Use of intraoperative sodium tetradecyl sulfate for the treatment of a spinal epidural hemangioma. Technical note.

Spinal hemangiomas can be categorized into three different groups based on location. Vertebral body (VB) hemangiomas are frequent incidental findings on magnetic resonance (MR) imaging. There is a subdivision of these with spinal epidural extension that have been reported in the literature. Spinal hemangiomas can also be epidural without VB involvement; these are extremely rare with few reported cases in the thoracic epidural spinal column. The diagnosis and imaging characteristics as well as the surgical tools used in gross-total resection of spinal epidural hemangioma are not well understood. The authors present a detailed characterization of a spinal epidural hemangioma in a 30-year-old woman who presented with complaints of gradual onset of low-back pain that worsened over 1 year. The MR imaging findings indicated a large L2-S1 epidural spinal mass causing thecal sac compression. The patient underwent an L2-S1 laminectomy, and a vascular extradural mass was noted on the posterior aspect of the dura mater. Preoperative spinal angiography as well as intraoperative angiography was performed. Total resection of the tumor was achieved using intraoperative embolization with sodium tetradecyl sulfate and microscopic dissection. The postoperative MR imaging findings and clinical outcome were excellent. The findings and use of sodium tetradecyl sulfate in gross-total resection are discussed. The authors also review treatment modalities and demonstrate the utility and effectiveness of intraoperative sodium tetradecyl sulfate in grosstotal resection of large difficult spinal epidural hemangiomas.

Brain tumor imaging and surgical management: the neurosurgeon's perspective.

Advances in imaging technologies have influenced neurosurgical techniques and decisions and have enabled previously impossible resections, and neurosurgeons rely on the various modalities to make surgery as safe as possible. We look at the different technologies that have developed and how they are used by neurosurgeons, in combination with the knowledge of anatomy, to evaluate brain and spinal tumors and make surgical decisions that improve treatment outcomes.

Guglielmi detachable coil extraction: suction generated by pusher-wire withdrawal after coil detachment within an intracranial aneurysm.

We present a case of Guglielmi detachable coil extraction into a microcatheter after coil detachment during embolization of a superior hypophyseal artery aneurysm; extraction was a result of the suction generated during pusher-wire withdrawal. Experimental simulations using many coil and microcatheter combinations were used to identify factors that contribute to the likelihood of this phenomenon.

Endovascular treatment for dural arteriovenous fistulae of the superior petrosal sinus.

OBJECTIVE: To determine the usefulness of endovascular embolization for treatment of dural arteriovenous fistulae of the superior petrosal sinus. METHODS: We performed a retrospective review of 18 patients treated during a 16-year period. Transarterial and/or transvenous embolizations were performed as a preoperative adjunct or definitive therapy. Clinical follow-up status was supplemented by telephone interviews to determine Glasgow Outcome Scale scores. RESULTS: Fourteen patients (78%) were treated with a combination of endovascular therapy and open surgery, and 4 were treated by embolization alone (22%). Angiographic cure was achieved in all patients (100%). Thirty-day morbidity and mortality were 11 and 0%, respectively. The mean follow-up period was 5.4 years. At the latest follow-up examination, all patients had returned to independent clinical status (Glasgow Outcome Scale scores of 1 or 2). CONCLUSION: Endovascular treatment of dural arteriovenous fistulae of the superior petrosal sinus can result in cure when access to the site of the fistula can be achieved. Preoperative embolization is a safe and effective adjunct to minimize bleeding during open neurosurgery.

Robotic-assisted superficial temporal artery-to-middle cerebral artery anastomosis.

Robotic-assisted surgery is becoming more prevalent and accepted in the USA and is routine in many medical centers across a variety of specialties, but mainly in urology and general surgery. However, neurosurgery has yet to embrace this new technology. We used the da Vinci(®) robot (Intuitive Surgical, Sunnyvale, California) to perform a robotic-assisted superficial temporal artery-to-middle cerebral artery bypass on a cadaveric head. The object of this technical note is to describe the use of the da Vinci(®) robot to perform an extracranial-intracranial bypass. Using a cadaveric human head, the da Vinci(®) robot was successfully used to anastomose the superficial temporal artery to an M2 branch of the middle cerebral artery. We were successfully able to demonstrate the utility of using the da Vinci(®) robot in extracranial to intracranial anastomosis in a cadaveric head. The optics were excellent and physiologic tremor was eliminated. More studies are needed to assess the feasibility, safety, and utility of this device in living tissue within the field of neurosurgery.

Intraorbital arteriovenous fistulae of the ophthalmic veins treated by transvenous endovascular occlusion: technical case report.

OBJECTIVE AND IMPORTANCE: Intraorbital arteriovenous fistulas (AVF) of the ophthalmic veins are an extremely rare phenomenon. This article describes two such cases treated solely by transvenous occlusion and not hitherto described in the literature. METHODS AND RESULTS: Two women, aged 51 and 63 years old, presented with proptosis and chemosis mimicking a carotid-cavernous fistula. In both cases, cerebral angiography revealed an intraorbital dural AVF of the superior and inferior ophthalmic vein, respectively. Both patients underwent transvenous ablation of the dural AVF retrograde via the facial vein and subsequently had complete resolution of the presenting symptoms. CONCLUSION: Ophthalmic vein fistulas are a rare form of AVF with presenting symptoms mimicking those of carotid cavernous fistulae. This report describes two cases of ophthalmic vein fistulas successfully treated and angiographically obliterated via transvenous embolization with resolution of the patient's presenting symptoms.

Percutaneous vertebroplasty: an emerging therapy for vertebral compression fractures.

Osteoporosis is a debilitating disease that occurs in epidemic proportions in Western societies and has a large economic impact. Percutaneous vertebroplasty is successful in alleviating subacute and chronic pain caused by osteoporotic compression fractures and pathological vertebral fractures from tumor infiltration. The technique is safe and can be performed on an outpatient basis utilizing high-resolution fluoroscopy.

Vascular myelopathies-vascular malformations of the spinal cord: presentation and endovascular surgical management.

Spinal cord vascular malformations are often a cause of spinal myelopathy. Endovascular surgical approaches to spinal cord vascular malformations have become an important adjunct and often the primary treatment of these disorders. Spinal cord vascular malformations may be divided into several categories based on their anatomy and location. They may present with a wide range of symptoms far removed from the vascular pathology. Early recognition and treatment can effect a better outcome and often reverse presenting neurologic deficits. Emerging magnetic resonance imaging techniques allow visualization of flow voids, some vascular anatomy, and intramedullary pathology and are a good screening modality. However, selective diagnostic spinal angiography remains the study of choice to diagnose and elaborate on the anatomy and potential treatment protocols. Rapidly evolving endovascular techniques and technology are revolutionizing the treatment of vascular pathology in the central nervous system, either as an adjunct to traditional neurosurgical techniques or as definitive therapy. We review the diagnosis and treatment options for spinal cord vascular malformations.