Emergency extra-intracranial bypass surgery in a patient with neurologic deficit after an accident in carotid occlusive test: A case report.

OBJECTIVE: BTO is the procedure performed to assess the collateral circulation within the Willis circle in a giant ICA aneurysm. An ICA occlusion after BTO is very rare. We present a case of an internal carotid artery occlusion as a complication of BTO that required urgent revascularization surgery. CASE PRESENTATION: A 56-year-old female with a history of transient ischemic attacks for one year was diagnosed with multiple aneurysms: a giant aneurysm of the left supra-clinoid ICA, two small ones on left MCA and right ophthalmic. A BTO was performed to assess collateral supply and determine whether bypass surgery should be necessary. During the procedure, the balloon was detached while insufflating, and the patient had a subsequent neurological decline consistent with an MCA syndrome. EC-IC bypass surgery was performed with an end-to-side anastomosis of STA-MCA by trapping the giant aneurysm and clipping the ipsilateral MCA aneurysm. The patient had a reversal of neurological symptoms and made an uneventful recovery. DISCUSSION: We discuss the epidemiology of giant ICA aneurysms, the indications for BTO, and its complication. Emergency intracranial and extracranial bypass surgery in case of acute ICA injury is also discussed. We also highlighted the attributable factors to treatment strategies under restrictive conditions in Vietnam. CONCLUSIONS: ICA occlusion due to insufflated balloon detachment is an unreported complication in literature. Emergency bypass surgery is a potential treatment choice for this unusual iatrogenic complication.

A system divided: the state of neurosurgical training in modern-day Vietnam.

The current report is the first of its kind in describing the neurosurgical training in modern-day Vietnam. Starting with in-depth face-to-face interviews, followed by electronically distributed questionnaires, a detailed picture of the training systems emerged.Neurosurgical training in Vietnam is multifaceted and dichotomous. The country of nearly 100 million people currently has only one neurosurgery-specific residency program, at the University of Medicine and Pharmacy at Ho Chi Minh City (UMPHCMC). This program lasts for 3 years, and Westerners might recognize many similarities to programs native to their countries. A similar training program exists in the north, at the Hanoi Medical University, but at this institution, trainees focus on neurosurgery only in the final year of their 3-year training. Neurosurgical training that resembles the program in Hanoi permeates the rest of the country, and the goal for all of the programs is to rapidly produce surgeons who can be dispersed throughout the country to treat patients requiring urgent neurosurgical procedures who are medically unsuitable for transfer to large urban centers and multispecialty hospitals. For the privilege of practicing elective neurosurgery, trainees around the country are required to acquire further training in Ho Chi Minh City or Hanoi or during fellowships abroad.A clear description of the neurosurgical training systems in Vietnam is hard to achieve, as there exist many diverse pathways and no standard definition of the endpoint for training. Unification and a clearer certification standard will likely help to elevate the standards of training and the state of neurosurgical practice in Vietnam.

Spontaneous Thrombosis of Giant Dissecting Fusiform Middle Cerebral Aneurysm After Double-Barrel Superficial Temporal Artery-Middle Cerebral Artery Bypass: A Case Report of Decision-Making in a Limited Resource Environment.

BACKGROUND: The treatment of giant fusiform middle cerebral artery (MCA) aneurysms remains daunting owing to their tendency to be associated with precarious end-vessel anatomy and the need for complex microsurgical techniques to appropriately address the aneurysm and the vasculature at risk. Extracranial-intracranial bypass revascularization remains a valuable tool for treating these complex lesions. In the present report, we have described a rare occurrence in which the creation of a double-barrel superficial temporal artery (STA-MCA) bypass facilitated spontaneous obliteration of the aneurysm. We have also highlighted our decision-making process, which was affected by operating in a low-to-middle income country with limited resources. CASE DESCRIPTION: A 32-year-old man had presented with recurrent ischemic events in the left MCA distribution and subsequent subarachnoid hemorrhage due to rupture of a giant complex fusiform MCA aneurysm. The patient underwent double-barrel STA-MCA bypass and was scheduled for second-stage clip reconstruction or partial trapping. Postoperative imaging studies revealed progressive thrombosis of the M1 segment, resulting in occlusion of the aneurysm without subsequent trapping or clipping. The patient recovered remarkably without further repeat hemorrhage or ischemic injury. We also reviewed the reported data. CONCLUSIONS: Double-barrel STA-MCA bypass is a potential salvage surgical technique to treat selected ruptured complex giant fusiform MCA aneurysms. In rare selected cases, the flow alteration induced by the bypass alone can potentially facilitate aneurysm thrombosis.

How I do it: superficial temporal artery to middle cerebral artery bypass for treatment of giant middle cerebral artery aneurysm.

BACKGROUND: Giant middle cerebral artery aneurysms are frequently anatomically complicated. Trapping may yield poor outcome, and bypass revascularization is often necessary as an adjunctive treatment to preserve flow. METHOD: The technical nuances of superficial temporal artery to middle cerebral artery bypass are described in the setting of clip reconstruction of giant middle cerebral artery (MCA) aneurysm. In addition to an operative video, the anatomy and surgical technique are demonstrated in virtual reality to enhance the didactic clarity. CONCLUSION: Meticulous technique is paramount for successful superficial temporal artery MCA bypass. Along with clip reconstruction, it is a critical part of the treatment of complex, giant MCA aneurysms.

Outcome of Microsurgery for Arteriovenous Malformations in a Resource-Restricted Environment: Single-Surgeon Series from Vietnam.

BACKGROUND: The health care expenditure in Vietnam is equivalent to 1% of that in the United States. For most patients with brain arteriovenous malformations (AVM), surgery is the only available treatment modality. This study reports on the outcomes on AVM microsurgery in this resource-restricted environment. METHODS: This is a prospectively collected, retrospectively analyzed case series of consecutive patients who underwent surgical resection of AVM by a single surgeon in Vietnam. All surgeries were performed in a 3-year period in Hanoi. The primary endpoints were obliteration of the AVM and surgical morbidity (modified Rankin Scale [mRS] > 1). RESULTS: There were 86 patients and 62% presented with hemorrhage. Only 2 patients had preoperative embolization, and 47 patients (54%) had preoperative digital subtraction angiography. All patients underwent microsurgical resection of their AVM. Excluding the 4 patients who died, the AVM obliteration rate was 98%. The mean follow-up was 20.1 months. Before surgery, 36% of patients had at least some disability (mRS > 1). Postoperatively, this was reduced to 10% (McNemar P = 0.007). For the overall cohort, neurologic status was improved from initial encounter to final assessment (P = 0.001). Because of resource restrictions, some patients with hemorrhage experienced delays in treatment. There was no difference in outcome between patients who were admitted before or after 24 hours post ictus (P = 0.6). The days spent waiting for surgery did not correlate with final mRS in univariate regression (R2 = 0.01). CONCLUSIONS: Notwithstanding the limitation in health care resources in Vietnam, surgery for AVMs was successful in eliminating the malformation, with obliteration rates and morbidity comparable with international standards.

Comparison between fixed-dose, intracoronary bolus-only versus standard weight-adjusted dose, intravenous bolus and infusion administration of abciximab in patients undergoing primary percutaneous coronary intervention.

We studied the safety and effectiveness of fixed-dose, intracoronary bolus-only abciximab in 195 patients who underwent primary percutaneous coronary intervention for ST-segment elevation myocardial infarction. The patients were divided into 2 groups: Group A (n=120, 61.5%) received fixed-dose, intracoronary bolus-only, abciximab 10 mg; and Group B (n=75, 38.5%) received standard intravenous bolus (0.25 mg/kg) and maintenance abciximab infusion of 0.125 µg/kg/min for 12 h. There was no statistically significant difference in the baseline and post-procedure TIMI flow between Groups A and B. Final TIMI 3 flow was achieved in 90.0% and 89.3% of the patients in Groups A and B, respectively (p=0.14). Final TIMI myocardial perfusion grade 2/3 was achieved in 92.5% and 96.0% of the patients in Groups A and B, respectively (p=0.45). The six-month clinical outcomes were similar between Groups A and B (8.3% versus 5.3%, p=0.62).