Robotic spinal angiography: A single-center experience.

BACKGROUND AND OBJECTIVES: Robotic neurointervention enhances procedural precision, reduces radiation risk, and improves care access. Originally for interventional cardiology, the CorPath GRX platform has been used in neurointerventions. Recent studies highlight robotic cerebral angiography benefits, but information on spinal angiography is limited. While a new generation of robotic solutions is on the horizon, this series evaluates our experience with the CorPath GRX in spinal angiographic procedures, addressing a key gap in neurointerventional research. METHODS: In this single-center retrospective case series, we analyzed 11 patients who underwent robotic-assisted diagnostic procedures with the CorPath GRX system from February 2022 to March 2023 at our institution. A descriptive synthesis was performed on the demographic, baseline, surgical, and postoperative data collected. RESULTS: The average age of the 11 patients was 54 ± 20.34 years, with six (54.55%) female. The mean body mass index was 29.58 ± 7.86, and 7 (63.64%) were non-smokers. Of the 11 procedures using the CorPath GRX system, four (36.36%) were partially converted to manual technique. General anesthesia was used in nine cases (81.82%), and right-side femoral access in ten (90.91%) patients. Mean fluoroscopy time was 24.81 ± 10.19 min, contrast dose 174.09 ± 57.31 mL, dose area product 472.23 ± 437.57 Gy·cm², and air kerma 2438.84 ± 2107.06 mGy. No robot-related complications and minimal procedure-related complications were reported. CONCLUSION: The CorPath GRX system, a robotic-assisted platform, has proven reliable and safe in spinal angiography, evidenced by its enhanced procedural accuracy and reduced radiation exposure for operators.

Management of Previously Failed Coiling and Clipping of a Middle Cerebral Artery Aneurysm.

Endovascular coiling techniques have emerged as an alternative and effective approach for treating intracranial aneurysms. However, in some cases, previously coiled aneurysms may require secondary treatment with surgical clipping, presenting a more complex challenge compared with the initial intervention.1,2 We present the case of a 39-year-old man with a residual class III Raymond-Roy occlusion partially coiled aneurysm at the left middle cerebral artery bifurcation (Video 1). Faced with the risks of rerupture, the patient underwent microsurgical treatment after providing consent. Despite successful initial microsurgical clipping, postoperative complications arose due to coil protrusion into the middle cerebral artery bifurcation, resulting in thrombotic occlusion of the frontal M2 branch. Emergency repeat microsurgical intervention and administration of a thrombolytic agent were performed to address complications, ultimately preserving blood flow. Subsequent endovascular placement of a flow-diverting stent 7 weeks after discharge confirmed complete occlusion of the aneurysm. The patient had no neurological deficit on follow-up. When planning microsurgical clipping of an aneurysm previously treated with coils, it is critical to consider coil placement, as there is a risk of prolapse if the coil is in the neck of the aneurysm. Thrombosis of the cerebral arteries is a potential complication of microsurgical clipping of partially coiled intracranial aneurysms, and injection of a fibrinolytic agent into thrombosed arterial branches may be an effective intraoperative method for treating intra-arterial thrombosis.3 This case illustrates the challenges associated with treating partially coiled aneurysms, highlighting the significance of careful planning when considering microsurgical treatment.

Middle meningeal artery patency after surgical evacuation for chronic subdural hematoma.

BACKGROUND: Chronic subdural hematoma (CSDH) often requires surgical evacuation, but recurrence rates remain high. Middle meningeal artery (MMA) embolization (MMAE) has been proposed as an alternative or adjunct treatment. There is concern that prior surgery might limit patency, access, penetration, and efficacy of MMAE, such that some recent trials excluded patients with prior craniotomy. However, the impact of prior open surgery on MMA patency has not been studied. METHODS: A retrospective analysis was conducted on patients who underwent MMAE for cSDH (2019-2022), after prior surgical evacuation or not. MMA patency was assessed using a six-point grading scale. RESULTS: Of the 109 MMAEs (84 patients, median age 72 years, 20.2% females), 58.7% were upfront MMAEs, while 41.3% were after prior surgery (20 craniotomies, 25 burr holes). Median hematoma thickness was 14 mm and midline shift 3 mm. Hematoma thickness reduction, surgical rescue, and functional outcome did not differ between MMAE subgroups and were not affected by MMA patency or total area of craniotomy or burr-holes. MMA patency was reduced in the craniotomy group only, specifically in the distal portion of the anterior division (p = 0.005), and correlated with craniotomy area (p < 0.001). CONCLUSION: MMA remains relatively patent after burr-hole evacuation of cSDH, while craniotomy typically only affects the frontal-distal division. However, MMA patency, evacuation method, and total area do not affect outcomes. These findings support the use of MMAE regardless of prior surgery and may influence future trial inclusion/exclusion criteria. Further studies are needed to optimize the timing and techniques for MMAE in cSDH management.

Endovascular biopsy in neurointerventional surgery: A systematic review.

INTRODUCTION: Endothelial cells (ECs) continuously line the cerebrovasculature. Molecular aberrations in the ECs are hallmarks and contributory factors to the development of cerebrovascular diseases, including intracranial aneurysms and arteriovenous malformations (AVMs). Endovascular biopsy has been introduced as a method to harvest ECs and obtain relevant biologic information. We aimed to summarize the literature on endovascular biopsy in neurointerventional surgery. METHODS: We conducted a comprehensive literature search in multiple databases, identifying eligible studies focusing on neurosurgical applications of endovascular biopsy. The systematic review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. The relevant information was collected, including study characteristics, biopsy techniques, and key findings. RESULTS: Nine studies met the inclusion criteria and were included. The studies involved the collection of ECs using various endovascular devices including coils, guide wires, different stents, and forceps. Endothelial-enrichment techniques, such fluorescence-activated cell sorting (FACS), collected ECs and facilitated downstream applications of bulk or single-cell RNA sequencing (scRNAseq). The studies provided insights into gene expression profiles and identified potential biomarkers associated with intracranial aneurysms. However, challenges were observed in obtaining an adequate number of ECs and identifying consistent biomarkers. CONCLUSION: Endovascular biopsy of endothelial cells (ECs) in cerebrovascular pathologies shows promise for gene expression profiling. However, many studies have been limited in sample size and underpowered to identify "signature genes" for aneurysm growth or rupture. Advancements in minimally invasive biopsy methods have potential to facilitate applications of precision medicine in the treatment of cerebrovascular disorders.

Transcriptomics of intracranial aneurysms: current state and opportunities in flow diversion.

Over the last 2 decades, the field of transcriptomics has emerged as a major subdiscipline in biology. Transcriptomic techniques have been used by many groups over this time to better understand intracranial aneurysm development, rupture, and treatment. However, only a few studies have applied transcriptomics to understand the mechanisms behind flow diversion (FD) specifically, despite its increasing importance in the neurointerventional armamentarium. FD is an increasingly safe and effective treatment option for intracranial aneurysms. However, the clinical understanding and use of FD has far outpaced the understanding of the underlying mechanisms. To make FD more predictable, clinically efficacious, and safe, it is important to understand the biological mechanisms at play that lead to successful and unsuccessful FD. In this review, the authors focus on the current understanding of FD biology, the recent advances in transcriptomics, and what future studies could be performed to deepen the understanding of FD. They propose the new concept of the FD microenvironment to be studied, which may unlock a deeper biological understanding. This review provides the background for prospective studies into the development of targeted aneurysm therapy, whether by modified devices or by medical adjuncts.

Liquid embolic agents for middle meningeal artery embolization in chronic subdural hematoma: Institutional experience with systematic review and meta-analysis.

INTRODUCTION: Chronic subdural hematoma (CSDH) is associated with high recurrence rates. Middle meningeal artery embolization (MMAE) has emerged as a promising treatment option. In this systematic review and meta-analysis, we aimed to assess the safety and efficacy of MMAE for CSDH using liquid embolic agents and compare them with particles. METHODS: We systematically reviewed all studies describing MMAE for CSDH with liquid embolic agents, according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. Additionally, we included a cohort of patients from our institution using liquid and particle embolic agents. Data were analyzed using random-effects proportions and comparisons meta-analysis, and statistical heterogeneity was assessed. RESULTS: A total of 18 studies with 507 cases of MMAE with liquid embolic agents (including our institutional experience) were included in the analysis. The success rate was 99% (95% confidence interval [CI]: 98-⁠100%), all complications rate was 1% (95% CI: 0-⁠5%), major complications rate was 0% (95% CI: 0-⁠0%), and mortality rate was 1% (95% CI: 0-⁠6%). The rate of hematoma size reduction was 97% (95% CI: 73-⁠100%), complete resolution 64% (95% CI: 33-⁠87%), radiographic recurrence 3% (95% CI: 1-⁠7%), and reoperation 3% (95% CI: 1-⁠7%). No significant differences in outcomes were found between liquid and particle embolic agents. Sensitivity analyses revealed that liquid embolic agents were associated with lower reoperation rates in upfront MMAE (risk ratio 0.13, 95% CI: 0.02-⁠0.95). CONCLUSION: MMAE with liquid embolic agents is safe and effective for the treatment of CSDH. Outcomes are comparable to particles, but liquids were associated with a decreased risk of reoperation in upfront MMAE. However, further studies are needed to support our findings.

Surgical Treatment of Large and Giant Anterior Cerebral Artery Aneurysms in the Endovascular Era: Analysis of Large Clinical Series.

OBJECTIVE: Analysis of results of surgical treatment of 112 patients with large and giant anterior cerebral artery (ACA) aneurysms. METHODS: This is the largest clinical series of large and giant ACA aneurysms ever reported. Retrospective analysis of medical charts, radiographic studies, and intraoperative videos was performed. Univariate and multivariate analysis of relations among 3 types of outcomes (complete aneurysm occlusion, ischemic complications, and clinical outcomes) and predicting factors was performed. RESULTS: Most aneurysms were communicant (84.8%). Aneurysms of the A1 segment and distal segments (A2-A5) were encountered rarely. Complete aneurysm occlusion (class I) was shown in 95 cases (90.5%). In 4 patients, only exploration and wrapping were performed because of severe atherosclerosis and chronic intraluminal thrombi. Partial occlusion (class III) was shown in 2 patients, and neck residual (class II) in 4 patients. Cerebral ischemia developed in 29 patients postoperatively. Occlusion or injury of the A1 segment and anterior communicating artery perforators and recurrent branch of Heubner were the most common reason for ischemic complications. At follow-up, 97 patients (86.6%) had favorable outcomes. Ten patients (8.9%) had unfavorable outcomes because of postoperative complications. CONCLUSIONS: Microsurgery provides effective and relatively safe occlusion of complex ACA aneurysms. Direct clipping can be applied in most cases independent of their precise location. In certain cases, alternative methods can be safely used. According to multivariate analysis, giant aneurysm size, aneurysm-related mass effect, involvement of large arterial branches in the aneurysm wall, and intraoperative complications were significant predicting factors for ischemic complications.

The Prediction of Functional Outcome After Microsurgical Treatment of Unruptured Intracranial Aneurysm Based on Machine Learning.

Our study aimed to create a machine learning model to predict patients' functional outcomes after microsurgical treatment of unruptured intracranial aneurysms (UIA). Data on 615 microsurgically treated patients with UIA were collected retrospectively from the Electronic Health Records at N.N. Burdenko Neurosurgery Center (Moscow, Russia). The dichotomized modified Rankin Scale (mRS) at the discharge was used as a target variable. Several machine learning models were utilized: a random forest upon decision trees (RF), logistic regression (LR), support vector machine (SVM). The best result with F1-score metric = 0.904 was produced by the SVM model with a label-encode method. The predictive modeling based on machine learning might be promising as a decision support tool in intracranial aneurysm surgery.

Surgical treatment of ruptured right middle cerebral artery mycotic aneurysm and central nervous system aspergillosis: Clinical case and literature review.

BACKGROUND: Central nervous system (CNS) aspergillosis is more often met in patients with expressed immune suppression. Still, in 50% of cases of meningitis caused by Aspergillus spp., it is observed in patients without expressed immune suppression. The prognosis of CNS aspergillosis is unfavorable with the general rate of lethality around 70%. CASE DESCRIPTION: Clinical case of a 58-year-old man who developed an Aspergillus abscess in the chiasmosellar region and an associated mycotic aneurysm of the right middle cerebral artery (MCA) and intracerebral hemorrhage. Microsurgical clipping of the fusiform-ectatic aneurysm of the right MCA in the conditions of rupture was performed. An extra-intracranial micro anastomosis was formed on the right. An open biopsy of the neoplasm in the chiasmosellar region was made. The neoplasm was yellow and destroyed the bone plate of the skull base. Biopsy results: Mycotic lesion (aspergillosis). The analysis of surgical treatment for mycotic aneurysms in the acute period of hemorrhage in patients with aspergillosis revealed a high rate of lethality. The issue of the feasibility and effectiveness of complicated revascularization interventions in the patients with hemorrhage and aspergillosis remains unsolved. CONCLUSION: The lack of generally accepted tactics of the treatment of this pathology requires further studies and systemic analysis. A high risk of the lethal outcome in patients with invasive mycotic infection and rupture of mycotic aneurysm highlight the importance of timely diagnostics and the beginning of antimycotic therapy. WThe issue of the evaluation of the revascularization methods effectiveness in patients after surgical treatment of a mycotic aneurysm associated with cerebral aspergillosis remains poor.

External Ventricular Drainage Complication Risks and Accuracy Analysis.

OBJECTIVE: The setting of external ventricular drainage (EVD) is one of the most frequent procedures in the neurosurgical practice. However, complication risks of this procedure may grow from 5% to 39%. The number of publications concerning the advancement of ventricular drainage setting technique and complication risks identification is increasing year after year. We posed a question on the dependence of complication risks and catheter setting accuracy on the different factors of routine practice of the N. N. Burdenko National Medical Research Center for neurosurgery within the scope of this work. METHODS: The data on patients whose EVD was set in the premotor area in 2019 were collected retrospectively. The surgeons were divided into 3 groups according to their experience valued in years. RESULTS: The result of drainage setting was considered satisfactory if its end was in the frontal horn or body of the ipsilateral ventricle. Generally, 122 patients passed EVD placement during 2019. According to computed tomography scans of the brain, the drainage position was satisfactory in 85 patients (75.9%) and unsatisfactory in 27 patients (24.1%). CONCLUSIONS: The procedures were performed by surgeons with <2 years of experience in 16.1% of cases, 2-5 years of experience in 25% of cases, and >5 years of experience in 58.9% of cases. The complication risk and accuracy of drainage setting do not depend on surgeon experience, type of bone access, and position in the premotor area.

Giant Middle Cerebral Artery Aneurysms: A 55-Patient Series.

BACKGROUND: The treatment of middle cerebral artery (MCA) giant aneurysms (GAs) represents a challenging task. METHODS: The data for 55 patients treated for MCA GA (≥25 mm) at the N.N. Burdenko NMRCN between 2010 and 2019 were analyZed. RESULTS: The GAs were located in the M1 segment in 11 (20%) patients, MCA bifurcation in 33 (60%), M2 in 7 (12.7%), and M3 in 4 (7.3%). There were 32 (58.2%) saccular and 23 (41.8%) fusiform GAs. MCA GAs were treated with neck clipping (50.9%), clipping with the artery lumen formation (3.6%), bypass surgeries (34.5%), wrapping (3.6%), and endovascular surgery (7.3%). A worsening of the neurologic state in the perioperative period was observed in 50.9% of patients. The complete closure of GA was achieved in 78.2%. Surgery-related mortality was 1.8%. The long-term outcome was favorable in 76.9% of patients. Surgery-related and disease-related plus treatment failures-related mortality was 9.6%. CONCLUSIONS: Microsurgical clipping and bypass surgery are the main operative interventions for MCA GA treatment. These operations are technically complex and are followed by a relatively high percentage of complications. The main tasks that require further investigations are the introduction of new precise diagnostic methods for the collateral circulation assessment in the cortical MCA branches, the perfection of the algorithm for the bypass selection, and investigation of the long-term results of the endovascular and combined treatments. It is of major importance to thoroughly observe the patients long-term after the surgery and ensure the possibility for further angiographic studies.

Neuronavigation device for stereotaxic external ventricular drainage insertion.

BACKGROUND: The insertion of an external ventricular drainage (EVD) is one of the most frequently used neurosurgical procedures. It is performed to adjust intracranial hypertension in cases of severe craniocerebral injury, acute posthemorrhagic hydrocephalus, meningitis, and oncological diseases related to impaired circulation of cerebrospinal fluid circulation (CSF). METHODS: In 2020, three patients with subarachnoid aneurysmal hemorrhage underwent insertion of an EVD navigation percutaneous stereotaxic device. Three cases introduced. RESULTS: In all cases, satisfactory EVD functioning was noted during the surgery and during the early postoperative period. The EVD insertion procedure took an average of 10 min. The EVD insertion route calculations using the software took about 5-15 min. No cases showed any infection, hemorrhagic complications, or EVD dysfunction. According to the control brain computed tomography data, the catheter position was satisfactory and corresponded to the target coordinates in all cases. CONCLUSION: The use of the device, with its high accuracy and efficiency, can reduce the incidence of unsatisfactory EVD implantation cases in patients with neurosurgical pathology.

Surgical Treatment of Unruptured Brain AVMs: Short- and Long-Term Results.

Unruptured brain AVMs (bAVMs) remain a controversial subject for practicing neurosurgeons, especially in the light of ARUBA and other observational studies. This retrospective study aims to analyze our experience with unruptured bAVMs to see whether it is beneficial in the long-term and how it corresponds to large literature trials. The study comprised 160 adult patients with unruptured bAVMs surgically treated in Burdenko NMC (Moscow) in 2009-2017. Mean age: 33.4 ± 10лет. Clinical presentations were: seizures in 99 (61.9%), chronical headaches-49 (30.6%), ischemic symptoms-4 (2.5%), asymptomatic in 8 (5%) patients. Spetzler-Martin scale: I-18 pt. (11.3%), II-71 pt. (44.4%), III-60 pt. (37.5%), IV-11 pt. (6.8%). Good outcomes (mRS = 0-2) at discharge were achieved in 149 (93.1%), satisfactory (mRS-3)-9 (5.6%). Follow-up was complete for 97 (60.6%) patients, mean-59.3 (13-108 month). Excellent outcomes (mRS = 0-1) reached in 94.8%. For epilepsy patients, Engel I outcome was found in 50 (84.8%); for chronic headaches, 43 (66.1%) patients reported improvement. Postoperative visual field defects were followed in 22 of 55 (40%), complete recovery was reported in 6 (27%) and partial recovery in 8 (36%) patients. Overall, our results support the conclusion that surgery for low-grade bAVMs (S-M I-II) is a beneficial, low-risk option.

External Ventricular Drainage in Patients With Acute Aneurysmal Subarachnoid Hemorrhage After Microsurgical Clipping: Our 2006-2018 Experience and a Literature Review.

Introduction The placement of an external ventricular drain (EVD) is widely practiced in neurosurgery for various diseases and conditions accompanied by impaired cerebrospinal fluid (CSF) circulation, intracranial hypertension (ICHyp), intraventricular hemorrhage (IVH), and hydrocephalus. Specialists have been using this method in patients with acute aneurysmal subarachnoid hemorrhage (aSAH) for more than 50 years. Extensive experience gained at the Burdenko Neurosurgical Center (BNC) in Moscow, the Russian Federation, in the surgical treatment of patients with acute aSAH enabled us to describe the results of using an EVD in patients after microsurgery. The objective of the research was to assess the effectiveness and safety of the EVD and clarify the indications for the microsurgical treatment of aneurysms in patients with acute SAH. Materials and methods From 2006 until the end of 2018, 645 patients registered in the BNC database underwent microsurgery for acute (0-21 days) aSAH. During the case study, we assessed the severity of hemorrhage according to the Fisher scale, the condition of patients on the Hunt-Hess (H-H) scale during surgery, the time of placement of EVD (before, during, and after surgery), and the duration of EVD. The number of patients with parenchymal intracranial pressure (ICP) transducers was assessed by the degree of correlation of ICP data through the EVD and parenchymal ICP transducer. One of the aims of the research was to compare the frequency of using EVD and decompressive craniectomy (DCH). The incidence of EVD-associated meningitis was analyzed. The need for a ventriculoperitoneal shunt (VPS) in patients after using EVD was also assessed. Overall outcomes were assessed using a modified Rankin scale (mRS) at the time of patient discharge. Exclusion criteria were as follows: patients aged less than 18 years and the lack of assessed data. Patients undergoing endovascular and conservative treatments also were excluded. Results Among the patients enrolled in the study, 22% (n=142) had EVD. Among these, 99 cases (69.7%) had EVD installed in the operating room just before the start of the surgical intervention. In some cases, ventriculostomy was performed on a delayed basis (16.3%). A satisfactory outcome (mRS scores of 1 and 2) was observed in 24.7% (n=35). Moderate and profound disability at the time of discharge was noted in 55.7% (n=79). Vegetative outcome at discharge was noted in 8.4% (n=12), and mortality occurred in 12.3% (n=15). Conclusion EVD ensures effective monitoring and reduction of ICP. EVD is associated with a relatively low risk of infectious, liquorodynamic, and hemorrhagic complications and does not worsen outcomes when used in patients with aSAH. We propose that all patients in the acute stage of SAH with H-H severity of III-V should receive EVD immediately before surgery.

Chondrosarcoma of the Skull Base: A Case Study and Literature Review.

Chondrosarcomas (CSs) are rare malignant tumors composed of cells derived from the transformed chondrocytes. Only 2% of the total cases of CS are found at the skull base, thus representing a 0.1-0.2% prevalence. We present the case of a patient with CS at the middle cranial fossa who was admitted for surgery to the Burdenko National Medical Research Center of Neurosurgery. In addition, we engage in a review of the literature to discuss the current approaches to the diagnostics and surgery of CS and delve deep into its embryo- and oncogenesis.

Microsurgical Angioarchitectonics of Deep Brain Structures and Deep Arterial Anastomoses.

BACKGROUND: Surgeries for deep and eloquent cerebral lesions require a detailed knowledge of normal brain anatomy and accurate planning. Important parts of brain anatomy are the cerebral blood supply and collateral circulation system. In addition to well-known cortical and basal (circle of Willis) anastomoses, there is also a deep interarterial anastomotic circle that is not described in the literature. METHODS: Twenty brain specimens were studied for deep arterial anastomotic connections between branches of the anterior and posterior choroidal arteries. RESULTS: We have marked 3 symmetric zones of deep arterial anastomoses that form an epithalamic circle. CONCLUSIONS: Epithalamic anastomoses provide an additional mechanism of blood distribution that may play a role during surgical interventions or stroke.

A Rare Case of Brain Angiolipoma Imitating Arteriovenous Malformation: Differential Diagnosis, Surgical Treatment, and Literature Review.

BACKGROUND: Angiolipomas are mesenchymal tumors composed of mature adipocytes with abnormal vascular elements. They are most commonly found in subcutaneous tissues of the trunk and are rarely seen at craniospinal axes. CASE DESCRIPTION: We present an untypical case of frontal lobe angiolipoma manifested with seizures and initially described as an arteriovenous malformation. CONCLUSION: MRI with fat-suppression sequence plays key role in angiolipomas diagnostics.

Treatment of Brain Arteriovenous Malformations with Hemodynamic Aneurysms: A Series of 131 Consecutive Cases.

BACKGROUND: The natural history of hemodynamic aneurysms (HAs) associated with brain arteriovenous malformations (AVMs) remains controversial, with no single approach to treatment. The purpose of this study was to justify preventive treatment tactics for HAs that pose an increased risk of rupture based on hemodynamic studies demonstrating hypertension in the afferent bed after AVM exclusion. METHODS: This retrospective analysis included 131 of 1740 patients (8%) with brain AVMs and at least 1 aneurysm treated at Burdenko Neurosurgical Institute between 2000 and 2016. Treatment consisted of microsurgery, endovascular interventions, or a combination of modalities. Patients were evaluated with the modified Rankin Scale before and after treatment. RESULTS: A total of 205 aneurysms were discovered. Multiple HAs were found in 46 patients (35%), and were significantly more often associated with posterior fossa AVMs; in addition, most were distally located. There was no difference in the incidence of hemorrhage between proximal and distal HAs. Microsurgical treatment was marked by high radicalism; 85% of HAs and 94% of AVMs were totally excluded based on control studies. In 10 cases, aneurysms were found after AVM removal, including 4 de novo aneurysms. In 1 case, the aneurysm regressed after AVM treatment. The mortality rate was 2.3%. CONCLUSIONS: Preoperative imaging should be carefully examined for associated aneurysms before and after surgical treatment. Our data suggests that HA exclusion, either as the first step or simultaneously with AVM treatment, is most beneficial to patients.

Reversal of intraoperative arterial thrombosis with a fibrinolytic agent when treating large and giant partially thrombosed aneurysms of the middle cerebral artery.

OBJECTIVE: Thrombosis of the cerebral arteries is one of the complications of microsurgical operations for partially thrombosed intracranial aneurysms. The object of this study was to assess the frequency of intraoperative arterial thrombosis (IAT) during microsurgical treatment of large and giant partially thrombosed aneurysms of the middle cerebral artery (MCA) and also to assess the efficacy of the treatment of this complication. MATERIALS: The authors analyzed a consecutive series of 53 patients who underwent surgery for partially thrombosed aneurysms of the MCA at the Burdenko Neurosurgical Institute between January 2005 and September 2014. Thirty-two patients had large aneurysms (15-25 mm) and 21 had giant aneurysms (> 25 mm). Clipping of aneurysms was performed in 47 patients, trapping was performed in 3, and wrapping was performed in 3. RESULTS: IAT was diagnosed in 10 patients (18.9%). The authors describe a technique for IAT reversal involving the injection of modified human recombinant prourokinase (mr-proUK). Of the 7 patients who underwent injection of mr-proUK in the thrombosed artery, 5 (71.4%) were discharged without any change in neurological status, 1 (14.3%) experienced moderate deterioration (modified Rankin Scale [mRS] score of 2), and 1 (14.3%) experienced severe deterioration (mRS score of 4). Among the 3 patients who had complications and did not receive an injection of mr-proUK, 2 experienced severe deterioration (mRS score of 3 and 4) and 1 had moderate deterioration (mRS score of 2). CONCLUSIONS: The primary risk factor of thrombectomy with temporary trapping is thrombosis in the MCA branches. The injection of a fibrinolytic agent into thrombosed MCA branches is an effective method for the treatment of IAT.

Lateral supraorbital approach to ipsilateral PCA-P1 and ICA-PCoA aneurysms.

BACKGROUND: Aneurysms of the posterior cerebral artery (PCA) are rare and often associated with anterior circulation aneurysms. The lateral supraorbital approach allows for a very fast and safe approach to the ipsilateral lesions Circle of Willis. A technical note on the successful clip occlusion of two aneurysms in the anterior and posterior Circle of Willis via this less invasive approach has not been published before. The objective of this technical note is to describe the simultaneous microsurgical clip occlusion of an ipsilateral PCA-P1 and an internal carotid artery - posterior communicating artery (ICA-PCoA) aneurysm via the lateral supraorbital approach. CASE DESCRIPTION: The authors present a technical report of successful clip occlusions of ipsilateral located PCA-P1 and ICA-PCoA aneurysms. A 59-year-old female patient was diagnosed with a PCA-P1 and an ipsilateral ICA-PCoA aneurysm by computed tomography angiography (CTA) after an ischemic stroke secondary to a contralateral ICA dissection. The patient underwent microsurgical clipping after a lateral supraorbital craniotomy. The intraoperative indocyanine green (ICG) videoangiography and the postoperative CTA showed a complete occlusion of both aneurysms; the parent vessels (ICA and PCA) were patent. The patient presents postoperative no new neurologic deficit. CONCLUSION: The lateral supraorbital approach is suitable for the simultaneous microsurgical treatment of proximal anterior circulation and ipsilateral proximal PCA aneurysms. Compared to endovascular treatment, direct visual control of brainstem perforators is possible.