Long-term follow up of surgical management of blood blister-like aneurysms at non-branching sites of the internal carotid artery.

To describe long-term follow-up of 25 patients who presented with subarachnoid hemorrhages due to blood blister-like aneurysms (BBAs) treated with direct clipping or clip reinforcement with or without direct neck repair. Between June 1993 and July 2009, 25 consecutive patients with ruptured BBAs of the supraclinoid internal carotid artery were retrospectively reviewed. The mean age of patients was 39.5 ± 11.3 years. The mean duration of clinical follow-up was 128.9 months (range, 85-196 months). All aneurysms were located in the supraclinoid portion of the internal carotid artery. The mean aneurysm diameter was 4.04 ± 1.3 mm on intra-operative microscopic field. Tearing of the aneurysmal neck during dissection occurred in 8 (32%) patients. Six of 7 patients with neck tearing underwent direct neck repair. Surgeons treated aneurysms via direct clipping with a Bemsheet® in 5 (20%) patients or by clip reinforcement with a silicone sheet in 20 (80%) patients. Clinical outcomes were favorable (modified Rankin Scale [mRS]: 0-2) in 21 (84%) of 25 patients. Four (16%) patients had an unfavorable outcome (mRS: 3-6). The patient with severe disability (mRS: 4) was treated with clip reinforcement and direct neck repair. Mild stenosis, moderate stenosis, and total occlusion of the parent artery were confirmed in 10 (40%) patients, 6 (24%) patients, and 1 (4%) patient, respectively. Although surgical treatment of BBAs was associated with varying degrees of parent vessel patency loss, long-term follow-up results for more than 10 years showed that direct surgical clipping or clip reinforcement with a silicone sheet appeared to be a curative surgery.

Acquired dural arteriovenous fistula after cerebellopontine angle meningioma: A case report.

RATIONALE: Intracranial brain surgeries, including ventriculostomy, burr hole, craniotomy, and craniectomy, are the most common causes of acquired dural arteriovenous fistula (dAVF). Here we report a case of acquired dAVF after a cerebellopontine angle meningioma surgery. PATIENT CONCERNS: A 51-year-old woman was diagnosed with a 40-mm cerebellopontine angle meningioma. The patient underwent surgery via a retrosigmoid suboccipital approach. A small craniotomy and an additional craniectomy were performed. At 7 months after the surgery, she presented with pulsating tinnitus and headache. DIAGNOSIS: Magnetic resonance imaging and digital subtraction angiography showed a dAVF that was fed by the occipital artery and drained into transverse and sigmoid sinuses. INTERVENTIONS: We performed Onyx® (Irvine, CA) embolization. OUTCOMES: The patient's symptoms completely improved. LESSONS: Craniectomy defects, partially exposed sinuses, and incomplete cranioplasty might be risk factors for iatrogenic dAVF after a retrosigmoid suboccipital craniotomy or craniectomy. Complete reconstructive cranioplasty is an essential procedure to prevent a direct connection between the venous sinus and the external carotid artery.

Subarachnoid hemorrhage due to middle cerebral artery dissection mimicking aneurysm - Case report.

We report a case of subarachnoid hemorrhage due to a dissecting middle cerebral artery that was misdiagnosed as saccular aneurysm. A 74-years old female patient presented with headache and neck pain for 4 days. Brain magnetic resonance imaging revealed subarachnoid hemorrhage in both Sylvian fissures. A ruptured left middle cerebral artery bifurcation saccular aneurysm and unruptured basilar tip aneurysm were diagnosed. The patient was treated surgically using the transsylvian approach. However, no saccular aneurysm was found during the surgery, and the diagnosis was corrected for middle cerebral artery dissection. We treated the dissected segment of the middle cerebral artery and performed clip reinforcement. We experienced a case of middle cerebral artery dissection with no neurological deficit, which was misdiagnosed as a saccular aneurysm. If the stump of the occlusion is conical, dissection should be suspected. High-resolution magnetic resonance imaging and angiography should be performed for a differential diagnosis if dissection is suspected.

Gamma knife radiosurgery as an alternative treatment of Barrow type B carotid cavernous fistulas: A case report.

RATIONALE: Barrow type B carotid-cavernous fistulas are dural shunts between the meningeal branches of the internal carotid artery and the cavernous sinus; these types of dural fistulas can produce specific patterns of symptoms based on the pattern of venous drainage. PATIENT CONCERNS AND DIAGNOSES: A 67-year-old man came to our hospital presenting with acute left orbital pain and double vision in the left eye. The diagnosis was carotid-cavernous fistula fed by the meningohypophyseal trunk and drained to the left superior ophthalmic vein. INTERVENTIONS AND OUTCOMES: We planned gamma knife radiosurgery for the left cavernous sinus including fistula point as an alternative treatment. The orbital pain disappeared in 2 weeks, and all signs and symptoms in the left eye completely improved within 2 months. LESSONS: Gamma knife radiosurgery may be an alternative treatment for carotid cavernous fistula. Furthermore, in patients with poor vascular access and no fatal presentation, this may be a reasonable first-line treatment option.

Predictive value of CT angiography source image ASPECTS in patients with anterior circulation acute ischemic stroke after endovascular treatment: ultimate infarct size and clinical outcome.

BACKGROUND AND PURPOSE: The objective of this study was to investigate the predictive value of computed tomographic angiography (CTA) source image Alberta Stroke Program Early CT Score (ASPECTS) on clinical outcome and final infarction extent after endovascular treatment (EVT) in patients with acute ischemic stroke (AIS). M: ethods : All eligible patients from January 2014 to March 2018 undergoing EVT due to anterior circulation AIS were retrospectively reviewed. The baseline ASPECTS on initial noncontrast CT (NCCT) and the CTA source image were compared with the follow-up MR diffusion-weighted imaging (DWI) ASPECTS. Receiver operating characteristic (ROC) curve analysis was used to assess the predictive value of CTA ASPECTS for prediction of final infarct extent and good clinical outcome. RESULTS: Our sample included a total of 122 eligible patients (64 males, mean age 70 years) with a median baseline National Institute of Health Stroke Scale (NIHSS) score of 12. Baseline ASPECTS on the CTA source image correlated with follow-up MR DWI ASPECTS better than NCCT ASPECTS (P<0.001). ROC curve analysis revealed baseline CTA ASPECTS (area under the curve [AUC] =0.74, 95% CI: 0.65 to 0.83, P<0.001) can better predict favorable functional outcome than NCCT ASPECTS (AUC=0.64, 95% CI: 0.54 to 0.74, P=0.008). Baseline NIHSS score <15, CTA ASPECTS≥8, and successful recanalization were independent predictors of good clinical outcomes. CONCLUSION: The ASPECTS on the CTA source image provides more information in the prediction of good clinical outcome and final infarction size than NCCT in patients with AIS treated with EVT.

Gamma Knife radiosurgery in steroid-intolerant Tolosa-Hunt syndrome: case report.

Tolosa-Hunt syndrome is a rare cause of painful ophthalmoplegia due to idiopathic chronic granulomatous inflammation in the cavernous sinus. Usually clinical manifestations are well controlled by corticosteroid therapy, but steroid dependency or resistance is common. We report a case of marked improvement of Tolosa-Hunt syndrome without symptom relapse after Gamma Knife radiosurgery in a patient with steroid intolerance.

Surgery versus Conservative Treatment for Spontaneous Supratentorial Intracerebral Hemorrhage in Spot Sign Positive Patients.

OBJECTIVE: An advantage of surgical treatment over conservative treatment of spontaneous intracerebral hemorrhage (ICH) is controversial. Recent reports suggest that contrast extravasations on CT angiography (CTA) might serve as a crucial predictor of hematoma expansion and mortality. The purpose of this study was aimed at investigating the efficacy of surgical treatment in patients with spot sign positive ICH. METHODS: We used our institutional medical data search system to identify all adult patients who admitted for treatment of ICH between January 1, 2007 and January 31, 2012. Patients were classified two groups into a surgical group (n=27) and a conservative treatment group (n=28). Admission criteria were the following: age 20-79 years, spontaneous supratentorial ICH, Glasgow Coma Score Ranging from 9 to 14, ICH volume ≥20 mL, and treatment within 24 hours. RESULTS: Fifty-five patients were analyzed. There was no significant difference in the ICU stay between the conservative treatment group (7.36±3.66 days) and the surgical treatment group (6.93±2.20 days; p=0.950). There was a significant difference in the in-hospital stay between the conservative treatment group (13.93±8.87 days) and the surgical treatment group (20.33±6.37 days; p=0.001). Overall mortality at day 90 after ICH was 36.4%; this included 16 of 28 patients (57.1%) in the conservative group and 4 of 27 patients (14.8%) in the surgical group. In univariate analysis, there was a positive effect of the surgical treatment in reducing mortality at 90 days (p=0.002), Glasgow Outcome Scale (GOS) at 90-day (p=0.006), and modified Rankin Scale (mRS) at 90-day (p=0.023). In multivariate logistic analysis, there was a significant difference in mortality (odds ratio, 0.211; 95% confidence interval, 0.049-0.906; p=0.036) between the groups at 90-day follow-up. However, there was no significant difference in GOS (odds ratio, 0.371; 95% confidence interval, 0.031-4.446; p=0.434) and mRS (odds ratio, 1.041; 95% confidence interval, 0.086-12.637; p=0.975) between the groups at 90-day follow-up. CONCLUSION: In this study of surgical treatment of supratentorial ICH in patients with spot sign positive in CTA was associated with less mortality despite of long duration of in-hospital stay. We failed to show that clinical outcome benefit of surgical treatment compared with conservative treatment in patients with spot sign positive ICH.

Malignant transformation of an epidermoid cyst in the cerebellopontine angle.

Intracranial squamous cell carcinoma is extremely rare, with most of the cases arising from malignant transformation of an epidermoid or a dermoid cyst. The patient presented with facial weakness. Initial magnetic resonance imaging revealed a mass in the right cerebellopontine angle. A subtotal resection was performed via right retrosigmoid suboccipital approach. Histopathological findings were consistent with an epidermoid tumor. Five months later, the patient underwent gamma knife radiosurgery due to highly probable recurrent epidermoid tumor. Two years after, the patient's neurological deficit had been newly developed, and follow-up magnetic resonance imaging demonstrated a large contrast-enhancing tumor in the left cerebellopontine angle, which compressed the brainstem. After resection of the tumor, histopathological examinations revealed a squamous cell carcinoma probably arising from an underlying epidermoid cyst. We report a case of an epidermoid tumor in the cerebellopontine angle that transformed into a squamous cell carcinoma.

Independent predictors for recurrence of chronic subdural hematoma.

BACKGROUND: Chronic subdural hematoma is characterized by blood in the subdural space that evokes an inflammatory reaction. Numerous factors potentially associated with recurrence of chronic subdural hematoma have been reported, but these factors have not been sufficiently investigated. In this study, we evaluated the independent risk factors of recurrence. METHODS: We analyzed data for 420 patients with chronic subdural hematoma treated by the standard surgical procedure for hematoma evacuation at our institution. RESULTS: Ninety-two (21.9 %) patients experienced at least one recurrence of chronic subdural hematoma during the study period. We did not identify any significant differences between chronic subdural hematoma recurrence and current antiplatelet therapy. The recurrence rate was 7 % for the homogeneous type, 21 % for the laminar type, 38 % for the separated type, and 0 % for the trabecular type. The rate of recurrence was significantly lower in the homogeneous and trabecular type than in the laminar and separated type. We performed a multivariate logistic regression analysis and found that postoperative midline shifting (OR, 3.6; 95 % CI, 1.618-7.885; p = 0.001), diabetes mellitus (OR, 2.2; 95 % CI, 1.196-3.856; p = 0.010), history of seizure (OR, 2.6; 95 % CI, 1.210-5.430; p = 0.014), width of hematoma (OR, 2.1; 95 % CI, 1.287-3.538; p = 0.003), and anticoagulant therapy (OR, 2.7; 95 % CI, 1.424-6.960; p = 0.005) were independent risk factors for the recurrence of chronic subdural hematoma. CONCLUSIONS: We have shown that postoperative midline shifting (≥5 mm), diabetes mellitus, preoperative seizure, preoperative width of hematoma (≥20 mm), and anticoagulant therapy were independent predictors of the recurrence of chronic subdural hematoma. According to internal architecture of hematoma, the rate of recurrence was significantly lower in the homogeneous and the trabecular type than the laminar and separated type.

Hemimasticatory spasm treated with microvascular decompression of the trigeminal nerve.

Hemimasticatory spasm is a very rare disorder of the trigeminal nerve characterized by paroxysmal involuntary contraction of the jaw-closing muscles. The mechanisms leading to hemimasticatory spasm are still unclear. Recently, injection of botulinum toxin has become the treatment of choice due to its excellent results. We report a case of a successful treatment of hemimasticatory spasm via microvascular decompression of the motor branch of the trigeminal nerve.

Surgical management of anterior cerebral artery aneurysms of the proximal (A1) segment.

OBJECTIVE: To report a series of 20 consecutive patients with aneurysms of the proximal segment (A1) of the anterior cerebral artery (ACA. METHODS: The medical records of patients who had undergone surgery for intracranial aneurysms at two institutions between January 1, 1989, and February 1, 2009, were reviewed. Mean patient age was 52.15 years (range 39-69 years). All 20 patients underwent direct surgery, with clipping or trapping, via standard pterional craniotomy. RESULTS: The incidence of A1 segment aneurysm was 0.59%. There were 16 women and 4 men, showing a strong predominance of this lesion in women. Mean aneurysm size was 6.95 mm (range 3-10 mm). Four patients (20%) had multiple aneurysms, and three patients (15%) had associated vascular anomalies. Among patients whose aneurysms originated from perforating arteries, dissection sacrificed the perforating arteries in two patients, and the perforating arteries occluded postoperatively in three patients. In the patients whose aneurysms did not originate from perforating arteries, no perforating arteries were sacrificed during dissection, and perforating arteries became occluded in two patients postoperatively. There was no statistically significant difference between the two groups of patients regarding the incidence of injury or occlusion. Clinical outcomes were as follows: good recovery in 15 (75%) patients, moderate disability in 2 (10%) patients, severe disability in 2 (10%) patients, and death in 1 (5%) patient. CONCLUSIONS: The important consideration in surgery for intracranial aneurysms is preservation of the perforating arteries, through cautious dissection around the neck or dome and avoidance of direct clip compression, even after releasing the retracted frontal lobe.

Surgical strategies using cerebral revascularization in complex middle cerebral artery aneurysms.

OBJECTIVES: To describe surgical strategies using cerebral revascularization for complex middle cerebral artery aneurysms unsuitable to microsurgical clipping. MATERIALS AND METHODS: In this study, the clinical features, case management, and results in 9 consecutive patients who underwent 10 cerebral revascularization procedures between January 1999 and April 2008 were retrospectively analyzed. The patient population consisted of 6 men and 3 women whose ages ranged from 15 to 71 years (mean, 42.4 years). The size of the aneurysms ranged from 12 to 35 mm (mean, 24.3 mm). Treated aneurysms were located in the M1 segment in 2 patients, the middle cerebral artery (MCA) bifurcation in 3 patients, the distal M3 segment in 3 patients, and the anterior temporal artery (ATA; the early cortical branch of the M1 segment) in 1 patient. A total of 10 revascularizations were performed. Three aneurysms were saccular and six aneurysms were fusiform. For the fusiform aneurysms of the M1 segment in 2 patients, superficial temporal artery (STA) trunk-saphenous vein (SV)-MCA bypasses followed by trapping were performed. For the large saccular MCA bifurcation aneurysms in 3 patients, STA-MCA bypasses followed by complete neck clipping, including the revascularized branch with the preservation of the flow of the other branch, were performed in 2 cases, and a STA trunk-SV-MCA bypass secondary to direct neck clipping with the preservation of both M2 branches was performed in 1 case. For the fusiform distal MCA aneurysms, STA-MCA bypasses in 2 patients and in situ MCA-MCA bypasses in 2 patients were performed. In one case involving distal MCA fusiform aneurysm, STA-MCA bypass and MCA-MCA bypass were performed simultaneously. In a case involving fusiform ATA aneurysm, primary reanastomosis after aneurysm excision was performed in 1 patient. RESULTS: The post-operative 3-month Glasgow outcome scales were good recovery in 6 patients, severe disability in 1 patient, a vegetative state in 1 patient, and death in 1 patient. A follow-up angiography was performed in 6 patients and revealed a patent bypass in 5 patients. In one case treated by direct neck clipping secondary to cerebral revascularization, the angiography obtained 2 weeks later showed graft occlusion, but there were no neurologic symptoms. Among the unfavorable outcomes of 3 patients who did not undergo follow-up angiography, surgery-related morbidity secondary to cerebral infarction was due to the size discrepancy between the donor and recipient vessels in 1 patient with severe disability. In the other 2 patients, the preoperative conditions were Hunt and Hess grade V. CONCLUSIONS: Cerebral revascularization is a safe and effective technique of treatment for selective cases of complex large or giant aneurysms and unclippable fusiform aneurysms in the MCA.