Cerebrospinal Fluid Leak During Stapes Surgery: The Importance of Temporal Bone CT Reconstructions in Oblique Anatomically Oriented Planes.

Stapes gusher is a massive flow of perilymph and cerebrospinal fluid leak that fills the middle ear immediately after surgical opening of the labyrinth, such as during stapedectomy. Stapes gusher usually occurs as the result of a congenital malformation that causes an abnormal communication between the perilymphatic space and the subarachnoid space involving the internal auditory canal or the cochlear duct. To date, the potential risk of stapes gusher cannot be assessed preoperatively, as there are not pathognomonic signs suggestive of this complication. However, high-resolution computed tomography scan (HRCT) of the temporal bone can provide information that may help recognizing patients at risk. Recently, an anatomic evaluation of the inner ear with oblique reformation at HRCT has been described. This reformation offers a new and more detailed topographic vision of temporal bone structures compared to the classic axial and coronal planes and may help identifying anatomical alterations otherwise not visible. In this article, we present a case of stapes gusher and the role of preoperative HRCT with oblique reformation in its prevention.

Rare and Symptomatic Cavernous Donut-Shaped Aneurysm Treated by Flow Diverter Deployment.

BACKGROUND: We describe the case of a 62-year-old woman who was admitted to our center for acute diplopia secondary to a left III cranial nerve palsy, left eyelid swelling and ptosis, and mild ipsilateral retroorbital pain. No other motor or sensitive deficits were observed. CASE DESCRIPTION: Computed tomography angiography and digital subtraction angiography were performed, showing a 25-mm left intracavernous aneurysm with a central intrasaccular thrombus, an intrasaccular "swirling" flow with a donut-shape appearance. A flow-diverter stent was deployed bridging the aneurysmal neck. CONCLUSIONS: Twelve months after the procedure the aneurysm was completely occluded, and the patient had totally recovered the cavernous syndrome. A careful literature review has been performed, and the different endovascular approaches have been analyzed.

Stent-assisted coiling in ruptured cerebral aneurysms: multi-center experience in acute phase.

INTRODUCTION: The purpose of this study is to report on a multi-center experience of ruptured intracranial aneurysms treated in acute phase with stent-assisted coil embolization, including primary success rates and midterm follow-up results. MATERIALS AND METHODS: Retrospective analysis was performed on a sample of 40 patients (14 men, 26 women, mean age 59.7 years) affected by ruptured saccular aneurysms and treated by stent-assisted coiling in acute phase; double antiplatelet therapy with clopidogrel bisulphate and acetylsalicylic acid was started after the procedure. Angiographic follow-up at 1 year was recorded. RESULTS: 20 % of the aneurysms were located in the posterior circulation, and 85 % presented a wide neck. Mean size of the sac was 7 mm (range 3-22 mm). Complete sac exclusion was obtained in 92.5 % and neck remnant in 7.5 %. The overall complications rate was 15 %. In 7.5 %, stent occlusion occurred intra-procedurally. In 12.5 %, re-bleeding was detected within 3 weeks after the procedure. Ischemic area related to the procedure was observed at follow-up in 7.5 %. Hydrocephalus developed in 15 %. 7.5 % presented with sac re-bleeding between 1 and 5 months after the procedure. In 15 %, the 3-6 months of follow-up revealed aneurysm refilling. 25 % of the patients presented vessel stenosis at the 1-year DSA of control. 33 % of the patients reported sensory-motor deficits. 82.5 % had a favorable outcome (GOS: IV-V), while 17.5 % presented a poor score (GOS: I-III). CONCLUSIONS: Stent-assisted coil embolization is a feasible endovascular treatment option for ruptured intracranial aneurysms, which is difficult to approach with simple coiling; however, neurointerventionalists need to consider a mild increase of post-procedural complications rate.