Unassisted and multiple microcatheter coiling of distal basilar aneurysms: Outcomes and literature review.

PURPOSE: The best treatment for distal basilar artery aneurysms is controversial. We aimed to review our single-centre experience with coil embolisation of aneurysms at this location and compare it with the surgical and endovascular literature. METHODS: Forty-two aneurysms in a distal basilar location in 42 consecutive patients (15 ruptured and 27 unruptured) were treated endovascularly from 2010 to 2015. Unassisted single and multiple microcatheter coil embolisation alone was used in all cases. We studied our immediate and long-term anatomical results, operative complications, and outcome. RESULTS: The immediate angiographic results showed complete occlusion in 34 (81%), a neck remnant in seven (16.6%) and a residual aneurysm in one patient (2.4%). There were two thromboembolic events (4.7%) without clinical sequelae; therefore, the operative morbidity and mortality were zero.Three patients with ruptured aneurysms (7.1%) died due to complicated vasospasm. Thirty-nine patients (93%) had clinical and MR imaging follow-up (mean 32.3 months ± 18.6, range from 12 to 66 months). There was recanalization in 30.8% with a retreatment rate of 15.3% and no new bleedings. The aneurysm size was the most important predictor of early anatomical outcome and recurrence. CONCLUSION: Unassisted and multiple microcatheter coiling is a safe treatment for distal basilar aneurysms. Early anatomical results and recurrence depend on the aneurysm size. Morbidity and mortality are lower and recurrence rates are higher in comparison with clipping or other adjunctive endovascular techniques.

Thrombectomy-Related Emboli: Direct Aspiration versus Stent Retriever Thrombectomy for Acute Ischemic Stroke: Our Experience and Literature Review.

OBJECTIVE: Thrombectomy-related emboli (TRE) represent a potentially dangerous complication of thrombectomy procedures for acute ischemic stroke. The aim of this study was to compare the rate of TRE in aspiration thrombectomy (ASP) and stent retriever thrombectomy techniques. METHODS: We retrospectively compared clinical and radiologic outcomes of 2 groups of consecutive patients with stroke, ASP group and SRT group, with TRE rates as the primary study endpoint. Emboli were classified as either affected territory emboli or unaffected territory emboli (uTRE). Relevant literature was also reviewed. RESULTS: The ASP group had better rates of successful recanalization (97.1% vs. 77.1%, P = 0.02), mean number of passes per case (2.0 vs. 3.3, P = 0.04), and mean operative time (34.1 minutes vs. 84.8 minutes, P < 0.0001). Thrombectomy technique (ASP vs. SRT) did not appear to predict rates of either affected territory emboli (odds ratio [OR] = 1.24, 95% confidence interval [CI] 0.33-4.63, P = 0.74) or uTRE (OR = 5.67, 95% CI 0.60-53.42, P = 0.13). Longer operative time was linked to higher uTRE rates (OR = 1.03, 95% CI 1.01-1.05, P = 0.02). ASP technique (OR 0.1, 95% CI 0.01-0.88; P = 0.04) and shorter operative time (OR = 0.98, 95% CI 0.97-0.99, P = 0.03) were linked to better rates of successful recanalization. CONCLUSIONS: The applied thrombectomy technique (ASP vs. SRT) is not an independent predictor of TRE rates. Operative time tends to affect the rates of uTRE and successful recanalization. The ASP technique offers higher rates of successful recanalization in less operative time.

Cranial dural arteriovenous shunts: selection of the ideal lesion for surgical occlusion according to the classification system.

BACKGROUND: The types of cranial dural arteriovenous fistulae (cDAVFs) that constitute good surgical candidates are unclear despite the use of classifications. We aimed to compare the DES classification with other classification schemes in identifying "ideal lesions for surgery." The DES scheme is based on two features: the level of the shunt (BVS, bridging vein shunt; DSS, dural sinus shunt; ISS, isolated sinus shunt; EVS, emissary vein shunt) and the type of leptomeningeal venous reflux (LVR) (direct, exclusive, strained). METHODS: In this observational cohort study, the angiographies of 20 consecutive patients treated over 1 year were analyzed retrospectively. We defined cDAVFs as ideal for surgery, if cure may be achieved by disconnecting the arterialized draining vein through a single craniotomy. To evaluate the performance of each classification scheme in identifying the "ideal lesion for surgery," we carried out a sensitivity analysis of the Borden, Cognard, and DES schemes. RESULTS: Eight lesions were Borden type 3 and 1 type 2, and 11 type 1. According to Cognard, 2 lesions were type IV, 2 type III, 1 type IIa+b, 11 type I, and 4 lesions could not be clearly classified. According to the DES scheme, 8 lesions were DSS, 4 BVS, 3 ISS, and 5 EVS. All 4 lesions classified as BVS in the DES were ideal lesions for surgery (sensitivity, specificity, PPV, NPV 100%). Not all high-grade lesions according to Borden were good surgical candidates. CONCLUSION: The DES scheme, as opposed to other classifications, facilitates the therapeutic decision-making especially for selecting candidates for surgery.

A White Matter Fiber Microdissection Study of the Anterior Perforated Substance and the Basal Forebrain: A Gateway to the Basal Ganglia?

BACKGROUND: Studies detailing the anatomy of the basal forebrain (BF) from a neurosurgical perspective are missing. OBJECTIVE: To describe the anatomy of the BF and of the anterior perforated substance (APS), the BF emphasizing surgical useful anatomical relationship between surface landmarks and deep structures. METHODS: White matter fiber microdissection was performed on 5 brain specimens to analyze the topographic anatomy of the APS and expose layer-by-layer fiber tracts and nuclei of the BF. RESULTS: The APS, as identified anatomically, surgically, and neuroradiologically, has clear borders measured 23.3 ± 3.4 mm (19-27) in the mediolateral and 12.5 ± 1.2 mm (11-14) in the anteroposterior directions. A detailed stratigraphy of the BF was performed from the APS up to basal ganglia and thalamus allowing identification and dissection of the main components of the BF (septum, nucleus accumbens, amygdala, innominate substance) and its white matter tracts (band of Broca, extracapsular thalamic peduncle, ventral amygdalohypothalamic fibers). The olfactory trigone together with diagonal gyrus and the APS proper is a relevant superficial landmark for the basal ganglia (inferior to the nucleus accumbens, lateral to the caudate head, and medial to the lentiform nucleus). CONCLUSION: The findings in our study supplement available anatomic knowledge of APS and BF, providing reliable landmarks for precise topographic diagnosis of BF lesions and for intraoperative orientation. Surgically relevant relationships between surface and deep anatomic structures are highlighted offering thus a contribution to neurosurgeons willing to perform surgery in this delicate area.

Multiple anomalies in the origin and course of vertebral arteries and aberrant right subclavian artery in a child with moyamoya syndrome.

Here we report, for the first time, a combination of five-vessel aortic arch, anomalous origin of the right vertebral artery (VA) from the common carotid artery (CCA), an aberrant right subclavian artery (SCA), and bilateral symmetrical segmental agenesis of VAs.In this case report, we present a patient with moyamoya syndrome (MMS) and Down syndrome (DS) who has bilateral symmetrical segmental agenesis of VAs, left VA originating from aortic arch and anomalous origin of right VA arising from CCA in combination with an aberrant right SCA. Therefore, five vessels are originating from aortic arch. Here, we report, for the first time, a combination of five-vessel aortic arch with an aberrant right SCA and symmetrical segmental agenesis of both VAs. The possible embryological mechanisms of the anomalies as well as an relation with MMS and DS are discussed.

Multiple anomalies in the origin and course of vertebral arteries and aberrant right subclavian artery in a child with moyamoya syndrome.

Here we report, for the first time, a combination of five-vessel aortic arch, anomalous origin of the right vertebral artery (VA) from the common carotid artery (CCA), an aberrant right subclavian artery (SCA), and bilateral symmetrical segmental agenesis of VAs.In this case report, we present a patient with moyamoya syndrome (MMS) and Down syndrome (DS) who has bilateral symmetrical segmental agenesis of VAs, left VA originating from aortic arch and anomalous origin of right VA arising from CCA in combination with an aberrant right SCA. Therefore, five vessels are originating from aortic arch. Here, we report, for the first time, a combination of five-vessel aortic arch with an aberrant right SCA and symmetrical segmental agenesis of both VAs. The possible embryological mechanisms of the anomalies as well as an relation with MMS and DS are discussed.

Combining monoenergetic extrapolations from dual-energy CT with iterative reconstructions: reduction of coil and clip artifacts from intracranial aneurysm therapy.

PURPOSE: To compare and to combine iterative metal artifact reduction (MAR) and virtual monoenergetic extrapolations (VMEs) from dual-energy computed tomography (DECT) for reducing metal artifacts from intracranial clips and coils. METHODS: Fourteen clips and six coils were scanned in a phantom model with DECT at 100 and 150SnkVp. Four datasets were reconstructed: non-corrected images (filtered-back projection), iterative MAR, VME from DECT at 120 keV, and combined iterative MAR + VME images. Artifact severity scores and visibility of simulated, contrast-filled, adjacent vessels were assessed qualitatively and quantitatively by two independent, blinded readers. RESULTS: Iterative MAR, VME, and combined iterative MAR + VME resulted in a significant reduction of qualitative (p < 0.001) and quantitative clip artifacts (p < 0.005) and improved the visibility of adjacent vessels (p < 0.05) compared to non-corrected images, with lowest artifact scores found in combined iterative MAR + VME images. Titanium clips demonstrated less artifacts than Phynox clips (p < 0.05), and artifact scores increased with clip size. Coil artifacts increased with coil size but were reducible when applying iterative MAR + VME compared to non-corrected images. However, no technique improved the severe artifacts from large, densely packed coils. CONCLUSIONS: Combining iterative MAR with VME allows for an improved metal artifact reduction from clips and smaller, loosely packed coils. Limited value was found for large and densely packed coils.

Rapid Documented Growth of Aneurysm Bleb Led to Rupture of an Incidental Intracranial Anterior Communicating Artery Aneurysm.

Background A major challenge in the management of patients with unruptured intracranial aneurysms (UIAs) is to identify criteria indicating a higher risk of future UIA rupture. We report a rare patient with documented short-term bleb growth of an UIA followed by a fatal aneurysm rupture supporting the high risk of rupture of short-term shape changes in UIAs. Case Description A 72-year-old man with an incidental unruptured anterior communicating artery aneurysm of 9 mm showed a bleb growth on the aneurysm sac at 6-week follow-up computed tomography angiography (CTA). Aneurysm treatment was recommended by the interdisciplinary board (PHASES score: 9 points; rupture risk 4.3% in 5 years). The patient wanted to discuss the treatment plan with his family before making a final decision. Two days after the CTA showing bleb growth, he was admitted emergently with a severe subarachnoid hemorrhage (SAH) (World Federation of Neurologic Surgeons grade 5; Fisher 3). The aneurysm was occluded with coils. However, the patient died on day 14 after SAH due to delayed ischemic neurologic deficits and multiple organ failure. Conclusions This case illustrates the high rupture risk of an UIA presenting a documented growth of an aneurysm bleb over a short follow-up time. In retrospect, this patient might have benefited from emergent aneurysm occlusion. The interest of this report comes from the proof that aneurysmal bleb growth constitutes a high risk for short-term aneurysm rupture.

Missed Anterior Inferior Cerebellar Artery Aneurysm Mimicking Vestibular Neuritis-Clues to Prevent Misdiagnosis.

We discuss a case with combined vestibulocochlear and facial neuropathy mimicking a less urgent peripheral vestibular pattern of acute vestibular syndrome (AVS). With initial magnetic resonance imaging read as normal, the patient was treated for vestibular neuropathy until headaches worsened and a diagnosis of subarachnoid hemorrhage was made. On conventional angiography, a ruptured distal right-sided aneurysm of the anterior inferior cerebellar artery was diagnosed and coiled. Whereas acute vestibular loss usually points to a benign peripheral cause of AVS, combined neuropathy of the vestibulocochlear and the facial nerve requires immediate neuroimaging focusing on the cerebellopontine angle. Imaging should be assessed jointly by neuroradiologists and the clinicians in charge to take the clinical context into account.

Ventriculoatrial Shunts in Adults, Incidence of Infection, and Significant Risk Factors: A Single-Center Experience.

BACKGROUND: In recent years, the number of ventriculoatrial (VA) shunt insertions has decreased worldwide, the major cause being the risk of shunt infection. VA shunts remain as an alternative option to ventriculoperitoneal shunts. We describe our 10-year experience with VA shunts by analyzing the incidence of shunt infections and predisposing cofactors. METHODS: During a median follow-up of 15.3 months, 259 shunt insertions, performed on 255 patients, were analyzed. The infection rate was calculated and the predisposing cofactors age, gender, cause of the hydrocephalus, previous external ventricle drainage, antibiotic-impregnated catheters, the number of revisions, the educational level of the surgeons, and the duration of the operations were analyzed. Two observation times were stratified. RESULTS: We found overall infections in 18 patients (7.1%), 16 deep infections (6.3%) including 1 shunt nephritis (0.4%) and 2 superficial infections (0.8%). Wound dehiscence occurred in 17 patients (6. 6%). Analyzing follow-up time, the infection rate was 3.65% (95% confidence interval, 0.9%-5.9%) at survival time 1, 3.38% (95% confidence interval, 1.1%-6.2%) at survival time 2. In the first 6 months, 95% of patients were free of infection. Only the number of revision procedures was associated with the number of infections (P value < 0.0005). CONCLUSIONS: In our patient cohort, the infection rate related to VA shunt insertion is low; the only statistically significant risk factor was the number of revisions. If the VA shunt is applied following a standardized protocol, the infection risk does not represent an argument for reluctance towards the VA draining concept.

Prediction of Lumbar Disc Herniation Patients' Satisfaction with the Aid of an Artificial Neural Network.

AIM: To identify key determinants of lumbar disc herniation (LDH) patients' satisfaction and to evaluate the efficiency of an artificial neural network (ANN) model to prognosticate satisfaction derived from the hospital stay in this specific patient group. MATERIAL AND METHODS: A single item question was used to assess patient satisfaction. Principal component analysis evaluated several aspects of care (15 items). An ANN encompassed all variables and its prediction ability was tested. The ANN performance was correlated to a binary logistic regression (BLR) model. RESULTS: Higher levels of satisfaction were reported by females, older patients, Greeks, and patients with elementary education staying in not rural areas. A history of a single previous hospitalisation was correlated with more satisfaction. The accuracy of ANN was 96% for satisfaction prediction outperforming the BLR model. CONCLUSION: Satisfactory health services are influenced by sex, age, nationality, and number of prior admissions. The self-perceived health state plays also a crucial role. The current study is the first one reporting on the capability of an ANN to accurately predict the satisfaction levels of LDH patients.

Complications of Sigmoid Sinus Transvenous Occlusion for the Endovascular Treatment of Dural Arteriovenous Shunts with Emphasis on Inner Ear Dysfunction.

OBJECTIVE: Embolization of cranial dural sinus arteriovenous fistulae with transvenous occlusion of the involved sinuses is an established strategy when the collateral brain drainage allows it. We aimed to investigate the frequency and types of complications after endovascular occlusion of the sigmoid sinus. METHODS: From our database, we detected 52 endovascularly treated consecutive cases of cranial dural arteriovenous shunts involving the sigmoid sinus. The cases treated through the transvenous approach alone or combined with the transarterial one were analyzed retrospectively. Previously reported series and cases were reviewed and critically analyzed. RESULTS: In 15 cases, a transvenous approach was used and in 4 combined a transvenous approach with a transarterial approach. Two patients (13.3%) both treated with the transvenous approach alone presented postoperatively with vertigo and hearing loss. In the first case, the sinus occlusion involved the whole sigmoid sinus, whereas in the second case the occlusion was restricted to a parallel channel posteriorly to the proximal segment of the sigmoid sinus. Magnetic resonance imaging and ear, nose, and throat investigations failed to elucidate the cause and pathomechanism of these symptoms. No other complications occurred. CONCLUSIONS: Although the transvenous occlusion of the sigmoid sinus generally is a safe therapeutic option for the treatment of dural arteriovenous fistulae, inner ear dysfunction is still a possible complication. The combined analysis of the reported and our cases did not allow a plausible explanation of this complication and its pathomechanism remains obscure.

Langer-Giedion syndrome associated with congenital dural arterio-venous fistula.

Langer-Giedion syndrome (LGS) is a rare disease caused by deletion of chromosome 8q23.3-q24.11. Clinical manifestations include among others multiple exostoses, short stature, intellectual disability, and typical facial dysmorphism. Dural arterio-venous shunts (DAVS) in the pediatric age are rare lesions, which have been classified into three types: dural sinus malformations (DSM), infantile type DAVS (IDAVS), and adult type DAVS (ADAVS). We report a case of a patient with a known LGS who was diagnosed with complex intracranial dural AV fistula at the age of 20. An association between LGS and intracranial dural AV fistulas has to our knowledge never been reported before.

Cranial dural arteriovenous shunts. Part 4. Clinical presentation of the shunts with leptomeningeal venous drainage.

Cranial dural arteriovenous fistulae have been classified into high- and low-risk lesions mainly based on the pattern of venous drainage. Those with leptomeningeal venous drainage carry a higher risk of an aggressive clinical presentation. Recently, it has been proposed that the clinical presentation should be considered as an additional independent factor determining the clinical course of these lesions. However, dural shunts with leptomeningeal venous drainage include a very wide spectrum of inhomogeneous lesions. In the current study, we correlated the clinical presentation of 107 consecutive patients harboring cranial dural arteriovenous shunts with leptomeningeal venous drainage, with their distinct anatomic and angiographic features categorized into eight groups based on the "DES" (Directness and Exclusivity of leptomeningeal venous drainage and features of venous Strain) concept. We found that among these groups, there are significant angioarchitectural differences, which are reflected by considerable differences in clinical presentation. Leptomeningeal venous drainage of dural sinus shunts that is neither direct nor exclusive and without venous strain manifested only benign symptoms (aggressive presentation 0%). On the other end of the spectrum, the bridging vein shunts with direct and exclusive leptomeningeal venous drainage and venous strain are expected to present aggressive symptoms almost always and most likely with bleeding (aggressive presentation 91.5%). Important aspects of the above correlations are discussed. Therefore, the consideration of leptomeningeal venous drainage alone, for prediction of the clinical presentation of these shunts appears insufficient. Angiographic analysis based on the above concept, offers the possibility to distinguish the higher- from the lower-risk types of leptomeningeal venous drainage. In this context, consideration of the clinical presentation as an additional independent factor for the prediction of their clinical course seems superfluous and possibly misleading. Topography is connected to the clinical presentation of the dural shunts inasmuch as the former determines the venous anatomy and the angioarchitectural features of the lesions.

Intra-arterial administration of papaverine during mechanical thrombectomy for acute ischemic stroke.

BACKGROUND: The use of stent retrievers for mechanical thrombectomy in acute ischemic stroke may induce significant vasospasm, which at the early phases of reperfusion may be crucial for rethrombosis of the recanalized vessel. We aimed to study whether the use of intra-arterial papaverine in selected cases of vasospasm was associated with improved cerebral perfusion, arterial reocclusion, or increased hemorrhagic complications. METHODS: We retrospectively studied 9 consecutive patients with large artery acute occlusion, treated with stent retriever and intra-arterial papaverine. Onset to administration of intravenous recombinant tissue-plasminogen activator time, baseline National Institute of Health Stroke Scale, time to reperfusion, number of passes of the stent retriever, modified Rankin Scale score at discharge, postprocedural hemorrhage, onset to reperfusion time, papaverine dose, and thrombolysis in cerebral infarction grade were recorded in all patients. RESULTS: After papaverine administration, the caliber of the infused arteries and their flow was increased in all cases. In none of the treated cases a reocclusion occurred after papaverine infusion. In one of the studied patients (11%), a parenchymal bleeding occurred 36 hours postoperatively. CONCLUSIONS: This small study suggests that intra-arterial infusion of papaverine for the treatment of cerebral vasospasm after mechanical thrombectomy in acute ischemic stroke is effective and safe.

Cranial dural arteriovenous shunts. Part 2. The shunts of the bridging veins and leptomeningeal venous drainage.

Leptomeningeal venous drainage of cranial dural arteriovenous fistulae is the most important determinant of adverse clinical course. Factors that predispose to its occurrence have not been adequately addressed in the literature. In the present study, we investigated the relation of shunt location to the development of leptomeningeal venous drainage, with regard to the bridging veins. Angiographic data of 211 consecutive patients with cranial dural arteriovenous fistulae treated over 19 years were analyzed. Dural shunts with leptomeningeal venous drainage were found in 107 patients; of these, 71 patients had pure leptomeningeal venous drainage (Borden type 3). The angioarchitecture of the shunt, including pattern of arterial feeders, relation with the bridging veins, primary venous drainage, and venous outflow restrictions were recorded. After analysis of the 71 Borden type 3 shunts with exclusive leptomeningeal venous drainage, three patterns emerged. The commonest was the fistula engaging a bridging vein that had lost its connection to the parent sinus into which it previously drained; it was characterized by an arterial network of feeders converging onto the wall of a bridging vein, with leptomeningeal venous reflux. The other patterns were those of "isolated" sinus segment characterized by arterial feeders converging on to the wall of the dural sinus with leptomeningeal venous reflux following the opacification of the sinus and fistulae in the vicinity of the cribriform plate with two subtypes. The main angioarchitectural features of the 36 Borden type 2 shunts with mixed sinusal-cortical venous drainage were the presence of a diffuse arterial network of vessels converging onto a site in the wall of the dural sinus, with leptomeningeal venous reflux following the opacification of the sinus. In this group, four exceptions were noticed with arterial feeders converging onto a bridging vein and having a mixed venous drainage to the cortical venous system and the sinuses. We concluded that the exact location of the shunt with regard to the bridging veins is a key factor in the development of leptomeningeal venous drainage. Cranial dural arteriovenous fistulae (CDAVFs) of either Borden type 2 or 3 do not constitute a homogeneous group. The great majority of these shunts present thrombotic phenomena.

The collateral circulation in pediatric moyamoya disease.

PURPOSE: The descriptions of collateral circulation in moyamoya have so far been a mixture of topography-based and vessels' source-based analyses. We aimed to investigate the anatomy and systematize the vascular anastomotic networks in pediatric moyamoya disease. METHODS: From a series of 25 consecutive complete angiographic studies of newly diagnosed children with moyamoya, 14 children had moyamoya disease and 11 were diagnosed with moyamoya syndrome, i.e., moyamoya angiopathy with some additional concomitant systemic disease. We retrospectively analyzed the arterial branches supplying the moyamoya anastomotic networks, their origin, course, location, and connections with the recipient vessels. RESULTS: We describe four types of anastomotic networks in children with moyamoya disease, two superficial-meningeal and two deep-parenchymal. As superficial-meningeal, we defined the leptomeningeal and the durocortical networks. Apart from the previously described leptomeningeal network observed in the convexial watershed zones, we report on the basal temporo-orbitofrontal leptomeningeal network. The second superficial-meningeal network is the durocortical network, which can be basal or calvarian in location. We define as deep-parenchymal networks the nonpreviously described subependymal network and the inner striatal and inner thalamic networks. The subependymal network is fed by the intraventricular branches of the choroidal system and diencephalic perforators, which at the level of the periventricular subependymal zone, anastomose with medullary-cortical arteries as well as with striatal arteries. The inner striatal and thalamic networks are constituted by intrastriatal connections among striatal arteries and intrathalamic connections among thalamic arteries when the disease compromises the origin of one or more sources of their supply. CONCLUSION: The previously inexplicitly described "moyamoya abnormal network" in pediatric moyamoya disease can be described as a composition of four anastomotic networks with distinct angioarchitecture. A better understanding of the collateralization in moyamoya may help in defining a new staging system of the disease with clinical relevance.