Efficacy of 3D evaluation of unruptured paraclinoid aneurysms within Leksell GammaPlan® for determination of their intradural localization.

BACKGROUND: Determination of the intradural unruptured paraclinoid aneurysm localization is difficult, but critical for selection of the optimal treatment strategy. OBJECTIVE: To assess efficacy of the three-dimensional (3D) evaluation of unruptured paraclinoid aneurysms within Leksell GammaPlan® (LGP; Elekta AB; Stockholm, Sweden) for determination of their intradural localization. METHODS: Overall, 125 incidentally diagnosed unruptured paraclinoid aneurysms in 118 patients (mean age, 55 years) underwent 3D evaluation of their localization within LGP using post-contrast thin-slice constructive interference in steady state (CISS) images, which in 41 cases were additionally co-registered and fused with the axial computed tomography angiography (CTA) source images. RESULTS: According to the evaluation within LGP, paraclinoid aneurysms were considered intradural, transitional, and extradural in 75, 25, and 25 cases respectively. Overall, 51 of 75 aneurysms deemed to be intradural, underwent microsurgical management, and intraoperative visual inspection confirmed their intradural localization in 45 cases, whereas it was transitional in 3, and extradural in 3. If during preoperative 3D evaluation within LGP only post-contrast CISS images were used, prediction of the pure intradural localization of aneurysm was correct in 88 % of cases (95 % CI: 79-97 %), and of the pure or partial (i.e., transitional) intradural localization in 94 % of cases (95 % CI: 88-100 %), whereas it was 100 % if co-registration and fusion of the contrast-enhanced CISS and CTA source images was done. CONCLUSION: Intradural localization of the unruptured paraclinoid aneurysms may be effectively predicted based on their 3D evaluation within LGP using post-contrast thin-slice CISS and CTA source images, which may help with clinical decision-making.

High-flow bypass using saphenous vein grafts with trapping of ruptured blood blister-like aneurysms of the internal carotid artery: patient series.

BACKGROUND: Trapping an aneurysm after the establishment of an extracranial to intracranial high-flow bypass is considered the optimal surgical strategy for ruptured blood blister-like aneurysms (BBAs) of the internal carotid artery (ICA). For high-flow bypass surgeries, a radial artery graft is generally preferred over a saphenous vein graft (SVG). However, SVGs can be advantageous in acute-phase surgeries because of their greater length, easy manipulability, ability to act as high-flow conduits, and reduced risk of vasospasms. In this study, the authors presented five cases of ruptured BBAs treated with high-flow bypass using an SVG followed by BBA trapping, and they reported on surgical outcomes and operative nuances that may help avoid potential pitfalls. OBSERVATIONS: After the surgeries, there were no ischemic or hemorrhagic complications, including symptomatic vasospasms. In three of the five cases, postoperative modified Rankin scale scores were between 0 and 2 at the 3-month follow-up. In one case, the SVG spontaneously occluded after surgery while the protective superficial temporal artery (STA) to middle cerebral artery (MCA) bypass became dominant, and the patient experienced no ischemic symptoms. LESSONS: High-flow bypass using an SVG with a protective STA-MCA bypass followed by BBA trapping is a safe and effective treatment strategy.

[Azygos anterior cerebral artery aneurysm in a patient with Noonan syndrome].

Noonan syndrome(NS)is a common, clinically and genetically heterogeneous condition characterized by distinctive facial features, short stature, congenital heart disease, and other comorbidities. However, there have been only a few case reports of cerebrovascular abnormalities in patients with NS. Especially, the cases of intracranial aneurysms with NS are very rare. In addition, comorbidities of azygos anterior cerebral artery(ACA)and NS have not been reported before now. We encountered such a rare case of azygos ACA unruptured aneurysm in patient with NS. The case was 64-year-old woman with NS complaining of gait disturbance. The three-dimensional CT angiography(3D-CTA)showed azygos ACA and an unruptured saccular aneurysm at the distal end of the A2 segment. An operation for this aneurysm was performed. We reviewed clinical features of NS with cerebrovascular disease such as aneurysm.

[Four cases of fusiform posterior inferior cerebellar artery aneurysms successfully treated by trapping and occipital artery-PICA bypass].

Aneurysms located on the proximal portion of the posterior inferior cerebellar artery (PICA) are rare, and even rarer are fusiform aneurysms in this location. Therefore the principles of surgical management are poorly understood and still subject to debate. The management plan for these lesions is based on the proper understanding of the PICA anatomy, and particularly the origin of important perforating arteries. As many anatomic variations of PICA can be observed and the perforator's origin is sometimes in complex anatomical relations with the aneurysm, the management has to be individualized in each case. The objective of management is to exclude of the aneurysm from the circulation while preserving the perforator and distal flow. We report four cases of PICA fusiform aneurysms of the anterior or lateral medullary segments which were treated successfully with trapping of the abnormal arterial segment and distal revascularization of PICA. Trapping was adjusted to the specific anatomical circumstances in each case, preserving perforators to the maximum and revascularizing (OA-distal PICA) distal territory.