfully managed with endovascular mechanical thrombectomy is presented. A 71-year-old man experienced a sudden onset of dysarthria and motor deficits. At the time of admission his National Institutes of Health Stroke Scale (NIHSS) score was 4. DWI demonstrated incomplete infarction within the left lenticulostriate artery (LSA) territory, MRA showed partial flow defect in the distal left M1 segment and non-visualization of the LSA, and ECG revealed atrial fibrillation, thus ischemic stroke caused by cardiogenic embolism was diagnosed. Tissue plasminogen activator was administered, but symptoms progressed and NIHSS score increased up to 8. Diagnostic angiogrpahy confirmed presence of the subocclusive thrombus within the distal left M1 segment and complete occlusion of LSA at its origin. Since conservative therapy was ineffective, mechanical thrombectomy utilizing ADAPT (a direct aspiration first-pass thrombectomy) technique was performed resulting in compete recanalization of the LSA accompanied by the prompt regress of neurological symptoms. Eventally, the patient demonstrated nearly full recovery (modified Rankin Scale score 1). Thus, mechanical thrombectomy should be considered as a reasonable option in cases of acute cerebral stroke caused by subocclusive thrombus and progressive neurological deficits despite standard conservative therapy. J. Med. Invest. 67 : 372-374, August, 2020.

Ruptured lenticulostriate artery aneurysm: a report of a case treated with endovascular embolisation.

A 65-year-old woman presented to the emergency department with sudden onset of left-sided weakness, headache and vomiting. A cerebral CT showed an acute intracerebral haemorrhage involving the right caudate nucleus and lentiform nucleus with mild midline shift and intraventricular extension. CT angiography did not reveal aneurysm or other vascular anomaly. Conventional cerebral angiography demonstrated a 3 mm right medial lenticulostriate branch aneurysm, arising from the right anterior cerebral artery (ACA). Endovascular treatment was performed from the left internal carotid via the anterior communicating artery into the right ACA. Complete occlusion was achieved with injection of N-butyl-2-cyanoacrylate. The patient had neurological rehabilitation during hospitalisation followed by outpatient physical therapy. Two years later, clinical follow-up demonstrated excellent recovery.

Lenticulostriate Artery Aneurysm: 2-Dimensional Operative Video.

Saccular aneurysms that arise from the origin of or along a lenticulostriate artery are rarely observed. In general, occlusion of the lenticulostriate artery is discouraged because of the risk of a capsular infarction. This patient was a woman with moyamoya disease who demonstrated a fusiform aneurysm of a lenticulostriate artery. Image guidance was critical to correctly identify the location of the aneurysm. The lenticulostriate artery was occluded by a surgical clip to obliterate the aneurysm and consequently the flow through the artery. However, the patient tolerated the procedure well and did not experience an ischemic stroke from the vessel occlusion. The patient gave informed consent for surgery and video recording. Institutional review board approval was deemed unnecessary. Used with permission from Barrow Neurological Institute, Phoenix, Arizona.

Successful Resection of a Growing Distal Medial Lenticulostriate Artery Pseudoaneurysm Presenting with Isolated Intraventricular Hemorrhage.

INTRODUCTION: Distal medial lenticulostriate artery (LSA) aneurysms associated with isolated intraventricular hemorrhage (IVH) are extremely rare. We report a very rare case of the isolated IVH due to the rupture of the distal medial LSA pseudoaneurysm that was not visible at the initial angiography but later emerged and grew. CASE REPORT: A 61-year-old woman with a history of hypertension had sudden onset of severe headache and mild consciousness disturbance. The computed tomography scan revealed the IVH, but the initial angiographies showed no evidence of aneurysm. The follow-up magnetic resonance imaging revealed that an intraventricular mass, arising from the right distal medial LSA, emerged and grew into the right anterior horn. Considering the risk of rebleeding, we resected the mass lesion via the transsulcal transventricular approach. The postoperative imaging showed complete obliteration of the mass lesion. Histopathological analysis indicated the pseudoaneurysm. The patient was discharged without any neurological deficit. CONCLUSIONS: The careful and repetitive follow-up imaging should be done in the cases with isolated IVH even if the initial image evaluations are unrevealing. The transsulcal transventricular approach can be the most minimally invasive surgical option for intraventricular lesion.

A Dissecting Aneurysm of the Distal Medial Lenticulostriate Artery: Case Report.

BACKGROUND: Medial lenticulostriate artery (MLSA) aneurysms are rare; to our knowledge, only 2 cases without an association with moyamoya disease have been documented. We treated a ruptured dissecting aneurysm of the distal MLSA surgically using a tube retractor. CASE DESCRIPTION: A 66-year-old woman suffered a sudden-onset disturbance in consciousness. Computed tomography showed diffuse subarachnoid hemorrhage and a dense intraventricular hematoma associated with acute hydrocephalus. She underwent emergent ventricular drainage. Angiography revealed a 3-mm distal MLSA aneurysm. On repeat angiographs, the aneurysm had not disappeared. Because the stenotic, narrow structure of the proximal portion of the MLSA disallowed the endovascular approach, we performed direct surgery via the transventricular approach using a tube retractor. The aneurysm on the intraventricular surface of the anterior horn of the lateral ventricle adjacent to the caudate nucleus was exposed. We resected the aneurysm under transcranial motor-evoked potential monitoring because neck clipping would have endangered the patency of the MLSA. Her postoperative course was uneventful. The pathologic diagnosis was ruptured dissecting aneurysm. CONCLUSIONS: There is no definitive strategy to treat distal MLSA aneurysms. Our experience illustrates that natural healing of the vessel wall cannot be expected in all cases. Therefore, less-invasive direct surgical as well as endovascular treatment should not be ruled out in patients with ruptured distal MLSA aneurysms.

Frameless neuronavigation based only on 3D digital subtraction angiography using surface-based facial registration.

OBJECT: Cerebrovascular lesions can have complicated abnormal anatomy that is not completely characterized by CT or MR angiography. Although 3D rotational angiography provides superior spatial and temporal resolution, catheter angiograms are not easily registered to the patient, limiting the use of these images as a source for neuronavigation. However, 3D digital subtraction angiography (DSA) contains not only vascular anatomy but also facial surface anatomy data. The authors report a novel technique to register 3D DSA images by using only the surface anatomy contained within the data set without having to fuse the DSA image set to other imaging modalities or use fiducial markers. METHODS: A cadaver model was first created to assess the accuracy of neuronavigation based on 3D DSA images registered by facial surface anatomy. A 3D DSA scan was obtained of a formalin-fixed cadaver head, with acquisitions of mask and contrast runs. The right common carotid artery was injected prior to the contrast run with a 45% contrast solution diluted with water-soluble red liquid latex. One week later, the head was registered to a neuronavigation system loaded with the 3D DSA images acquired earlier using facial surface anatomy. A right pterional craniotomy was performed and 10 different vascular landmarks were identified and measured for accuracy using the neuronavigation system. Neuronavigation based only on 3D DSA was then used to guide an open clipping procedure for a patient who presented with a ruptured distal lenticulostriate aneurysm. RESULTS: The accuracy of the measurements for the cadaver model was 0.71 ± 0.25 mm (mean ± SE), which is superior to the 1.8-5 mm reported for neuronavigation. The 3D DSA-based navigation-assisted surgery for the distal lenticulostriate aneurysm aided in localization, resulting in a small craniotomy and minimal brain dissection. CONCLUSIONS: This is the first example of frameless neuronavigation based on 3D catheter angiography registered by only the surface anatomy data contained within the 3D DSA image set. This is an easily applied technique that is beneficial for accurately locating vascular pathological entities and reducing the dissection burden of vascular lesions.

Trans-striatocapsular contralateral interhemispheric resection of anterior inferior basal ganglia cavernous malformation.

OBJECTIVE: To describe a technique to approach the anterior inferior basal ganglia. CASE DESCRIPTION: A 29-year-old man presented with several episodes of facial droop and a cavernous malformation anterior, inferior, and lateral to the head of the caudate nucleus. Several possible surgical approaches were considered, including a transsylvian approach and a contralateral interhemispheric approach. Ultimately, the patient underwent a contralateral interhemispheric trans-striatocapsular approach to the lesion and was discharged without neurologic deficit within 72 hours. CONCLUSION: The approach described here is a novel alternative to transsylvian or supracarotid approaches to the anterior inferior basal ganglia and in this patient provided a well-tolerated surgical corridor that allowed complete resection of his cavernoma. We discuss several advantages and disadvantages of the various approaches to the anterior inferior basal ganglia.

Microsurgical clipping of an unruptured lenticulostriate aneurysm.

Aneurysms of the lenticulostriate artery have been associated with hypertension, vasculopathy, tumors, and arteriovenous malformations. Although several cases of microsurgical treatment of ruptured lenticulostriate artery aneurysms have been reported, to our knowledge there is no published case of microsurgical treatment of an unruptured lenticulostriate artery aneurysm. We report a 66-year-old woman with a history of moyamoya disease, previously treated with a right-sided middle cerebral artery-to-superficial temporal artery bypass who presented with an unruptured aneurysm of a lenticulostriate artery. We report successful microsurgical treatment of this rare lesion and discuss the rationale for our treatment strategy.

Successful treatment of cervical dystonia induced by basal ganglion venous angioma with gamma knife thalamotomy.

Stereotatic radiosurgery is typically not the first line of treatment for cervical dystonia. We present a patient with a rare cervical dystonia induced by a venous angioma in the right basal ganglion. The patient was successfully treated with a gamma knife thalamotomy after failed treatments of botulinum toxin injections and peripheral denervation.

Gamma Knife surgery for basal ganglia and thalamic arteriovenous malformations.

OBJECT: Gamma Knife surgery (GKS) has emerged as the treatment of choice for small- to medium-sized cerebral arteriovenous malformations (AVMs) in deep locations. The present study aims to investigate the outcomes of GKS for AVMs in the basal ganglia and thalamus. METHODS: Between 1989 and 2007, 85 patients with AVMs in the basal ganglia and 97 in the thalamus underwent GKS and were followed up for more than 2 years. The nidus volumes ranged from 0.1 to 29.4 cm(3) (mean 3.4 cm(3)). The mean margin dose at the initial GKS was 21.3 Gy (range 10-28 Gy). Thirty-six patients underwent repeat GKS for residual AVMs at a median 4 years after initial GKS. The mean margin dose at repeat GKS was 21.1 Gy (range 7.5-27 Gy). RESULTS: Following a single GKS, total obliteration of the nidus was confirmed on angiograms in 91 patients (50%). In 12 patients (6.6%) a subtotal obliteration was achieved. No flow voids were observed on MR imaging in 14 patients (7.7%). Following single or repeat GKS, total obliteration was angiographically confirmed in 106 patients (58.2%) and subtotal obliteration in 8 patients (4.4%). No flow voids on MR imaging were observed in 18 patients (9.9%). The overall obliteration rates following one or multiple GKSs based on MR imaging or angiography was 68%. A small nidus volume, high margin dose, low number of isocenters, and no history of embolization were significantly associated with an increased rate of obliteration. Twenty-one patients experienced 25 episodes of hemorrhage in 850 risk-years following GKS, yielding an annual hemorrhage rate of 2.9%. Four patients died in this series: 2 due to complications of hemorrhage and 2 due to unrelated diseases. Permanent neurological deficits caused by radiation were noted in 9 patients (4.9%). CONCLUSIONS: Gamma Knife surgery offers a reasonable chance of obliterating basal ganglia and thalamic AVMs and does so with a low risk of complications. It is an optimal treatment option in patients for whom the anticipated risk of microsurgery is too high.

Fusiform lenticulostriate artery aneurysm with subarachnoid hemorrhage: the role for superselective angiography in treatment planning.

Aneurysms of the lenticulostriatal perforating arteries are rare and either involve the middle cerebral artery-perforator junction or are located distally in basal ganglia. We describe a rare ruptured fusiform lenticulostriatal perforating artery aneurysm arising from a proximal M2 MCA branch, discerned on superselective microcatheter angiography, presenting solely with subarachnoid hemorrhage (SAH). A 50-year-old previously healthy man presented with diffuse SAH and negative CT angiogram. Cerebral angiogram demonstrated a 2 mm fusiform aneurysm presumably arising from the right lateral lenticulostriate perforator but the exact origin of the perforator was unclear. Superselective angiography was required to precisely delineate the aneurysm and its vessel of origin and directly influenced treatment planning (surgical trapping). Superselective microcatheter angiography provides both an option for endovascular therapy as well as more accurate delineation for surgical planning for these rare aneurysms.

Clinical features and outcome in North American adults with idiopathic basal arterial occlusive disease without moyamoya collaterals.

OBJECTIVE: To define the clinical characteristics and outcome of patients with idiopathic stenosis or occlusion of the basal arteries, without moyamoya collateral vessel formation. METHODS: We identified patients who presented to our institution from 1996 to 2005 with occlusive disease of the distal internal carotid artery or the proximal middle or anterior cerebral arteries demonstrated by digital subtraction cerebral angiography. We excluded those with evidence of atherosclerotic disease, systemic vasculitis, moyamoya phenomenon, or any other condition that could otherwise explain their arterial occlusive disease. Medical records were reviewed for presenting symptoms and clinical characteristics. Outcome was determined from chart review and phone interviews. RESULTS: Twelve patients were identified. All presented with transient ischemic attack or stroke. Eleven were women. Age at presentation ranged from 34 to 71 years. Nine had a history of hypertension; 5 had unilateral intracranial disease. Recurrent stroke on medical therapy occurred in none of the 5 during an average follow-up of 29 months. Seven had bilateral disease. Ischemic stroke occurred between 2 and 107 months after the initial event in 5 of 8 medically treated hemispheres. Moyamoya collateral vessels developed in 1 patient as shown on follow-up angiography. CONCLUSION: The clinical features and outcome of these patients are similar to those reported in large case series of North American patients with moyamoya phenomenon. These data suggest a common etiology for the basal arterial occlusive process and a variable ability to form moyamoya collateral vessels.

Bilateral lenticulostriate artery aneurysms.

Aneurysms of lenticulostriate artery (LSA) have rarely been reported. We present an extremely rare case of bilateral aneurysm of LSA, which spontaneously disappeared. A 59-year-old man presented to us with a decreased level of consciousness. Twice repeated blood culture was negative. Computed tomography (CT) showed bilateral basal ganglia hemorrhage with intraventricular extension and acute hydrocephalus. We performed external ventricular drainage. Cerebral angiograms, on 3 days after the onset, disclosed two aneurysms on the left LSA and one aneurysm on the right LSA. Cerebral angiography after 9 weeks demonstrated complete disappearance of three aneurysms.

Basal ganglionic infarction before mechanical thrombectomy predicts poor outcome.

BACKGROUND AND PURPOSE: Use of mechanical thrombectomy for acute cerebrovascular occlusions is increasing. Preintervention MRI patterns may be helpful in predicting prognosis. METHODS: We reviewed all Merci thrombectomy cases of either terminal ICA or M1 occlusions and classified them according to diffusion MRI patterns of (1) completed basal ganglia infarct (pure M1a), (2) near-completed basal ganglia infarct (incomplete M1a), and (3) relative sparing of deep MCA field (M1b). We compared the M1a and M1b patients with respect to neurological deficit on presentation, recanalization rates, hospital length of stay, and disability on discharge. We also determined whether deep MCA compromise predicted hematomal hemorrhagic transformation (HT) and whether this correlated with worse clinical outcome at discharge. RESULTS: The M1a group had worse pre-Merci NIHSS (21 versus 14, P=0.004), worse discharge NIHSS (12 versus 4, P<0.001), longer hospital length of stay (11.5 versus 6.4 days, P=0.003), and higher rates of discharge mRS > or = 3 (OR 8.4, 95% CI 2.1 to 44.7) despite equivalent recanalization rates when compared to the M1b group. The M1a group had a higher rate of parenchymal hematomal HT (OR 6.7, 95% CI 1.02 to 183.3). Patients with such hematomal HT had higher rates of death or dependency discharge (100% versus 60%, OR=infinite). CONCLUSIONS: Among patients with ICA and M1 occlusions, preintervention diffusion MRI evidence of advanced injury in the basal ganglia bodes worse dysfunction and disability at discharge, longer hospital stays, and higher rates of hemorrhage after intervention when compared to other diffusion patterns.

The supracarotid-infrafrontal approach: surgical technique and clinical application to cavernous malformations in the anteroinferior Basal Ganglia.

OBJECTIVE: Many symptomatic cavernous malformations deep in the anteroinferior basal ganglia are deemed to be inoperable and managed conservatively because transcortical, transsylvian-transinsular, and transcallosal approaches are unsuitable. We present an approach to these lesions through the supracarotid triangle, between ascending perforators, and through the basomedial frontal lobe. METHODS: The supracarotid-infrafrontal approach incorporates an orbitozygomatic craniotomy, wide microsurgical exposure of the supracarotid triangle, dissection of perforating arteries, and image-guided resection through the posterior part of the medial orbital gyrus and anterior perforated substance. RESULTS: During 10 years of surgical experience with 269 patients with cavernous malformations, 5 patients were identified with lesions in the basal ganglia that were resected completely using the supracarotid-infrafrontal approach. Transient neurological deficits were observed postoperatively in 2 patients, and all patients had excellent outcomes (modified Rankin Scale score of 0 or 1; mean duration of follow-up, 1.4 years). CONCLUSION: Cavernous malformations in the anteroinferior basal ganglia come to the brain surface directly behind the internal carotid artery bifurcation, and the supracarotid-infrafrontal trajectory best matches the lesions' axes. The surgical corridor runs between perforating arteries, but entrance into these lesions opens additional working space that is not normally present when the approach is used with aneurysms. Careful handling of crossing and ascending perforating arteries is critical, as is delicate dissection of the lesion's superior pole where it abuts the internal capsule.

Treatment of ruptured lenticulostriate artery aneurysms.

OBJECT: Lenticulostriate artery (LSA) aneurysms are rarely reported in the literature, making management decisions challenging. Conservative, endovascular, and surgical treatments have been described primarily through case reports and reports of individual authors' experiences. The purpose of this study is to report neurological outcomes in a single-institution experience of ruptured lenticulostriate aneurysms treated surgically. METHODS: The authors have conducted a retrospective review of all cases involving patients with ruptured LSA aneurysms who presented to the Mt. Sinai Hospital neurosurgical service between September 2001 and January 2007. RESULTS: Over 5.4 years, the authors treated 6 patients with 7 LSA aneurysms-6 ruptured and 1 unruptured. The Hunt and Hess grade on admission ranged from I to IV, with subarachnoid hemorrhage in 5 of the 6 patients. Catheter angiography confirmed the presence of the aneurysms, and all patients underwent a pterional craniotomy and clipping or resection of the aneurysm, performed by a single surgeon. Associated risk factors in our series of patients included hypertension, cocaine abuse, and intracranial occlusive disease suggestive of moyamoya disease. Two types of LSA aneurysms were identified. The mean size of the 6 ruptured aneurysms was 3.2 mm. The LSA was preserved in 3 of 6 patients, but LSA preservation did not correlate with development of a postoperative infarct, clinically or radiologically. In patients with ruptured aneurysms, the mean modified Rankin Scale score at discharge was 1.7. The 3 patients in whom the LSA was sacrificed had good outcomes, suggesting that loss of the artery is clinically well tolerated. CONCLUSIONS: This case series demonstrates that surgical treatment of ruptured LSA aneurysms can be an appropriate, effective, and safe therapy.

A new Modified Intracerebral Hemorrhage score for treatment decisions in basal ganglia hemorrhage--a randomized trial.

OBJECTIVES: To develop a Modified Intracerebral Hemorrhage (MICH) score to determine optimal cut-offs for conservative treatment vs surgical intervention for basal ganglia hemorrhage and to predict outcomes. DESIGN: Prospective randomized trial. SETTING: A 1,720-bed medical center affiliated with a university. PATIENTS: In all, 226 patients with basal ganglia hemorrhage who presented at our hospital from 2001-2005. INTERVENTIONS: Group A (n = 113) underwent endoscopic surgery; group B (n = 113) underwent conservative treatment. Score differences on the Glasgow Outcome Scale and 1-yr Barthel Index were analyzed by chi-square test and Student's t-tests. Cut-offs for MICH scoring were evaluated using receiver operating characteristic curves for calculating the Youden Index. The treatment odds ratio was analyzed by univariate, multivariate, and multiple logistic regressions. MEASUREMENTS AND MAIN RESULTS: The optimal cut-off point for mortality was a MICH score > or = 3 in which the Youden Index is 0.66 (sensitivity, 76.3%; specificity, 89.8%; area under the receiver operating characteristic curve, 0.897). The positive and negative predictive values were 81.8% and 86.3%, respectively. The treatment odds ratio for surgical treatment was 6.87 (95% confidence interval, 3.13-14.5) at MICH scores > or = 3. The best cut-off for good functional outcomes (Glasgow Outcome Scale > or = 4 or Barthel index > or = 55) was MICH > or = 2. Conservative treatment achieved a better mean Barthel Index at MICH = 0 or 1 than surgical treatment, p < .01. At MICH scores = 3 or 4, 6-month mortality for conservative treatment was higher than for surgical treatment, p < .01 and p = .04, respectively. At MICH scores of 5, all patients died. CONCLUSIONS: MICH scoring provides a simple, reliable system for treatment decisions regarding basal ganglia hemorrhage and may accurately predict functional outcomes. Conservative treatment is recommended for basal ganglia ICH patients with low MICH scores (0, 1) to preserve neurologic function. Surgery is recommended for patients with a midlevel MICH score to obtain better functional outcomes (MICH = 2) and to reduce mortality (MICH = 3 or 4). At MICH scores = 5, there are no indications for surgery.