ABSTRACT
Spinal arteriovenous fistulae (AVFs) of the craniocervical junction are rare lesions that have variable angioarchitecture. These lesions are generally characterized by arteriovenous shunting at a single fistulous point, the disconnection of which is generally curative.1 We present a case of bilateral dural AVF at the C2 level treated with surgical ligation (Video 1). Our patient was an elderly woman who presented after cervical magnetic resonance imaging was performed as part of work-up for right-sided shoulder tingling. This study demonstrated prominent flow voids along the dorsal and ventral surfaces of the craniocervical junction, concerning for an underlying vascular malformation. Formal angiography demonstrated arteriovenous shunting into the perimedullary venous plexus from a dural branch of the vertebral artery at the C2 level. Significant retrograde cortical venous drainage was noted. She was treated with a C1 and partial C2 laminectomy and clip ligation of the right-sided fistula. Postoperative angiography confirmed obliteration of the fistula but now demonstrated persistent arteriovenous shunting from second fistulous point at the contralateral C2 level. She was then taken back to surgery for ligation of the second fistula. Instances of multiple, distinct, and synchronous arteriovenous fistulae have been rarely reported in the literature.2 In addition to demonstrating the nuances of surgical treatment of AVFs at this location, this case demonstrates the potential for synchronous AVFs and emphasizes the importance of thorough postoperative angiography. The patient provided consent to the production of this surgical video.
ABSTRACT
Thalamic cavernous malformations are challenging lesions to approach given their deep location and proximity to eloquent neurovascular structures. Several approaches to this region exist, and small nuances in the location of the lesion dictate different surgical trajectories. For cavernous malformations presenting to the superomedial surface of the thalamus, the interhemispheric transcallosal approach affords an excellent trajectory as the anterior two-thirds of the superomedial thalamus constitutes the lateral aspect of the floor of the body of the lateral ventricle. In addition, when the cavernous malformation extends laterally, the contralateral adjunct of the interhemispheric transcallosal approach provides optimal visualization of the lateral aspect of the lesion. In this video, we present the case of a 31-year-old woman who presented to our institution with a giant hemorrhagic thalamic cavernous malformation that resulted in rapid neurological decline characterized by ataxia, right hemiparesis, and diplopia. The cavernous malformation was removed using an interhemispheric contralateral transcallosal approach. The patient had near complete resolution of her preoperative deficits with mild residual weakness in her right hand at 3-month follow-up. At 3-year follow-up, magnetic resonance imaging revealed no active cavernous malformation, and the patient had no recurrence of symptoms. This manuscript was conducted in accordance with the ethical standards of our institution's Institutional Review Board. The patient gave informed consent for surgery and video recording.
ABSTRACT
BACKGROUND AND PURPOSE: A single aspiration maneuver using a large volume syringe is a common and effective technique for aspiration thrombectomy. Multiple aspiration cycles using large aspiration syringes has been proposed as a means to improve efficacy over single aspiration. In this study, we sought to investigate the efficacy of a "triple aspiration technique" where a large volume syringe is cycled three times prior to catheter retraction during aspiration thrombectomy. MATERIALS AND METHODS: A 3D-printed adult vasculature was used as a benchtop thrombectomy platform. Fibrin-rich and red blood cell-rich clots were prepared in centrifuge tubes using human plasma, red blood cells, and calcium chloride. Next, clots were placed in the carotid terminus of the model, and the performances of three different aspiration techniques-triple syringe, single syringe, and continuous pump aspiration-were compared in a randomized manner (1:1:1). Outcomes of interest included first-pass efficacy (FPE), complete clot removal (final mTICI 2c/3), the number of thrombectomy attempts to achieve mTICI 2c/3, vacuum pressure, and distal embolization. The distal emboli were detected using a 70-micron cell strainer placed at the outflow of the model and quantified using an image processing algorithm. The vacuum pressures were measured using a pressure transducer (Honeywell, NC, USA). RESULTS: A total of 102 replicates were performed, 34 for each technique. The triple aspiration technique provided a significantly higher rate of FPE than the syringe and pump aspiration techniques (67.6% vs. 41.1%, p= 0.02). Additionally, the triple aspiration technique achieved complete clot removal with a significantly lower number of thrombectomy attempts compared to single syringe aspiration (1.2 ± 0.5 vs. 1.8 ± 0.8, p=0.005). The triple aspiration technique generated significantly higher vacuum pressure than both the single syringe and vacuum pump aspiration (28.3 ± 0.2 vs. 27.2 ± 0.3 (p= 0.002) and 26.2 ± 0.4 (p=0.001), respectively). The differences in complete clot removal and distal embolization parameters were not statistically significantly different across the groups. CONCLUSIONS: Our findings suggest that the triple aspiration technique can improve FPE rates and vacuum pressure in aspiration thrombectomy. Further studies are needed to examine the safety and efficacy of triple aspiration in the clinical setting. ABBREVIATIONS: AcommA = anterior communicating artery; FPE = first pass efficacy; ICA = internal carotid artery; MCA = middle cerebral artery; MT = mechanical thrombectomy; mTICI = modified thrombolysis in cerebral infarction scale; PcommA = posterior communicating artery.
ABSTRACT
PURPOSE: Sickle-cell disease-associated moyamoya syndrome (SCD-MMS) carries a high risk for recurrent strokes and cerebrovascular morbidity in children. However, few data are available about complications that occur in children hospitalized with SCD-MMS. The purpose of this analysis was to determine the risk factors for in-hospital complications in pediatric SCD-MMS admissions, and thus aid physicians in optimizing future treatment plans. METHODS: A national database of pediatric hospital admissions was examined across the years 2003-2019. ICD-9 and ICD-10 diagnosis codes were analyzed to identify discharges with a primary diagnosis of SCD-MMS and identify in-hospital complications, defined as complication-associated diagnostic codes logged during the same admission. Patient demographics, comorbidities, and hospital characteristics were examined using univariate and multivariate logistic regression analyses to determine associations with in-hospital complications. RESULTS: In total, 274 admissions with a primary diagnosis of SCD-MMS were identified. During 64 (23.4%) admissions, transfusion therapy was given, and in 86 admissions (31.4%), surgical revascularization was performed. In 10 admissions (3.6%), a total of 11 in-hospital complications were identified. After multivariate regression, both comorbid chronic lung disease (adjusted OR 5.3 [1.1, 26.9], P = 0.04) and surgical revascularization (adjusted OR 10.2 [2.0, 52.4], P = 0.006) were associated with development of complications. CONCLUSIONS: In this nationwide database of pediatric SCD-MMS hospitalizations, comorbid chronic lung disease and surgical revascularization were associated with development of in-hospital complications. Patients with comorbid chronic lung disease or who are admitted for revascularization may warrant closer monitoring and greater medical optimization during the hospitalization.
Subject(s)
Anemia, Sickle Cell , Moyamoya Disease , Humans , Moyamoya Disease/epidemiology , Moyamoya Disease/complications , Anemia, Sickle Cell/complications , Anemia, Sickle Cell/epidemiology , Anemia, Sickle Cell/therapy , Female , Male , Child , Risk Factors , Cross-Sectional Studies , Adolescent , Child, Preschool , Hospitalization/statistics & numerical data , Infant , Databases, FactualABSTRACT
BACKGROUND: Vertebral artery loops are a rare cause of cervical radiculopathy. Surgical options for nerve root decompression include an anterior or posterior approach, with or without additional microvascular decompression. OBSERVATIONS: The authors describe a case of a 49-year-old man with a long-standing history of left-sided neck pain and migraines, who was found to have a vertebral artery loop in the left C3-4 neural foramen compressing the left C4 nerve root. The patient underwent a posterior cervical decompression with instrumented fusion and macrovascular decompression of the left C4 nerve root via Teflon felt insertion. In a literature review, we identified 20 similar cases that had also been managed surgically. LESSONS: Although the anterior approach is more frequently described in the literature, a posterior approach for nerve compression by a vertebral artery loop is also a safe and effective treatment. The authors report the third case of this surgical approach with a good outcome.
ABSTRACT
OBJECTIVE: Inferior petrosal sinus (IPS) sampling (IPSS) is a diagnostic procedure used to guide diagnostic localization of imaging-negative adrenocorticotropic hormone (ACTH)-secreting pituitary microadenomas. However, the efficacy of IPSS has been suboptimal at accurately lateralizing the adenoma, reducing surgical cure rates and leading to unintended pituitary dysfunction due to the added exploration. One rationale for the occasional imprecision is the existence of additional petrosal sinus collateral channels that connect the IPS bilaterally, which may lead to false localization results during sampling. The aim of this study was to explore a potential connection between normal anatomical variation in the angioarchitecture of the IPSs and the ACTH results obtained in subsequent IPSS tests. METHODS: A retrospective review was performed on all cases between 1998 and 2013 involving patients at a single institution who underwent IPSS for radiographically equivocal pituitary microadenomas. Cases were reviewed for tumor laterality noted on either operative or pathology reports, as well as the presence of angiographic evidence of cross-filling between the sinuses. In addition, ACTH levels from the right and left IPSs were documented at baseline and at 2, 5, and 10 minutes after corticotropin-releasing hormone (CRH) administration. A ratio of the change in ACTH levels measured at the time of maximal response (10 minutes) versus the levels measured at the initial response (2 minutes) was computed for each patient and compared between patients by their angiographic cross-filling status. RESULTS: There were 41 patients with a histopathologically confirmed right- or left-sided ACTH-secreting pituitary microadenoma who underwent preoperative IPSS. Among these patients, 28 (68%) showed angiographic evidence of cross-filling between the IPSs, and 13 showed no cross-filling. On average, ACTH levels increased by a factor of 3.91 ± 0.77 in the contralateral IPS in patients with angiographic cross-filling, compared with a factor increase of only 1.80 ± 0.27 in patients without cross-filling (p = 0.014). In comparison, ACTH levels increased by a factor of 2.01 ± 0.57 in the ipsilateral IPS in patients with cross-filling, and by 8.78 ± 7.30 in those without cross-filling (p = 0.373). CONCLUSIONS: The presence of angiographic cross-filling, suggestive of a greater degree of vascular channel networking between the right and left IPS, is a significant factor influencing the measured rates of change of ACTH in IPSS and may impact the specificity of this test to accurately determine microadenoma laterality in the preoperative setting.
Subject(s)
Pituitary ACTH Hypersecretion , Pituitary Neoplasms , Humans , Adrenocorticotropic Hormone , Pituitary ACTH Hypersecretion/diagnostic imaging , Petrosal Sinus Sampling/methods , Corticotropin-Releasing Hormone , Pituitary Neoplasms/diagnostic imaging , Pituitary Neoplasms/surgeryABSTRACT
BACKGROUND: Remarkable interest is rising around middle meningeal artery embolization (MMAE) as an emerging alternative therapy for chronic subdural hematoma (cSDH). The study aims to highlight a large center experience and the variables associated with treatment failure and build experimental machine learning (ML) models for outcome prediction. MATERIAL AND METHODS: A 2-year experience in MMAE for managing patients with chronic subdural hematoma was analyzed. Descriptive statistical analysis was conducted using imaging and clinical features of the patients and cSDH, which were subsequently used to build predictive models for the procedure outcome. The modeling evaluation metrics were the area under the ROC curve and F1-score. RESULTS: A total of 100 cSDH of 76 patients who underwent MMAE were included with an average follow-up of 6 months. The intervention had a per procedure success rate of 92%. Thrombocytopenia had a highly significant association with treatment failure. Two patients suffered a complication related to the procedure. The best performing machine learning models in predicting MMAE failure achieved an ROC-AUC of 70%, and an F1-score of 67%, including all patients with or without surgical intervention prior to embolization, and an ROC-AUC of 82% and an F1-score of 69% when only patients who underwent upfront MMAE were included. CONCLUSION: MMAE is a safe and minimally invasive procedure with great potential in transforming the management of cSDH and reducing the risk of surgical complications in selected patients. An ML approach with larger sample size might help better predict outcomes and highlight important predictors following MMAE in patients with cSDH.
Subject(s)
Embolization, Therapeutic , Hematoma, Subdural, Chronic , Humans , Hematoma, Subdural, Chronic/diagnostic imaging , Hematoma, Subdural, Chronic/therapy , Hematoma, Subdural, Chronic/etiology , Meningeal Arteries/diagnostic imaging , Meningeal Arteries/surgery , Treatment Outcome , Embolization, Therapeutic/methods , HeadABSTRACT
OBJECTIVE: The object of this study was to describe the use of patient-reported outcome measures (PROMs) in cerebrovascular neurosurgery and to outline a framework for incorporating them into future cerebrovascular research. METHODS: Following the standardized PRISMA guidelines, the authors performed a search of the PubMed and Embase databases in February 2023 using filters to investigate six specific cerebrovascular pathologies/procedures: subarachnoid hemorrhage (SAH), intracranial hemorrhage, ischemic stroke, arteriovenous malformation, chronic subdural hematoma, and carotid artery stenosis. PROMs in the identified articles were distinguished and classified as generic, symptom specific, or disease specific. RESULTS: A total of 259 studies including 51 PROMs were eligible for inclusion in the review. Most of the PROMs were generic or symptom specific. Only 5 PROMs were disease specific, and all of these pertained to stroke or SAH. CONCLUSIONS: There are only a limited number of disease-specific PROMs available for cerebrovascular pathologies and outcomes. Further validation of existing measures in independent cohorts, expanded incorporation of disease-specific PROMs in prospective trials, and the development of new PROMs specific to cerebrovascular conditions are critical to a better understanding of the impact of cerebrovascular diseases and novel therapies on patient lives.
ABSTRACT
We describe the technical nuances of in-situ bypass for treatment of a fusiform superior cerebellar artery (SCA) aneurysm via surgical trapping and a side-to-end in-situ bypass between duplicated SCAs. Our patient is a 40-year-old male who presented with an incidental aneurysm of the proximal right superior cerebellar artery (SCA). Formal angiography was performed that demonstrated a fusiform morphology of the aneurysm, as well as a duplicated SCA on that side. After extensive counseling, the patient elected to undergo surgical clip reconstruction with possible bypass. A large frontotemporal craniotomy was performed and a combined transsylvian-subtemporal approach to the ventral anterolateral brainstem was performed. After identifying the aneurysm, the tentorium was incised posterior to the insertion of the trochlear nerve to widen the operative field. An end-to-side anastomosis between the duplicated SCAs was performed, followed by trapping of the diseased arterial segment. The patient had an oculomotor nerve palsy post-operatively, however this resolved by his six-month follow-up. In-situ bypass is a viable technique for revascularizing the SCA territory during clip reconstruction of fusiform aneurysms. A duplicated SCA allows for an SCA to SCA bypass. Incising the tentorium can increase visualization of donor and recipient vessels and facilitate performance of the anastomosis.
Subject(s)
Intracranial Aneurysm , Male , Humans , Adult , Intracranial Aneurysm/diagnostic imaging , Intracranial Aneurysm/surgery , Basilar Artery/surgery , Craniotomy , Anastomosis, SurgicalABSTRACT
BACKGROUND: The distal suboccipital segment of the occipital artery is commonly used as a donor vessel for aneurysms of the posterior circulation requiring revascularization techniques. Isolating this segment of vessel can be challenging due to its course in and out of the various layers of the suboccipital musculature. METHODS: We describe the use of the proximal suboccipital segment of the occipital artery within the occipital groove at the lateral skull base as a donor segment for an interposition graft in revascularization surgery. We present a case detailing the use of this technique for treatment of a dissecting PICA aneurysm and photographs from cadaveric dissections demonstrating relevant anatomy. RESULTS: Our patient is a 62-year-old man who presented with a high-grade subarachnoid hemorrhage from a proximal dissecting-type aneurysm of the posterior inferior cerebellar artery (PICA). Endovascular options were limited to coil sacrifice of the parent vessel, and thus the patient was taken for a far lateral craniotomy, trapping of the aneurysm, and revascularization of the PICA territory via a saphenous vein interposition graft sewn proximally and distally to the occipital artery within the occipital groove and a cortical segment of the affected PICA, respectively. Postoperative imaging demonstrated filling of the PICA territory via the graft, and the patient ultimately recovered from his subarachnoid hemorrhage. CONCLUSIONS: The use of the proximal suboccipital segment of the occipital artery is a viable option for a donor in posterior fossa revascularization surgery.
Subject(s)
Cerebral Revascularization , Intracranial Aneurysm , Subarachnoid Hemorrhage , Male , Humans , Middle Aged , Subarachnoid Hemorrhage/diagnostic imaging , Subarachnoid Hemorrhage/surgery , Intracranial Aneurysm/diagnostic imaging , Intracranial Aneurysm/surgery , Cerebellum/blood supply , Vertebral Artery/surgery , Vascular Surgical Procedures , Cerebral Revascularization/methodsABSTRACT
The lateral recess of the fourth ventricle can be challenging to access surgically. We present a case of a previously ruptured arteriovenous malformation (AVM) of the fourth ventricle that was surgically resected via a retrosigmoid craniotomy and transinferior cerebellar peduncular approach. The patient is a 54-year-old female who experienced an intraventricular hemorrhage several months before presentation to our institution. Imaging studies suggested the presence of an AVM located in the right lateral recess of the fourth ventricle. After discussion of all possible treatment options, the patient elected to proceed with surgical resection. To access the lesion, we performed a retrosigmoid craniotomy and entered into the fourth ventricle via s small incision in the inferior cerebellar peduncle. Postoperative imaging demonstrated complete removal of the AVM nidus. Video 1 demonstrates this approach and discusses the anatomic landmarks used to guide resection.
Subject(s)
Fourth Ventricle , Intracranial Arteriovenous Malformations , Female , Humans , Middle Aged , Fourth Ventricle/diagnostic imaging , Fourth Ventricle/surgery , Intracranial Arteriovenous Malformations/diagnostic imaging , Intracranial Arteriovenous Malformations/surgery , Cerebellum/diagnostic imaging , Cerebellum/surgery , Craniotomy/methods , Microsurgery/methodsABSTRACT
This is a case report of an adult with chronic subdural hematoma (cSDH) who underwent endovascular treatment for middle meningeal artery (MMA) embolization. There was a prominent meningo-ophthalmic branch with an absence of an ophthalmic artery from the internal carotid artery. MMA embolization was performed utilizing particles with no complications and the resolution of the cSDH was within 4 months. This case report demonstrates that despite extreme variant anatomy, MMA embolization with particles is feasible, effective, and safe when appropriate techniques are used.
ABSTRACT
Revascularization of the anterior circulation using a high-capacitance graft is sometimes necessary for treatment of cervical tumors encasing the internal carotid artery (ICA). In this surgical video, we aim to demonstrate the technical nuances of high-flow extra-to-intracranial bypass using a saphenous vein graft. The patient is a 23-year-old female who presented with a 4-month history of an enlarging left-sided neck mass, dysphagia, and 25-lb weight loss. Computed tomography and magnetic resonance imaging demonstrated an enhancing lesion encasing the cervical ICA. The patient underwent an open biopsy that established a diagnosis of a myoepithelial carcinoma. The patient was advised to undergo attempted gross total resection, which would require sacrifice of the cervical internal carotid artery. After the patient failed a balloon test occlusion of the left ICA, it was decided to perform a cervical ICA to middle cerebral artery M2 bypass using a saphenous vein graft, followed by tumor resection in staged fashion. Postoperative imaging demonstrated complete tumor removal and filling of the left anterior circulation via the saphenous vein graft. Video 1 discusses important preoperative and postoperative considerations, as well as highlights the technical nuances of this complex procedure. High-flow ICA to middle cerebral artery bypass using a saphenous vein graft can be employed to facilitate gross total resection of malignant tumors encasing the cervical internal carotid artery.
ABSTRACT
AIMS: Intracranial aneurysms are treated with a variety of endovascular devices including coils, stents, and flow diverters. The mechanisms by which these devices result in aneurysm occlusion and subsequent healing have been the subject of significant research using various animal models. The murine Helsinki aneurysm model is a sidewall aneurysm created by the end-to-side anastomosis of a donor aortic graft onto the abdominal aorta of a recipient animal. The aim of this systematic review is to assess the efficacy of different endovascular devices for the treatment of the Helsinki model aneurysm. METHODS: We performed a systematic review of Pubmed in accordance with PRISMA guidelines, yielding eight studies detailing the results of endovascular treatment of this preclinical aneurysm model. Studies were included if they provided rates of complete aneurysm occlusion after treatment. RESULTS: In these studies, aneurysms were treated with coiling (n=81, 7 studies), stenting (n=67, 3 studies), stent-coiling (n=13, 1 study), and flow diversion (n=49, 2 studies). The results of each individual study are discussed with the goal of providing a measure of the relative efficacy of different endovascular devices for the treatment of this particular model aneurysm. We also pay special attention to insights into the mechanisms underlying aneurysm healing after different forms of endovascular therapy. CONCLUSION: The data presented here may be useful to investigators attempting to demonstrate superiority of novel endovascular devices relative to previous device iterations using this preclinical model.
Subject(s)
Embolization, Therapeutic , Endovascular Procedures , Intracranial Aneurysm , Mice , Animals , Treatment Outcome , Embolization, Therapeutic/methods , Endovascular Procedures/methods , Intracranial Aneurysm/diagnostic imaging , Intracranial Aneurysm/surgery , Stents , Retrospective StudiesABSTRACT
Aneurysms associated with a vertebrobasilar fenestration are rare lesions and can grow to a giant size, presenting significant therapeutic challenges. Endovascular treatment of these aneurysms has traditionally been with coiling; however, flow diverter placement within the fenestration arms has recently proven to be a viable treatment strategy. The authors present a case of a giant vertebrobasilar fenestration aneurysm in a patient presenting with a cranial nerve VI palsy. The lesion was treated by using a combination of flow diverter placement and vertebral artery sacrifice. The nuances of flow diversion therapy for these aneurysms and the management of intra- and postoperative complications are discussed. The video can be found here: https://stream.cadmore.media/r10.3171/2022.7.FOCVID2256.