Multiple anterior choroidal arteries and perioperative ischemic complications in unruptured anterior choroidal artery aneurysms treated with microsurgical clipping.

BACKGROUND: This study aimed to identify the association between the number of anterior choroidal arteries (AchoAs) and procedure-related ischemic complications in microsurgical clipping of unruptured AchoA aneurysms. METHODS: We retrospectively reviewed the clinical, radiological, and intraoperative findings of 153 patients with unruptured AchoA aneurysms treated with microsurgical clipping between January 2012 and November 2020 in a single tertiary institution. Intraoperative video clips were reviewed, and the AchoA type was categorized into two according to the number of AchoAs: (1) single-type group with single origin and single branch and (2) multiple-type group with duplicated origin or divided multiple branches. Uni- and multivariate analyses were performed to assess the relationship between clinical and radiological factors and perioperative ischemic complications. RESULTS: Of the 153 patients, 52 (34%) were categorized as multiple-type group. The frequency of perioperative ischemic complications, including decreased intraoperative motor evoked potential (MEP), silent infarction, and postoperative ischemic symptoms, was significantly higher in the multiple-type group than in the single-type group (13 [25%] vs 6 [5.9%], p = 0.001). Multivariate logistic regression analysis showed that multiple-type group (odds ratio [OR], 3.725; 95% confidence interval [CI], 1.171-11.845, p = 0.026) and multilobulated shape (OR, 9.512; 95% CI, 2.093-43.224; p = 0.004) were significantly associated with perioperative ischemic complications. Among 9 patients with decreased MEP, postoperative ischemic symptoms developed in 2 patients after clip adjustment. CONCLUSIONS: Multiple-type AchoA aneurysms and multilobulated shape are significantly correlated with perioperative ischemic complications. Postoperative ischemic complications can be minimized by recognizing these variations and using multimodal approach with MEP monitoring.

Extracranial Carotid-Vertebral Artery Bypass Technique and Surgical Outcomes.

Vertebral artery (VA) occlusion is frequently encountered, usually without acute ischemic injury of the brain. However, when it is accompanied by hypoplasia or stenosis of the opposite VA, brain ischemia may develop due to insufficient collateral supply. Both hemodynamic instability and embolic infarction can occur in VA occlusion, which may cause severe symptoms in a patient. Extracranial carotid-VA bypass should be considered for symptomatic VA occlusion patients, especially when the patient has repeated ischemic brain injuries. In this report, the cases of three extracranial carotid-VA bypass patients are introduced, along with a brief description of the surgical techniques. All three cases were treated with different bypass methods according to their disease location.

Acute Ischemic Stroke Caused by Internal Carotid Artery Occlusion: Impact of Occlusion Type on the Prognosis.

BACKGROUND: We aimed to compare clinical outcomes of acute ischemic stroke (AIS) due to internal carotid artery (ICA) occlusion following mechanical thrombectomy (MT), focusing on occlusion types. METHODS: We retrospectively reviewed 67 AIS patients who had an ICA occlusion on computed tomography angiography and underwent MT in a single tertiary center. ICA occlusion types were categorized as (1) true cervical ICA (cICA) occlusion (true occlusion), (2) pseudo-occlusion of the cICA (pseudo-occlusion), and (3) distal ICA (dICA) occlusion. We compared the clinical characteristics and their outcomes according to the ICA occlusion type. RESULTS: Fourteen patients were diagnosed with true occlusion, 32 with pseudo-occlusion, and 21 with dICA occlusion. The main etiologies were atherothrombotic in true occlusion (64.3%) and cardioembolic in pseudo-occlusion (81.3%) and dICA occlusion (71.4%) (P < 0.001). Pseudo-occlusion showed lower rates of successful reperfusion (37.5%, P = 0.009, 78.6% in true occlusion and 71.4% in dICA occlusion) and poor functional outcome at 3 months (18.8%, P = 0.037, 50% in true occlusion and 47.6% in dICA occlusion) with statistical significance. The infarction volume (169.4 ± 154.4 mL, P = 0.004, 29.2 ± 52.7 mL in true occlusion and 105.8 ± 13.4 mL in dICA occlusion) was significantly higher in pseudo-occlusion. On multivariate logistic analysis, pseudo-occlusion (odds ratio [OR]: 4.84, 95% confidence interval [CI] 1.02-22.87, P = 0.023) was an independent risk factor for poor reperfusion, which was significantly associated with a poor functional prognosis (OR: 22.04, 95% CI 1.99-243.83, P = 0.012). CONCLUSIONS: Patients with pseudo-occlusion showed poorer clinical outcomes compared with other ICA occlusion types, possibly due to a poor reperfusion rate after MT.

Eosinophilic meningitis following suboccipital craniotomy without bovine dural graft: illustrative case.

BACKGROUND: Eosinophilic meningitis is a rare known complication after brain surgery associated with duraplasty using artificial bovine graft. However, eosinophilic meningitis after craniotomy without bovine dural graft has not been reported. OBSERVATIONS: A 48-year-old female presented with lateral medullary infarction caused by a vertebral artery dissecting aneurysm incorporating the posterior inferior cerebellar artery (PICA). The authors performed occipital artery-PICA anastomosis and repaired the dura by primary suture without bovine graft. Thereafter, endovascular internal trapping using coils was conducted. Severe headache developed at postoperative day 17, and the patient was diagnosed with eosinophilic meningitis. After administration of a high-dose corticosteroid for 2 weeks, her symptoms and laboratory findings were improved. LESSONS: Postoperative eosinophilic meningitis is rarely related to craniotomy without using bovine graft. Neurosurgeons should consider the possibility of eosinophilic meningitis after craniotomy without a xenogeneic dural material.

A Case of Diffuse Leptomeningeal Glioneuronal Tumor Misdiagnosed as Chronic Tuberculous Meningitis without Brain Biopsy.

Here we report a rare case of diffuse leptomeningeal glioneuronal tumor (DLGNT) in a 62-year-old male patient misdiagnosed as having tuberculous meningitis. Due to its rarity and radiologic findings of leptomeningeal enhancement in the basal cisterns on magnetic resonance imaging (MRI) similar to tuberculous meningitis, DLGNT in this patient was initially diagnosed as communicating hydrocephalus from tuberculous meningitis despite absence of laboratory findings of tuberculosis. The patient's symptoms and signs promptly improved after a ventriculoperitoneal shunting surgery followed by empirical treatment against tuberculosis. Five years later, mental confusion and ataxic gait developed in this patient again despite well-functioning ventriculoperitoneal shunt. Aggravation of leptomeningeal enhancement in the basal cisterns was noted in MRI. An additional course of antituberculosis medication with steroid was started without biopsy of the brain. Laboratory examinations for tuberculosis were negative again. After four months of improvement, his mental confusion, memory impairment, dysphasia, and ataxia gradually worsened. A repeated MRI of the brain showed further aggravation of leptomeningeal enhancement in the basal cisterns. Biopsy of the brain surface and leptomeninges revealed a very rare occurrence of DLGNT. His delayed diagnosis of DLGNT might be due to prevalence of tuberculosis in our country, similarity in MRI finding of prominent leptomeningeal enhancement in the basal cisterns, and extreme rarity of DLGNT in the elderly. DLGLT should be considered in differential diagnosis of medical conditions presenting as communicating hydrocephalus with prominent leptomeningeal enhancement. A timely histologic diagnosis through a leptomeningeal biopsy of the brain and spinal cord in case of unusual leptomeningeal enhancement with uncertain laboratory findings is essential because cytologic examination of the cerebrospinal fluid in DLGNT is known to be negative.