Contemporary Treatment of Intracranial Blood Blister Aneurysms - A Systematic Review.

INTRODUCTION: Blood blister aneurysms (BBAs) are rare aneurysms affecting non-branched points of intracerebral arteries. Due to their small size and fragility, BBAs are prone to rupture, and can be challenging to diagnose and treat. Several treatment options have been suggested yet there is no consensus regarding the best modality to reduce morbidity and mortality. MATERIALS AND METHODS: A systematic review of the literature was conducted searching for articles discussing the treatment of BBAs. Inclusion criteria included: articles published between January 2010 and August 2020, English language, with each paper including at least 15 patients. Studies included required detailed reporting of patient demographics, treatment, and patient outcomes (including complications, recurrence, neurologic functional status, and mortality). RESULTS AND DISCUSSION: A total of 25 studies with 883 patients were included. Most were female (n = 594, 67.3%) and aneurysms were overwhelmingly located in the supraclinoid internal carotid artery (99%). Aneurysms were variable in size and mostly presented with subarachnoid haemorrhage. Endovascular treatment (n = 518, 58.7%) was more common than microsurgery (n = 365, 41.1%) while only 2 patients were managed conservatively. Complications were more common in patients treated microsurgically. Microsurgical procedures had an unfavorable outcome (mRS 4-6, GOS 1-3) rate of 27.8% (n = 100/360) while that of endovascular procedures was 14.7% (n = 70/477). Endovascular procedures had a lower mortality rate than microsurgical interventions (8.4% vs 11%). CONCLUSION: This review demonstrates that endovascular treatment of blood blister aneurysm has reduced morbidity and mortality when compared with microsurgical treatment. Small sample sizes and substantial study heterogeneity makes strong conclusions difficult.

A Systematic Review of Neuropsychological Outcomes After Treatment of Intracranial Aneurysms.

BACKGROUND: Aneurysmal subarachnoid hemorrhage is a cause of profound morbidity and mortality. Its effects extend beyond functional neurological status to neurocognitive and psychological functioning. Endovascular treatment is becoming more prevalent after increasing evidence for its safety and efficacy; however, there is a relative paucity of evidence specific to neurocognitive status after treatment. OBJECTIVE: To assess and compare neuropsychological outcomes after the treatment of ruptured and unruptured intracranial aneurysms. METHODS: A systematic review of the literature was conducted searching for articles assessing the neuropsychological and cognitive outcomes after the treatment of ruptured and unruptured intracranial aneurysms. Inclusion criteria were English language, publication between January 2000 and October 2020, and discussion of neuropsychological outcomes in adequate detail. Outcomes were categorized into 8 domains: 5 Neurocognitive (Language, Executive Function, Complex Attention, Memory and Learning, and Perceptual motor function), Intelligence Quotient, Affect, and Quality of Life. RESULTS: Twenty-four articles were included comprising 2236 patients (924 surgical clipping, 1095 endovascular coiling, and 217 controls). These studies reported that most tests revealed no significant difference [n = 356/421 (84.56%)] between treatment modalities. More studies reported significantly superior test scores in the fields of language, executive function, and memory and learning after coiling [n = 53/421 tests (12.59%)] compared with clipping [n = 12/421 tests (2.85%)]. CONCLUSION: The current available data and published studies demonstrate a trend toward improved neurocognitive and psychological outcomes after endovascular treatment. Although these findings should be considered when deciding on the optimal treatment method for each patient, drawing definitive conclusions is difficult because of heterogeneity between patients and studies.

Clipping versus coiling: A critical re-examination of a decades old controversy.

BACKGROUND: Two major studies, The International Subarachnoid Aneurysm Trial and the Barrow Ruptured Aneurysm Trial, compare the long-term outcomes of clipping and coiling. Although these demonstrated coiling's initial benefits, rebleeding and retreatment rates as well as converging patient outcomes sparked controversy regarding its durability. This article will critically examine the available evidence for and against clipping and coiling of intracranial aneurysms. Critics of endovascular treatment state that the initial benefit seen with endovascular coiling decreases over the duration of follow-up and eventually functional outcomes of both treatment modalities are similar. Combined with the increased rate of retreatment and rebleeding, these trials reveal that coiling is not as durable and not as effective as a long-term treatment compared to clipping. Also, due to the cost of devices following endovascular treatment and prolonged hospitalization following clipping, the financial burden has been considered controversial. SUMMARY/KEY MESSAGES: Short-term outcomes reveal better morbidity and mortality outcomes following coiling. Despite the higher rates of retreatment and rebleeding with coiling, there was no significant change in functional outcomes following retreatment. Furthermore, examining more recent trials reveals a decreased rate of recurrence and rebleeding with improved technology and expertise. Functional outcomes deteriorate for both cohorts over time while recent results revealed improved long-term cognitive outcomes and levels of health-related quality of life after coiling in comparison to clipping. The expense of longer hospital stays following clipping must be balanced against the expense of endovascular devices in coiling.

Antiplatelet Drugs for Neurointerventions: Part 2 Clinical Applications.

Endovascular techniques have expanded to include balloon and stent-assistance, flow diversion and individualized endovascular occlusion devices, to widen the treatment spectrum for more complex aneurysm morphologies. While usually well-tolerated by patients, endovascular treatment of intracranial aneurysms carries the risk of complications, with procedure-related ischemic complications being the most common. Several antiplatelet agents have been studied in a neurointerventional setting for both prophylaxis and in the setting of intraprocedural thrombotic complications. Knowledge of these antiplatelet agents, evidence for their use and common dosages is important for the practicing neurointerventionist to ensure the proper application of these agents.Part one of this two-part review focused on basic platelet physiology, pharmacology of common antiplatelet medications and future directions and therapies. Part two focuses on clinical applications and evidence based therapeutic regimens.

Antiplatelet Drugs for Neurointerventions: Part 1 Clinical Pharmacology.

The development of endovascular treatment for intracranial aneurysms has established new techniques such as balloon and stent-assistance, flow diversion and endosaccular occlusion devices. Antiplatelet treatment is an important aspect to reduce risk of thrombus formation on microcatheters and implanted devices when utilizing these methods. It is particularly relevant for flow diverting stents to prevent early and late stent thrombosis. Consideration of platelet physiology and appropriate selection of antiplatelet medication is important as platelet dysfunction drives many of the pathological processes and complications of neurointerventional procedures. Part one of this review focuses on basic platelet physiology, pharmacology of common antiplatelet medications and future directions and therapies. Part two focuses on clinical applications and evidence-based therapeutic regimens.

Brown-Sequard syndrome associated with Horner's syndrome following a penetrating drill bit injury to the cervical spine.

We report a 41-year-old male who presented with a partial Brown-Sequard syndrome and Horner's syndrome following a penetrating drill bit injury to his mid cervical spine. As the injury was not a complete hemisection of the spinal cord, the patient presented with ipsilateral motor deficit and hyperesthesia and diminished contralateral fine touch sensation; however, proprioception, vibration and temperature were all initially intact. A cervical CT and MRI scan showed a damaged spinal cord at the C5/6 level with posterior cord compression secondary to haematoma. A decompressive laminectomy and evacuation of the haematoma was performed. Over the following 5 days the patient's right-sided motor deficit improved daily; however, he developed a contralateral deficit to pain and temperature upon wakening from the operation which did not resolve. The right-sided Horner's syndrome also persisted.

A Review of the Management of Cerebral Vasospasm After Aneurysmal Subarachnoid Hemorrhage.

BACKGROUND: Despite decades of research, cerebral vasospasm (CV) continues to account for high morbidity and mortality in patients who survive their initial aneurysmal subarachnoid hemorrhage. OBJECTIVE: To define the scope of the problem and review key treatment strategies that have shaped the way CV is managed in the contemporary era. METHODS: A literature search was performed of CV management after aneurysmal subarachnoid hemorrhage. RESULTS: Recent advances in neuroimaging have led to improved detection of vasospasm, but established treatment guidelines including hemodynamic augmentation and interventional procedures remain highly variable among neurosurgical centers. Experimental research in subarachnoid hemorrhage continues to identify novel targets for therapy. CONCLUSIONS: Proactive and preventive strategies such as oral nimodipine and endovascular rescue therapies can reduce the morbidity and mortality associated with CV.

One and a half syndrome following penetrating head injury: Case report.

The authors report a case of a 22-year-old otherwise healthy female who presented following a head injury during a bar altercation, with no associated loss of consciousness and an unknown mechanism of injury. Examination revealed an isolated 1cm laceration on the right upper eyelid, superior to her medial canthus. She experienced diplopia on right horizontal gaze due to a left internuclear ophthalmoplegia (INO) with an associated left conjugate horizontal gaze palsy, collectively described as a left one-and-a-half syndrome. CT and MRI demonstrated evidence of a deep penetrating injury above the right medial canthus, traversing the ethmoid and sphenoid sinuses, the dorsum sella, narrowly missing the basilar artery, penetrating the pons, and extending to the floor of the contralateral fourth ventricle. The patient was diagnosed with multiple sinus fractures, lesions in her left paramedian pontine reticular formation (PPRF) and medial longitudinal fasciculus (MLF), and progressive pneumocephalus. She underwent a transsphenoidal endoscopic repair via a vascularized mucosal flap without complication. Postoperatively, the patient's pneumocephalus resolved and her conjugate gaze markedly improved; however, minimal diplopia remained. This case demonstrates the importance of the clinical exam, and its benefit in localizing imaging findings and guiding treatment.

Computational fluid dynamic analysis of intracranial aneurysmal bleb formation.

BACKGROUND: The management of unruptured aneurysms is controversial, with the decision to treat influenced by aneurysm characteristics including size and morphology. Aneurysmal bleb formation is thought to be associated with an increased risk of rupture. OBJECTIVE: To correlate computational fluid dynamic (CFD) indices with bleb formation. METHODS: Anatomic models were constructed from 3-dimensional rotational angiography data in 27 patients with cerebral aneurysms harboring a single bleb. Additional models representing the aneurysm before bleb formation were constructed by digitally removing the bleb. We characterized hemodynamic features of models both with and without the blebs using CFDs. Flow structure, wall shear stress (WSS), pressure, and oscillatory shear index (OSI) were analyzed. RESULTS: There was a statistically significant association between bleb location at or adjacent to the point of maximal WSS (74%, P = .019), irrespective of rupture status. Aneurysmal blebs were related to the inflow or outflow jet in 89% of cases (P < .001), whereas 11% were unrelated. Maximal wall pressure and OSI were not significantly related to bleb location. The bleb region attained a lower WSS after its formation in 96% of cases (P < .001) and was also lower than the average aneurysm WSS in 86% of cases (P < .001). CONCLUSION: Cerebral aneurysm blebs generally form at or adjacent to the point of maximal WSS and are aligned with major flow structures. Wall pressure and OSI do not contribute to determining bleb location. The measurement of WSS using CFD models may potentially predict bleb formation and thus improve the assessment of rupture risk in unruptured aneurysms.

Sacral ganglioneuroma in a 19-year-old woman.

Ganglioneuroma is a rare benign neural crest tumour, located usually in the posterior mediastinum and retroperitoneum. It tends to acquire significant size before symptoms or clinical signs become apparent. We report a 19-year-old female who underwent excision of a pelvisacral ganglioneuroma via a Pfannenstiel incision, after an abdominopelvic CT scan for investigation of left iliac fossa pain and menorrhagia detected a pelvic mass. This report highlights the importance of complete surgical excision of these lesions and the collaboration of multiple surgical units in managing these often large, variably located tumours.