Case series of 100 supraorbital mini-craniotomies in patients with good grade aneurysmal subarachnoid haemorrhage at a single neurosurgical Centre.

BACKGROUND: Endovascular techniques are becoming more common for cerebral aneurysms, but not all patients are suitable and open surgery is necessary for some. The traditional pterional approach requires a large craniotomy and this carries some morbidity in itself. With the growing expectation for minimally invasive surgery, we present our experience in supraorbital mini-craniotomy for good grade aneurysmal subarachnoid haemorrhage. METHODS: Data on good-grade subarachnoid haemorrhage patients having aneurysms clipped via this approach were collected prospectively. Aneurysms at all anterior circulation sites were included, with the exception of the pericallosal artery, which was not within reach. A long-term follow-up questionnaire was sent to patients who had a supraorbital approach to clip the aneurysm at more than 1 year from hospital discharge. RESULTS: Our results demonstrate mortality of 1% and severe residual disability in 10% of patients. Approach-related complications were low and it was considered that the operating space was not restricted in any of our cases. Return to work was achieved in 70% of patients who were working at the time of their haemorrhage. CONCLUSIONS: Supraorbital micro-craniotomy is a safe approach for patients with proximal anterior circulation aneurysms, with low mortality and morbidity.

Ventriculostomy associated haemorrhage: a complication of anti-platelet therapy during coiling.

A young man with Fisher grade IV subarachnoid haemorrhage (SAH) underwent aneurysm coiling following external ventriculostomy. Coiling was complicated by thrombus formation and parent vessel occlusion necessitating anti-platelet therapy. Several hours after anti-platelet therapy, catastrophic haemorrhage associated with the ventriculostomy tract occurred. Timing and location of haemorrhage suggest combined anti-platelet therapy and ventriculostomy may have been causal. The literature on ventriculostomy haemorrhage rates and risks with concomitant anti-platelet therapy are reviewed. Where endovascular coiling is being considered, the possibility of ventriculostomy-related haemorrhage should be considered and should influence subsequent treatment decisions.

Delayed post-operative haemorrhage after carmustine wafer implantation: a case series from two UK centres.

OBJECT: Significant haemorrhage following intracranial tumour resection may occur in 1-2% of cases and the majority occur within the first few hours post-operatively. Implantation of carmustine wafers has been associated with increased operative site complications in some series, but post-operative haematoma is not routinely reported. We analyzed the characteristics of post-operative haemorrhage after carmustine wafer insertion. METHODS: We performed a retrospective audit of surgical site haematoma after tumour resection and insertion of carmustine wafers in two neurosurgical units in the UK (University Hospital of North Staffordshire, Stoke-on-Trent, March 2003 - July 2012; Wessex Neurological Centre, Southampton, October 2005 - January 2013). RESULTS: During the specified time periods, carmustine wafers were inserted in 181 operations in 177 patients. We identified acute operative site haematomas after carmustine wafer insertion in 8 (4.4%) patients. All presented in a delayed fashion on or after Day 2 post-operatively. In contrast, acute operative site haematoma was present in 4/491 (0.81%) of patients who underwent resection without gliadel wafer insertion. CONCLUSIONS: In contrast to the expected timing of bleeding following intracranial tumour resection, all carmustine wafer patients who experienced haemorrhage presented in a delayed fashion on or after Day 2 post-operatively. The causative factors for universally delayed post-operative haematoma after carmustine wafer insertion are unclear and further studies are required to characterize this phenomenon.

An unusual aneurysm of a basilar perforating artery presenting with a subarachnoid haemorrhage.

A 65-year-old man had a perimesencephalic subarachnoid haemorrhage with normal angiography initially. After a rebleed 5 days later, a repeat angiogram revealed a pea-like aneurysm a short distance behind and below the basilar bifurcation. It was not amenable to endovascular treatment and the feeding vessel was coagulated and divided at open surgery via a sub temporal approach. He developed a right hemiparesis and dysphasia, from which he slowly recovered. Basilar perforating artery aneurysms are extremely rare, with only 4 previous cases reported.

Pituitary apoplexy after joint arthroplasty.

Pituitary apoplexy is a rare but potentially life-threatening condition caused by the sudden enlargement of a pituitary adenoma secondary to infarction and hemorrhage. The clinical syndrome is characterized by sudden onset of headache, ocular palsies, visual disturbances, and altered state of consciousness. We report 2 patients who had postoperative pituitary apoplexy after total hip and total knee arthroplasty. Asymptomatic pituitary adenomas are difficult to diagnose preoperatively. Its existence is an unlikely suspect until the clinical symptoms develop after surgery. This is the first reported case following total hip arthroplasty.

Subarachnoid hemorrhage emanating from a ruptured infundibulum: case report and literature review.

BACKGROUND: Infundibula are frequently regarded as incidental anatomical variants that are of no pathogenetic significance. CASE DESCRIPTION: A 51-year-old man presented with a sudden onset of severe occipital headache. Computed tomographic scan revealed a predominantly perimesencephalic pattern of SAH with a slight bias toward the left side. Angiography demonstrated a left PCo-A IF as the sole abnormality. At craniotomy, the left PCo-A IF was found to represent the sole abnormality. The IF was markedly reddened posteriorly, contained a capping clot, and lay immediately adjacent to a mass of xanthochromatous tissue. The PCo-A was hypoplastic and lacked perforating vessels; therefore, the IF base was successfully clipped with a straight Sugita clip parallel to the left ICA. At discharge and at clinical follow-up, our patient was asymptomatic and lacked neurologic signs. CONCLUSIONS: Infundibula may rarely represent a direct source of rupture and SAH. Exploratory craniotomy is required to establish the diagnosis and to provide definitive treatment. To label a case of SAH as angiogram-negative may be unwise when an IF potentially colocalizes to the SAH source.