Diagnostic Accuracy of Somatosensory Evoked Potential Monitoring in Evaluating Neurological Complications During Endovascular Aneurysm Treatment.

BACKGROUND: Somatosensory evoked potential (SSEP) monitoring is used extensively for early detection and prevention of neurological complications in patients undergoing many different neurosurgical procedures. However, the predictive ability of SSEP monitoring during endovascular treatment of cerebral aneurysms is not well detailed. OBJECTIVE: To evaluate the performance of intraoperative SSEP in the prediction postprocedural neurological deficits (PPNDs) after coil embolization of intracranial aneurysms. METHODS: This population-based cohort study included patients ≥18 years of age undergoing intracranial aneurysm embolization with concurrent SSEP monitoring between January 2006 and August 2012. The ability of SSEP to predict PPNDs was analyzed by multiple regression analyses and assessed by the area under the receiver operating characteristic curve. RESULTS: In a population of 888 patients, SSEP changes occurred in 8.6% (n = 77). Twenty-eight patients (3.1%) suffered PPNDs. A 50% to 99% loss in SSEP waveform was associated with a 20-fold increase in risk of PPND; a total loss of SSEP waveform, regardless of permanence, was associated with a greater than 200-fold risk of PPND. SSEPs displayed very good predictive ability for PPND, with an area under the receiver operating characteristic curve of 0.84 (95% CI 0.76-0.92). CONCLUSION: This study supports the predictive ability of SSEPs for the detection of PPNDs. The magnitude and persistence of SSEP changes is clearly associated with the development of PPNDs. The utility of SSEP monitoring in detecting ischemia may provide an opportunity for neurointerventionalists to respond to changes intraoperatively to mitigate the potential for PPNDs.

Long-term outcomes of intradural cervical dorsal root rhizotomy for refractory occipital neuralgia.

OBJECT Occipital neuralgia (ON) causes chronic pain in the cutaneous distribution of the greater and lesser occipital nerves. The long-term efficacy of cervical dorsal root rhizotomy (CDR) in the management of ON has not been well described. The authors reviewed their 14-year experience with CDR to assess pain relief and functional outcomes in patients with medically refractory ON. METHODS A retrospective chart review of 75 ON patients who underwent cervical dorsal root rhizotomy, from 1998 to 2012, was performed. Fifty-five patients were included because they met the International Headache Society's (IHS) diagnostic criteria for ON, responded to CT-guided nerve blocks at the C-2 dorsal nerve root, and had at least one follow-up visit. Telephone interviews were additionally used to obtain data on patient satisfaction. RESULTS Forty-two patients (76%) were female, and the average age at surgery was 46 years (range 16-80). Average follow up was 67 months (range 5-150). Etiologies of ON included the following: idiopathic (44%), posttraumatic (27%), postsurgical (22%), post-cerebrovascular accident (4%), postherpetic (2%), and postviral (2%). At last follow-up, 35 patients (64%) reported full pain relief, 11 (20%) partial relief, and 7 (16%) no pain relief. The extent of pain relief after CDR was not significantly associated with ON etiology (p = 0.43). Of 37 patients whose satisfaction-related data were obtained, 25 (68%) reported willingness to undergo repeat surgery for similar pain relief, while 11 (30%) reported no such willingness; a single patient (2%) did not answer this question. Twenty-one individuals (57%) reported that their activity level/functional state improved after surgery, 5 (13%) reported a decline, and 11 (30%) reported no difference. The most common acute postoperative complications were infections in 9% (n = 5) and CSF leaks in 5% (n = 3); chronic complications included neck pain/stiffness in 16% (n = 9) and upper-extremity symptoms in 5% (n = 3) such as trapezius weakness, shoulder pain, and arm paresthesias. CONCLUSIONS Cervical dorsal root rhizotomy provides an efficacious means for pain relief in patients with medically refractory ON. In the appropriately selected patient, it may lead to optimal outcomes with a relatively low risk of complications.

Endothelin-1 gene polymorphisms influence cerebrospinal fluid endothelin-1 levels following aneurysmal subarachnoid hemorrhage.

Aneurysmal subarachnoid hemorrhage is a type of stroke with high morbidity and mortality. Increased endothelin-1 (ET-1) levels have been associated with increased risk of cerebral vasospasm, which is associated with increased morbidity. The purpose of this study was to investigate the relationships between ET-1 genotypes and ET-1 protein levels in cerebrospinal fluid (CSF) measured 72 hr before angiographic vasospasm measurement in subjects at high risk of cerebral vasospasm. Specifically, this study evaluated the differences between variant positive and variant negative groups of nine different ET-1 single-nucleotide polymorphisms (SNPs) in relationship with the ET-1 protein exposure rate. The CSF ET-1 protein levels were quantified using enzyme-linked immunosorbent assay. One functional SNP and eight ET-1 tagging SNPs were selected because they represent genetic variability in the entire ET-1 gene. The variant negative group of SNP rs2070699 was associated with a significantly higher ET-1 exposure rate than the variant positive group (p = 0.004), while the variant positive group of the rs5370 group showed a trend toward association with a higher ET-1 exposure rate (p = 0.051). Other SNPs were not informative. This is the first study to show differences in ET-1 exposure rate 72 hr before angiography in relation to ET-1 genotypes. These exploratory findings need to be replicated in a larger study; if replicated, these differences in genotypes may be a way to inform clinicians of those patients at a higher risk of increased ET-1 protein levels, which may lead to a higher risk of angiographic vasospasm.

Intraoperative neurophysiological monitoring of microvascular decompression for glossopharyngeal neuralgia.

PURPOSE: To evaluate if adding cranial nerves (CNs) V and VI to standard intraoperative neurophysiological monitoring (IONM) of microvascular decompressions for glossopharyngeal neuralgia improve its efficacy. METHODS: We reviewed all patients who received a microvascular decompression for glossopharyngeal neuralgia at our institution between January 2008 and August 2012. All received upper extremity somatosensory evoked potentials, brainstem auditory evoked potentials, and free-running electromyography of muscles innervated by ipsilateral CNs VII, IX, and X. The sample was divided into 12 patients who received additional monitoring of CNs V and VI and 15 who did not. RESULTS: No difference on neurotonic activity presence was found on CN V (standard IONM: 0% versus additional CNs IONM: 8.33%; p = 0.423), CN VI (never present on the additional CN patients), CN VII (standard IONM: 73.33% versus additional CNs IONM: 66.64%; p = 0.973), CN IX (standard IONM: 40.0% versus additional CNs IONM: 25.0%; p = 0.683), or CN X (standard IONM: 46.67% versus additional CNs IONM: 33.33%; p = 0.701) between groups. Additionally, no differences of brainstem auditory evoked potentials wave V's delay, and amplitude at the end of the decompression, or closing of the case were found between groups. CONCLUSIONS: Monitoring free-running electromyography of additional CNs V and VI does not improve the efficacy of IONM of microvascular decompressions for glossopharyngeal neuralgia.

Haptoglobin genotype and functional outcome after aneurysmal subarachnoid hemorrhage.

OBJECT: Haptoglobin allele heterogeneity has been implicated in differential reactive oxidant inhibition and inflammation. Haptoglobin α2-α2 has a lower affinity for binding hemoglobin, and when bound to hemoglobin, is cleared less easily by the body. The authors hypothesized that haptoglobin α2-α2 genotype should be less protective for downstream injury after aneurysmal subarachnoid hemorrhage (aSAH) and should portend a worse outcome. METHODS: Patients with Fisher Grade 2 or higher aSAH were enrolled in the study. Genotyping for haptoglobin genotype was performed from blood and/or CSF. Demographic information, medical condition variables, and hospital course were abstracted from the medical record upon enrollment into the study. Outcome data (modified Rankin Scale score, Glasgow Outcome Scale score, and mortality) were collected at 3 months posthemorrhage. RESULTS: The authors enrolled 193 patients who ranged in age from 18 to 75 years. Only Caucasians were used in this analysis to minimize bias from variable haptoglobin allele frequencies in populations of different ancestral backgrounds. The sample had more women than men (overall mean age 54.45 years). Haptoglobin α2 homozygotes were older than the other individuals in the study sample (57.27 vs 53.2 years, respectively; p = 0.02) and were more likely to have Fisher Grade 3 SAH (p = 0.02). Haptoglobin α2-α2 genotype, along with Fisher grade and Hunt and Hess grade, was associated with a worse 3-month outcome compared to those with the haptoglobin α1-α1 genotype according to modified Rankin Scale score after controlling for covariates (OR 4.138, p = 0.0463). CONCLUSIONS: Patients with aSAH who carry the haptoglobin α2-α2 genotype had a worse outcome. Interestingly, the presence of a single α-2 allele was associated with worse outcome, suggesting that the haptoglobin α-2 protein may play a role in the pathology of brain injury following aSAH, although the mechanism for this finding requires further research. The haptoglobin genotype may provide additional information on individual risk of secondary injury and recovery to guide care focused on improving outcomes.

Carotid artery injury during endoscopic endonasal skull base surgery: incidence and outcomes.

BACKGROUND: Injury to the internal carotid artery (ICA) during endoscopic endonasal skull base surgery is a feared complication that is not well studied or reported. OBJECTIVE: To evaluate the incidence, to identify potential risk factors, and to present management strategies and outcomes of ICA injury during endonasal skull base surgery at our institution. METHODS: We performed a retrospective review of all endoscopic endonasal operations performed at our institution between 1998 and 2011 to examine potential factors predisposing to ICA injury. We also documented the perioperative management and outcomes after injury. RESULTS: There were 7 ICA injuries encountered in 2015 endonasal skull base surgeries, giving an incidence of 0.3%. Most injuries (5 of 7) involved the left ICA, and the most common diagnosis was chondroid neoplasm (chordoma, chondrosarcoma; 3 of 7 [2% of 142 cases]). Two injuries occurred during 660 pituitary adenoma resections (0.3%). The paraclival ICA segment was the most commonly injured site (5 of 7), and transclival and transpterygoid approaches had a higher incidence of injury, although neither factor reached statistical significance. Four of 7 injured ICAs were sacrificed either intraoperatively or postoperatively. No patient suffered a stroke or neurological deficit. There were no intraoperative mortalities; 1 patient died postoperatively of cardiac ischemia. One of the 3 preserved ICAs developed a pseudoaneurysm over a mean follow-up period of 5 months that was treated endovascularly. CONCLUSION: ICA injury during endonasal skull base surgery is an infrequent and manageable complication. Preservation of the vessel remains difficult. Chondroid tumors represent a higher risk and should be resected by surgical teams with significant experience.

Stereotactic radiosurgery with or without embolization for intracranial dural arteriovenous fistulas.

Treatment options for symptomatic dural arteriovenous fistulas (DAVFs) include surgery, embolization and stereotactic radiosurgery (SRS). We reviewed our DAVF experience at the University of Pittsburgh and assessed the role of SRS. We evaluated 40 consecutive patients who underwent Gamma Knife SRS for 44 DAVFs. Twenty-eight patients had upfront SRS before or after embolization performed at our institution, and 12 patients underwent delayed SRS for recurrent or residual DAVFs after initial embolization. The median SRS target volume was 2.0 cm3, and the median marginal dose was 21.0 Gy. At a median follow-up of 45 months (range, 23-116 months), a total of 28 patients with 32 DAVFs had obliteration. The obliteration rate was 83% for patients who had upfront SRS and embolization. The obliteration rate was lower (67%) for patients managed with SRS alone. The obliteration rate was 71% for patients who had delayed SRS for recurrent or residual DAVFs following prior embolization. In our experience cavernous/carotid fistulas were associated with higher rates of obliteration and symptomatic improvement compared to transverse/sigmoid sinus region fistulas. Our experience suggests that successful DAVF obliteration is possible in most patients with upfront SRS in conjunction with embolization. SRS alone is an effective treatment for selected patients with a small-volume, low-risk DAVF.

Is a head CT necessary after uncomplicated coiling of unruptured intracranial aneuryms?

UNLABELLED: In this study, we sought to determine whether routine head computed tomographies (CTs) after uncomplicated coil embolization of intracranial aneurysms can add any significant clinical value. METHODS: We retrospectively reviewed the medical records of 139 patients with unruptured aneurysms who underwent 150 elective coiling procedures between January 2008 and June 2010. A total of 6 head CTs were obtained emergently after intraprocedural complications and 122 head CTs were obtained routinely after uncomplicated coil embolization of intracranial aneurysms. RESULTS: The 122 head CTs that were obtained routinely after uncomplicated coil embolization of unruptured intracranial aneurysms did not show any acute or subacute changes. CONCLUSION: A head CT after uncomplicated coil embolization of an intracranial aneurysm does not add any significant clinical value and should not be ordered routinely.

Early postmarket results after treatment of intracranial aneurysms with the pipeline embolization device: a U.S. multicenter experience.

BACKGROUND: The pipeline embolization device (PED) is the latest technology available for intracranial aneurysm treatment. OBJECTIVE: To report early postmarket results with the PED. METHODS: This study was a prospective registry of patients treated with PEDs at 7 American neurosurgical centers subsequent to Food and Drug Administration approval of this device. Data collected included clinical presentation, aneurysm characteristics, treatment details, and periprocedural events. Follow-up data included degree of aneurysm occlusion and delayed (> 30 days after the procedure) complications. RESULTS: Sixty-two PED procedures were performed to treat 58 aneurysms in 56 patients. Thirty-seven of the aneurysms (64%) treated were located from the cavernous to the superior hypophyseal artery segment of the internal carotid artery; 22% were distal to that segment, and 14% were in the vertebrobasilar system. A total of 123 PEDs were deployed with an average of 2 implanted per aneurysm treated. Six devices were incompletely deployed; in these cases, rescue balloon angioplasty was required. Six periprocedural (during the procedure/within 30 days after the procedure) thromboembolic events occurred, of which 5 were in patients with vertebrobasilar aneurysms. There were 4 fatal postprocedural hemorrhages (from 2 giant basilar trunk and 2 large ophthalmic artery aneurysms). The major complication rate (permanent disability/death resulting from perioperative/delayed complication) was 8.5%. Among 19 patients with 3-month follow-up angiography, 68% (13 patients) had complete aneurysm occlusion. Two patients presented with delayed flow-limiting in-stent stenosis that was successfully treated with angioplasty. CONCLUSION: Unlike conventional coil embolization, aneurysm occlusion with PED is not immediate. Early complications include both thromboembolic and hemorrhagic events and appear to be significantly more frequent in association with treatment of vertebrobasilar aneurysms.

Decompressive hemicraniectomy, strokectomy, or both in the treatment of malignant middle cerebral artery syndrome.

OBJECTIVE: We sought to evaluate the impact of a craniotomy for strokectomy (CS) with bone replacement, decompressive hemicraniectomy (DHC), or DHC with a strokectomy (DHC+S) on outcome after malignant supratentorial infarction. METHODS: We conducted a retrospective cohort study of cases of malignant supratentorial infarction treated by CS (n = 18), DHC (n = 17), or DHC+S (n = 33) at our institution from 2002 to 2008. End points included functional outcome measured by the modified Rankin Scale and incidence of mortality at 1 year. RESULTS: Mean age, gender, side, vessel, and time from ictus to surgery were not statistically different between treatment groups. Stroke volume was significantly higher in the CS group. Operative time and blood loss were significantly higher in the DHC+S group. At 1 year, the median modified Rankin Scale score was 4 and overall survival was 71%. Functional outcomes and mortality for both the CS and DHC+S groups were not significantly different from the DHC group (P = 0.24). After adjusting for patient age, stroke volume, and time to surgery, there was no significant difference in outcome. CONCLUSION: In patients with malignant supratentorial infarction, a strokectomy alone may be equivalent to a decompressive hemicraniectomy with or without brain resection.

Endovascular treatment of tandem extracranial/intracranial anterior circulation occlusions: preliminary single-center experience.

BACKGROUND AND PURPOSE: Acute ischemic stroke due to tandem occlusions of the extracranial internal carotid artery and intracranial arteries has a poor natural history. We aimed to evaluate our single-center experience with endovascular treatment of this unique stroke population. METHODS: Consecutive patients with tandem occlusions of the internal carotid artery origin and an intracranial artery (ie, internal carotid artery terminus, M1 middle cerebral artery, or M2 middle cerebral artery) were studied retrospectively. Treatment consisted of proximal revascularization with angioplasty and stenting followed by intracranial intervention. Endpoints were recanalization of both extracranial and intracranial vessels (Thrombolysis In Myocardial Ischemia ≥2), parenchymal hematoma, and good clinical outcome (modified Rankin Scale ≤2) at 3 months. RESULTS: We identified 77 patients with tandem occlusions. Recanalization occurred in 58 cases (75.3%) and parenchymal hematoma occurred in 8 cases (10.4%). Distal embolization occurred in 3 cases (3.9%). In 18 of 77 patients (23.4%), distal (ie, intracranial) recanalization was observed after proximal recanalization, obviating the need for distal intervention. Good clinical outcomes were achieved in 32 patients (41.6%). In multivariate analysis, Thrombolysis In Myocardial Ischemia ≥2 recanalization, baseline National Institutes of Health Stroke Scale score, baseline Alberta Stroke Programme Early CT score, and age were significantly associated with good outcome. CONCLUSIONS: Endovascular therapy of tandem occlusions using extracranial internal carotid artery revascularization as the first step is technically feasible, has a high recanalization rate, and results in an acceptable rate of good clinical outcome. Future randomized, prospective studies should clarify the role of this approach.

Role of endothelin-1 in human aneurysmal subarachnoid hemorrhage: associations with vasospasm and delayed cerebral ischemia.

BACKGROUND: Endothelin-1 (ET-1) is a potent vasoconstrictor implicated in the pathogenesis of vasospasm and delayed cerebral ischemia (DCI) in aneurysmal subarachnoid hemorrhage (aSAH) patients. The aim of this study was to investigate the relationship between cerebrospinal fluid (CSF) ET-1 levels and angiographic vasospasm and DCI. METHODS: Patients with aSAH were consented (n = 106). Cerebral vasospasm was determined by angiography. DCI was determined by transcranial Doppler (TCD) results and/or angiogram results with corresponding clinical deterioration. CSF ET-1 levels over 14 days after the initial insult was quantified by ELISA. ET-1 analysis included a group-based trajectory analysis and ET-1 exposure rate during 24, 48, and 72 h prior to, as well as 72 h post angiography, or clinical deterioration. RESULTS: Trajectory analysis revealed two distinct groups of subjects with 56% of patients in the low ET-1 trajectory group (mean at day 1 = 0.31 pg/ml; SE = 0.04; mean at day 14 = 0.41 pg/ml; SE = 0.15) and 44% of patients in the high ET-1 trajectory group (mean at day 1 = 0.65 pg/ml; SE = 0.08; mean at day 14 = 0.61 pg/ml; SE = 0.06). Furthermore, we observed that ET-1 exposure rate 72 h before angiography and clinical spasm was a significant predictor of both angiographic vasospasm and DCI, whereas, ET-1 exposure after angiography and clinical spasm was not associated with either angiographic vasospasm or DCI. CONCLUSION: Based on these results we conclude that ET-1 concentrations are elevated in a sub-group of patients and that the acute (72 h prior to angiography and clinical neurological deterioration), but not chronic, elevations in CSF ET-1 concentrations are indicative of the pathogenic alterations of vasospasm and DCI in aSAH patients.

Endovascular therapy for cardiac catheterization associated strokes.

BACKGROUND: Stroke is one of the most feared complications after cardiac catheterization. Endovascular treatment combining mechanical and pharmacological therapy has been reported as an effective treatment option in selected patients with acute stroke due to large-vessel occlusion. Little is known about safety and clinical outcome when this approach is utilized in cardiac catheterization associated strokes. METHODS AND RESULTS: We analyzed clinical and radiological characteristics and outcomes in the endovascular acute stroke treatment databases from two University Hospitals from July 2006 to December 2008 (Cleveland Clinic Foundation) and September 1999 and December 2008 (UPMC Presbyterian hospital), respectively. Of a total of 419 acute stroke interventions, 14 (3.34%) were identified as strokes during or immediately after cardiac catheterization. The mean age was 71 ± 7 years; eight were women (57.1%). Mean National Institute of Health Stroke Scale was 17 (±7.6). Four patients underwent intravenous thrombolysis followed by intraarterial intervention. Median time to treatment was 240 minutes from last time seen normal (range 66-1,365 minutes). Seven patients (50%) had a favorable outcome (modified Rankin Scale [mRS]≤ 2). In-patient mortality was 42%. CONCLUSION: In acute strokes following cardiac catheterization, multimodal endovascular therapy is safe and feasible and despite a high mortality is associated with a higher than expected rate of favorable outcomes compared to the natural history of the disease. Despite a significant proportion of patients developing symptoms in hospitals where neurointerventions are available, the median time to treatment was longer than expected. Future efforts should focus on faster implementation of recanalization therapies for this form of acute stroke.

Microvascular decompression for hemifacial spasm: evaluating outcome prognosticators including the value of intraoperative lateral spread response monitoring and clinical characteristics in 293 patients.

Hemifacial spasm is a socially disabling condition that manifests as intermittent involuntary twitching of the eyelid and progresses to muscle contractions of the entire hemiface. Patients receiving microvascular decompression of the facial nerve demonstrate an abnormal lateral spread response (LSR) in peripheral branches during facial electromyography. The authors retrospectively evaluate the prognostic value of preoperative clinical characteristics and the efficacy of intraoperative monitoring in predicting short- and long-term relief after microvascular decompression for hemifacial spasm. Microvascular decompression was performed in 293 patients with hemifacial spasm, and LSR was recorded during intraoperative facial electromyography monitoring. In 259 (87.7%) of the 293 patients, the LSR was attainable. Patient outcome was evaluated on the basis of whether the LSR disappeared or persisted after decompression. The mean follow-up period was 54.5 months (range, 9-102 months). A total of 88.0% of patients experienced immediate postoperative relief of spasm; 90.8% had relief at discharge, and 92.3% had relief at follow-up. Preoperative facial weakness and platysmal spasm correlated with persistent postoperative spasm, with similar trends at follow-up. In 207 patients, the LSR disappeared intraoperatively after decompression (group I), and in the remaining 52 patients, the LSR persisted intraoperatively despite decompression (group II). There was a significant difference in spasm relief between both groups within 24 hours of surgery (94.7% vs. 67.3%) (P < 0.0001) and at discharge (94.2% vs. 76.9%) (P = 0.001), but not at follow-up (93.3% vs. 94.4%) (P = 1.000). Multivariate logistic regression analysis demonstrated independent predictability of residual LSR for present spasm within 24 hours of surgery and at discharge but not at follow-up. Facial electromyography monitoring of the LSR during microvascular decompression is an effective tool in ensuring a complete decompression with long-lasting effects. Although LSR results predict short-term outcomes, long-term outcomes are not as reliant on LSR activity.

Endoscopic endonasal skull base surgery: analysis of complications in the authors' initial 800 patients.

OBJECT: The development of endoscopic endonasal approaches, albeit in the early stages, represents part of the continuous evolution of skull base surgery. During this early period, it is important to determine the safety of these approaches by analyzing surgical complications to identify and eliminate their causes. METHODS: The authors reviewed all perioperative complications associated with endoscopic endonasal skull base surgeries performed between July 1998 and June 2007 at the University of Pittsburgh Medical Center. RESULTS: This study includes the data for the authors' first 800 patients, comprising 399 male (49.9%) and 401 female (50.1%) patients with a mean age of 49.21 years (range 3-96 years). Pituitary adenomas (39.1%) and meningiomas (11.8%) were the 2 most common pathologies. A postoperative CSF leak represented the most common complication, occurring in 15.9% of the patients. All patients with a postoperative CSF leak were successfully treated with a lumbar drain and/or another endoscopic approach, except for 1 patient who required a transcranial repair. The incidence of postoperative CSF leaks decreased significantly with the adoption of vascularized tissue for reconstruction of the skull base (< 6%). Transient neurological deficits occurred in 20 patients (2.5%) and permanent neurological deficits in 14 patients (1.8%). Intracranial infection and systemic complications were encountered and successfully treated in 13 (1.6%) and 17 (2.1%) patients, respectively. Seven patients died during the 30-day perioperative period, 6 of systemic illness and 1 of infection (overall mortality 0.9%). CONCLUSIONS: Endoscopic endonasal skull base surgery provides a viable median corridor based on anatomical landmarks and is customized according to the specific pathological process. This corridor should be considered as the sole access or may be combined with traditional approaches. With the incremental acquisition of skills and experience, endoscopic endonasal approaches have an acceptable safety profile in select patients presenting with various skull base pathologies.

PICA origin aneurysm diagnosed 27 years after microvascular decompression of cranial nerve VII.

The authors report a case of a posterior inferior cerebellar artery origin aneurysm causing brainstem compression and swallowing difficulty. The patient had an ipsilateral microvascular decompression of cranial nerve VII for hemifacial spasm 27 years prior to the discovery of the aneurysm. The aneurysm was successfully treated endovascularly. A discussion of possible etiologies of the aneurysm's formation is presented.

Benign perimesencephalic hemorrhage occurring after previous aneurysmal subarachnoid hemorrhage: a case report.

INTRODUCTION: Both aneurysmal subarachnoid hemorrhage and benign perimesencephalic hemorrhage are well-described causes of spontaneous subarachnoid hemorrhage that arise as a result of different pathologic processes. To the best of the authors' knowledge, there have been no reports of both vascular pathologies occurring in the same individual. CASE PRESENTATION: A 51-year-old Caucasian woman with a history of aneurysmal subarachnoid hemorrhage presented five years after her initial treatment with ictal headache, meningismus, nausea and emesis similar to her previous bleeding event. Computed tomographic imaging revealed perimesencephalic bleeding remote from her previously coiled anterior communicating artery aneurysm. Both immediate and delayed diagnostic angiography revealed no residual filling of the previously coiled aneurysm and no other vascular anomalies, consistent with benign perimesencephalic hemorrhage. The patient had an uneventful hospital course and was discharged to home in good condition. CONCLUSIONS: This report for the first time identifies benign perimesencephalic hemorrhage occurring in the setting of previous aneurysmal subarachnoid hemorrhage. The presence of a previously treated aneurysm can complicate the process of diagnosing benign perimesencephalic hemorrhage. Fortunately, in this case, the previously treated anterior communicating artery aneurysm was remote from the perimesencephalic hemorrhage and could be ruled out as a source. The patient's prior aneurysmal subarachnoid hemorrhage did not worsen the anticipated good outcome associated with benign perimesencephalic hemorrhage.

Stereotactic radiosurgery with or without embolization for intracranial dural arteriovenous fistulas.

BACKGROUND: Treatment options for dural arteriovenous fistulas (DAVFs) have expanded with the application of stereotactic radiosurgery (SRS). OBJECTIVE: To assess the role of SRS with or without embolization, we reviewed our entire DAVF experience. METHODS: Between 1991 and 2006, 40 patients with 44 DAVFs underwent Gamma knife SRS. Twenty-eight patients had upfront SRS before or after embolization and 12 patients underwent delayed SRS for recurrent or residual DAVFs after initial embolization. The median patient age was 60 years (range, 29-90). DAVFs were diagnosed in 7 patients after they sustained an intracranial hemorrhage. The median SRS target volume was 2.0 mL (range, 0.2-8.2 mL) and the median marginal dose was 21.0 Gy (range, 15-25 Gy). RESULTS: At a median follow-up of 45 months (range, 23-116 mo), a total of 28 patients (harboring 32 DAVFs) had obliteration confirmed by imaging. We found a 83% obliteration rate in patients who had upfront SRS with embolization and a 67% obliteration rate in patients who only had SRS. One patient died of an intracerebral hemorrhage 2 months after SRS. Cavernous carotid fistulas were associated with higher rates of occlusion (P = .012) and symptom improvement (P = .010) than were transverse-sigmoid sinus-related fistulas. CONCLUSION: When upfront SRS is possible in conjunction with embolization, successful DAVF obliteration is possible in most patients, especially those with carotid cavernous fistulas. SRS should target the entire fistula regardless of whether it precedes or follows embolization. In selected patients with a small-volume, low-risk DAVF, SRS alone is an effective treatment option in most patients.

Symptomatic delayed reocclusion after initial successful revascularization in acute ischemic stroke.

BACKGROUND: Endovascular stroke therapy is used for patients with ischemic stroke after failed intravenous thrombolysis or in patients not eligible for thrombolytics. With increasing experience, acute reocclusion has been described and likely worsens clinical outcomes. We assessed the rates and outcomes of delayed symptomatic reocclusion after endovascular therapy for acute ischemic stroke. METHODS: Patients with acute ischemic stroke undergoing endovascular procedures at out institutions from January 2008 to August 2008 were reviewed. In all, 107 consecutive acute stroke interventions were performed. Four patients (3.5%) experienced delayed symptomatic reocclusion detectable by the National Institutes of Health Stroke Scale (NIHSS). RESULTS: The 4 patients (age 45-79 years) had baseline NIHSS score ranging from 8 to 24. Three had right middle cerebral artery occlusions and one had a left middle cerebral artery occlusion. Successful recanalization (thrombolysis in myocardial infarction score 2-3) occurred in all cases after initial treatment. All patients improved postprocedure (NIHSS score 5-10). Clinical deterioration (NIHSS score 14-22) occurred 12 to 18 hours postprocedure. Successful recanalization was achieved in each patient, with improvement in NIHSS score (range 6-13) but not to a lower level compared with after the initial intervention. CONCLUSIONS: Delayed symptomatic reocclusion after initial endovascular stroke therapy can lead to sudden clinical deterioration and impact outcomes. The entity may be missed as many patients present with large clinical deficits at presentation thus requiring careful assessments of patients treated via endovascular methods.