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1.
BMJ Case Rep ; 13(10)2020 Oct 04.
Artigo em Inglês | MEDLINE | ID: mdl-33012707

RESUMO

This is a report of the first three cases of endovascular aneurysm treatment that were proctored by a remote interventionalist using a novel high-resolution low-latency streaming technology. The proctor was located in a neurovascular centre and supported the treating interventional teams in two distant cities (up to 800 km/500 miles apart). All aneurysms were treated using the Woven EndoBridge (WEB) embolisation system, either electively or following subarachnoid haemorrhage. On-site proctoring was not possible due to travel restrictions during the COVID-19 pandemic. WEB placement was feasible in all cases. Good rapport between proctors and treating physicians was reported, enabled by the high-resolution image transmission and uninterrupted feedback/discussion via audiostream. No clinical complications were encountered. Short-term follow-up revealed adequate occlusion of all treated aneurysms. The employed streaming technology provided effective remote proctoring during complex aneurysm cases, including the management of technical complications.


Assuntos
Betacoronavirus , Infecções por Coronavirus/prevenção & controle , Procedimentos Endovasculares/métodos , Aneurisma Intracraniano/terapia , Pandemias/prevenção & controle , Pneumonia Viral/prevenção & controle , Telemedicina/métodos , Angiografia Digital/métodos , Humanos , Aneurisma Intracraniano/diagnóstico por imagem
2.
Neurocirugía (Soc. Luso-Esp. Neurocir.) ; 31(4): 173-183, jul.-ago. 2020. ilus
Artigo em Inglês | IBECS | ID: ibc-193898

RESUMO

OBJECT: The breadth and complexity of neurovascular pathologies treated with endovascular neurosurgery has expanded dramatically in recent years. Many aneurysms remain difficult to treat safely. Transcirculation (contralateral and/or retrograde) approaches through the circle of Willis are useful alternatives for treating challenging lesions endovascularly. Here, we present a series of patients treated with unconventional transcirculation techniques. METHODS: A total of six patients were treated: four patients with five aneurysms, one patient with an MCA stroke, and one patient with a meningioma requiring preoperative embolization were initially thought not to be amenable to endovascular treatment. The decision was made to treat these patients with transcirculation approaches. All patients were treated by one interventionist. One aneurysm was located in the cavernous internal carotid artery (ICA), one in the vertebral artery, two in the paraclinoid ICA, and one in a cerebellar AVM feeder vessel were treated. RESULTS: Five of six patients (83%) made a full neurologic recovery. Three aneurysms were treated to complete occlusion, one aneurysm was left with small residual neck filling, and one aneurysm was not able to be treated. One patient underwent mechanical thrombectomy of a middle cerebral artery (MCA) embolus and MCA filling was restored after treatment. One patient underwent complete embolization of the deep vascular supply of a meningioma. CONCLUSIONS: Although many neurovascular pathologies remain unsuitable for endovascular treatment, transcirculation approaches can allow for safe, successful treatment of challenging lesions in select patients


OBJETIVO: La variedad y la complejidad de las enfermedades neurovasculares tratadas con neurocirugía endovascular ha aumentado drásticamente en los últimos años. Muchos aneurismas continúan siendo difíciles de tratar de forma segura. Los enfoques de transcirculación (contralateral y/o retrógrada) a través del círculo de Willis son alternativas útiles para el tratamiento endovascular de lesiones difíciles. Presentamos una serie de casos de pacientes tratados con técnicas de transcirculación no convencionales. MÉTODOS: Se trató a un total de 6 pacientes que inicialmente se creía que no eran aptos para el tratamiento endovascular: 4 pacientes con 5 aneurismas, un paciente con un ictus de la arteria cerebral media (ACM) y un paciente con un meningioma que requería embolización preoperatoria. Se tomó la decisión de tratar a estos pacientes con métodos de transcirculación. Todos los pacientes fueron tratados por un solo especialista. Se localizaron y trataron un aneurisma en el segmento cavernoso de la arteria carótida interna (ACI), otro en la arteria vertebral, 2 en el segmento paraclinoideo de la ACI y otro en una malformación arteriovenosa cerebelosa de un vaso nutriente. RESULTADOS: Cinco de los 6 pacientes (83%) alcanzaron una recuperación neurológica completa. Se trataron 3 aneurismas hasta una oclusión completa, un aneurisma se dejó con un pequeño relleno de cuello residual y otro aneurisma no pudo ser tratado. Un paciente fue sometido a una trombectomía mecánica de un émbolo en la ACM y el relleno de la ACM se restauró después del tratamiento. Un paciente se sometió a embolización completa del riego vascular profundo de un meningioma. CONCLUSIONES: Aunque muchas enfermedades neurovasculares siguen sin ser adecuadas para el tratamiento endovascular, los enfoques de transcirculación pueden permitir el tratamiento seguro y exitoso de lesiones difíciles en pacientes seleccionados


Assuntos
Humanos , Masculino , Feminino , Adulto , Pessoa de Meia-Idade , Idoso , Procedimentos Endovasculares/instrumentação , Doenças Arteriais Intracranianas/diagnóstico por imagem , Doenças Arteriais Intracranianas/cirurgia , Aneurisma Intracraniano/diagnóstico por imagem , Aneurisma Intracraniano/cirurgia , Trombectomia/métodos , Embolização Terapêutica/instrumentação
3.
Rinsho Shinkeigaku ; 60(9): 573-580, 2020 Sep 29.
Artigo em Japonês | MEDLINE | ID: mdl-32779599

RESUMO

MRI is a non-invasive imaging modality with a high contrast resolution useful in diagnosing intracranial artery dissections. However, conventional MRI techniques, including time-of-flight MR angiography or basi-parallel anatomical scanning provide only limited information because they focus on imaging findings rather than the vessel walls. A newly devised MRI technique, high-resolution vessel wall imaging (HRVWI), enables direct visualization of vessel wall and therefore more accurate diagnosis. With increasing use of HRVWI, physicians need to understand the clinical indications, MR sequences for assessment, optimization of acquisition parameters, and limitations in the interpretation of images. For precise interpretation of images, physicians should be aware of the pathological condition of intracranial artery dissection and its radiological findings. In this review, we provide an overview and principles of MRI assessment used for intracranial artery dissection paying special attention to its pathological findings and radiological presentations on HRVWI.


Assuntos
Aneurisma Dissecante/diagnóstico por imagem , Artérias Cerebrais/diagnóstico por imagem , Imagem de Difusão por Ressonância Magnética , Imageamento Tridimensional , Aneurisma Intracraniano/diagnóstico por imagem , Angiografia por Ressonância Magnética , Adulto , Idoso , Feminino , Humanos , Masculino , Pessoa de Meia-Idade
4.
Artigo em Russo | MEDLINE | ID: mdl-32649811

RESUMO

BACKGROUND: Assessment of rupture risk for intracranial aneurysms (IA) is a particular challenge in cases of so-called complex aneurysms due to their variable morphometric characteristics. Arterial branch arising from the dome or the neck of IA is one of the least explored features of complex aneurysms. The methods of computational fluid dynamics may be valuable to determine the influence of arterial branches of IA on local hemodynamics. OBJECTIVE: To analyze local hemodynamics in IA with arterial branch arising from the cupola or the neck depending on the structure of the aneurysm and blood flow rate in the parent vessel. MATERIAL AND METHODS: CT angiography data of 4 patients with IA were estimated in this study. Modifications of the baseline 3D models of the aneurysms resulted 12 patient-specific models included into analysis. Hemodynamic calculations were made by using of ANSYS Workbench 19 software package. RESULTS: Wall shear stress (WSS) was characterized by the most significant variability, especially in case of sidewall aneurysms. Small cross-sectional area of additional branch in relation to the neck of IA was not followed by considerable changes of blood flow patterns inside IA after «virtual¼ removal of the vessel. Otherwise, the intensity of flows was drastically reduced. Simulation of high inlet flows demonstrated substantial variation of WSS in the area of jet. CONCLUSION: Additional arterial branch arising from the dome or the neck of IA significantly influences local hemodynamics. This influence depends on the localization of IA in relation to the parent vessel and the diameter of additional arterial branch.


Assuntos
Imageamento Tridimensional , Aneurisma Intracraniano/diagnóstico por imagem , Hemodinâmica , Humanos , Hidrodinâmica , Estresse Mecânico
5.
Asian Cardiovasc Thorac Ann ; 28(5): 250-257, 2020 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-32486829

RESUMO

The correlation between intracranial and aortic aneurysms remains elusive. Data in the literature are scattered, and outcome reporting is swamped with heterogeneity and single-center bias. This calamity is adding to confusion on decision-making and delays the instigation of appropriate clinical applications. This literature review delves into the abyss of the lack of clinically driven scientific input, and highlights the trends explored thus far.


Assuntos
Aneurisma da Aorta Abdominal/epidemiologia , Aneurisma da Aorta Torácica/epidemiologia , Medicina Baseada em Evidências/tendências , Aneurisma Intracraniano/epidemiologia , Aneurisma da Aorta Abdominal/diagnóstico por imagem , Aneurisma da Aorta Abdominal/genética , Aneurisma da Aorta Torácica/diagnóstico por imagem , Aneurisma da Aorta Torácica/genética , Comorbidade , Predisposição Genética para Doença , Humanos , Aneurisma Intracraniano/diagnóstico por imagem , Aneurisma Intracraniano/genética , Valor Preditivo dos Testes , Prevalência , Medição de Risco , Fatores de Risco
6.
Ideggyogy Sz ; 73(05-06): 213-216, 2020 05 30.
Artigo em Inglês | MEDLINE | ID: mdl-32579312

RESUMO

The cause of intracerebral, subarachnoid and subdural haemorrhage is different, and the simultaneous appearance in the same case is extremely rare. We describe the case of a patient with a ruptured aneurysm on the distal segment of the middle cerebral artery, with a concomitant subdural and intracerebral haemorrhage, and a subsequent secondary brainstem (Duret) haemorrhage. The 59-year-old woman had hypertension and diabetes in her medical history. She experienced anomic aphasia and left-sided headache starting one day before admission. She had no trauma. A few minutes after admission she suddenly became comatose, her breathing became superficial. Non-contrast CT revealed left sided fronto-parietal subdural and subarachnoid and intracerebral haemorrhage, and bleeding was also observed in the right pontine region. The patient had leucocytosis and hyperglycemia but normal hemostasis. After the subdural haemorrhage had been evacuated, the patient was transferred to intensive care unit. Sepsis developed. Echocardiography did not detect endocarditis. Neurological status, vigilance gradually improved. The rehabilitation process was interrupted by epileptic status. Control CT and CT angiography proved an aneurysm in the peripheral part of the left middle cerebral artery, which was later clipped. Histolo-gical examination excluded mycotic etiology of the aneu-rysm and "normal aneurysm wall" was described. The brain stem haemorrhage - Duret bleeding - was presumably caused by a sudden increase in intracranial pressure due to the supratentorial space occupying process and consequential trans-tentorial herniation. This case is a rarity, as the patient not only survived, but lives an active life with some residual symptoms.


Assuntos
Aneurisma Roto/diagnóstico por imagem , Cerebelo/irrigação sanguínea , Hematoma Subdural/etiologia , Hematoma Subdural/cirurgia , Aneurisma Intracraniano/diagnóstico por imagem , Aneurisma Intracraniano/cirurgia , Angiografia Cerebral , Hemorragia Cerebral/etiologia , Hemorragia Cerebral/cirurgia , Angiografia por Tomografia Computadorizada , Feminino , Cefaleia , Humanos , Aneurisma Intracraniano/complicações , Pessoa de Meia-Idade , Resultado do Tratamento
7.
BMC Neurol ; 20(1): 232, 2020 Jun 06.
Artigo em Inglês | MEDLINE | ID: mdl-32505180

RESUMO

BACKGROUND: Partially thrombosed giant aneurysms at the basilar apex (BA) artery are challenging lesions with a poor prognosis if left untreated. Here we describe a rare case of extensive brain edema after growth of a surgically treated and thrombosed giant basilar apex aneurysm. CASE PRESENTATION: We performed a proximal surgical basilar artery occlusion on a 64-year-old female with a partially thrombosed giant BA aneurysm. MRI showed no ischemic lesions but showed marked edema adjacent to the aneurysm. She had a good recovery, but 3 months after surgical occlusion, her gait deteriorated together with urinary incontinence and worsening right hemiparesis. MRI showed that the aneurysm had grown and developed intramural hemorrhage, which caused extensive brain edema and obstructive hydrocephalus. She was treated by a ventriculoperitoneal shunt placement. Follow-up MRI showed progressive brain edema resolution, complete thrombosis of the lumen and shrinkage of the aneurysm. At 5 years follow-up the patient had an excellent functional outcome. CONCLUSIONS: Delayed growth of a surgically treated and thrombosed giant aneurysm from wall dissection demonstrates that discontinuity with the initial parent artery does not always prevent progressive enlargement. The development of transmural vascular connections between the intraluminal thrombus and adventitial neovascularization by the vasa vasorum on the apex of the BA seems to be a key event in delayed aneurysm growth. Extensive brain edema might translate an inflammatory edematous reaction to an abrupt enlargement of the aneurysm.


Assuntos
Artéria Basilar , Edema Encefálico , Aneurisma Intracraniano , Artéria Basilar/diagnóstico por imagem , Artéria Basilar/fisiopatologia , Artéria Basilar/cirurgia , Edema Encefálico/etiologia , Edema Encefálico/cirurgia , Feminino , Humanos , Aneurisma Intracraniano/complicações , Aneurisma Intracraniano/diagnóstico por imagem , Aneurisma Intracraniano/cirurgia , Imagem por Ressonância Magnética , Pessoa de Meia-Idade , Trombose/diagnóstico por imagem , Trombose/etiologia , Trombose/cirurgia , Derivação Ventriculoperitoneal
8.
J Vis Exp ; (159)2020 05 14.
Artigo em Inglês | MEDLINE | ID: mdl-32478731

RESUMO

Endovascular treatment for intracranial aneurysms gained importance over the past decades, consequently there is an increased need of testing endovascular devices. Animal models respecting rheological, hemodynamic and aneurysm wall conditions are highly warranted. Therefore, the aim of the present study was to design a novel standardized and reproducible surgical technique to create autologous arterial pouch bifurcation aneurysms with non-modified and modified wall conditions in rabbits. Bifurcation aneurysms were created by end-to-side anastomosis of the right on the left common carotid artery, both serving as parent arteries for the arterial pouch, which was microsurgically sewn on. Grafts were taken from the proximal right common carotid artery, either for the control (n = 7, immediate autologous re-implantation) or modified (n = 7, incubated with 100 international units elastase for 20 minutes before autologous re-implantation) group. Pouch and parent artery patency were controlled by fluorescence angiography immediately after creation. At follow-up (28 days), all rabbits underwent contrast enhanced magnetic resonance angiography and fluorescence angiography followed by aneurysm harvesting, macroscopic and histological evaluation. A total of 16 female New Zealand White rabbits were operated upon. Two animals died prematurely. At follow-up, 85.72% of all aneurysms remained patent. Both groups revealed an increase in aneurysm size over time; this was more pronounced in the control group (6.48 ± 1.81 mm3 at time of creation vs. 19.85 ± 6.40 mm3 at follow-up, p = 0.037) than in the modified group (8.03 ± 1.08 mm3 at time of creation vs. 20.29 ± 6.16 mm3 at follow-up, p = 0.054). Our findings demonstrate the adequacy of this new rabbit model which allows for the creation of bifurcation aneurysms with different wall conditions in a microsurgical approach. Given the excellent long-term patency and the property of aneurysm growth over time, this model may serve as an important tool for preclinical evaluation of novel endovascular therapies.


Assuntos
Artéria Carótida Primitiva/cirurgia , Aneurisma Intracraniano/cirurgia , Pontos de Referência Anatômicos , Animais , Artéria Carótida Primitiva/diagnóstico por imagem , Modelos Animais de Doenças , Feminino , Angiofluoresceinografia , Aneurisma Intracraniano/diagnóstico por imagem , Angiografia por Ressonância Magnética , Microcirurgia , Elastase Pancreática/metabolismo , Coelhos
10.
Yonsei Med J ; 61(5): 441-444, 2020 May.
Artigo em Inglês | MEDLINE | ID: mdl-32390369

RESUMO

Cerebral aneurysms associated with systemic lupus erythematosus (SLE) are more likely to grow rapidly and rupture, compared to those found in the general population. The main underlying pathology of intracranial aneurysm and its rupture is presumed to be SLE-related intracranial vasculitis and fragility of blood vessels due to prolonged use of steroid. For these reasons, both surgical and endovascular options are challenging. On the other hand, given the possibility that SLE may predispose to growth and rupture of intracranial aneurysm, early intervention for cerebral aneurysms associated with SLE may be more necessary and beneficial than other cerebral aneurysms in the general population. Here we would like to report on the unexpected complications that occurred during or after endovascular treatment of an SLE patient with multiple aneurysms. The complications include intraprocedural rupture of unruptured aneurysm, coil stretching, contrast-induced encephalopathy, and delayed ipsilateral intraparenchymal hemorrhage after stent-assisted coiling. Our unique case highlights that the SLE patient with multiple intracranial aneurysms had a higher risk of endovascular procedure-related complications, which might be due to the increased bleeding tendency and fragility of blood vessels.


Assuntos
Procedimentos Endovasculares/efeitos adversos , Aneurisma Intracraniano/complicações , Aneurisma Intracraniano/cirurgia , Lúpus Eritematoso Sistêmico/complicações , Complicações Pós-Operatórias/etiologia , Adulto , Encéfalo/diagnóstico por imagem , Encéfalo/patologia , Artéria Carótida Interna/diagnóstico por imagem , Artéria Carótida Interna/patologia , Feminino , Humanos , Aneurisma Intracraniano/diagnóstico por imagem , Fatores de Risco , Tomografia Computadorizada por Raios X , Resultado do Tratamento
11.
Medicine (Baltimore) ; 99(19): e20013, 2020 May.
Artigo em Inglês | MEDLINE | ID: mdl-32384459

RESUMO

INTRODUCTION: Clinically, anterior communicating artery complex fenestration combined with fenestration-related aneurysms is rare, and combination of this condition with tandem aneurysms is even rarer. PATIENT CONCERNS: A case of a 43-year-old man with spontaneous subarachnoid hemorrhage. DIAGNOSIS: A computed tomography angiography examination revealed a fenestrated anterior communicating artery complex combined with 2 aneurysms. Then, a digital subtraction angiography examination was performed to further determine the diagnosis, which showed a complex anatomical structure of the local tissue. After the aneurysms ruptured, they were partially wrapped by a hematoma and compressed, which increased the difficulty of surgery. INTERVENTIONS: An endovascular interventional therapy method was chosen, and a simple coil was successfully inserted through the blood vessel into the tandem aneurysms to maintain the integrity of the anatomical structure. OUTCOMES: The patient recovered well postoperatively. An imaging review after the operation did not show the aneurysms, and the upper and lower branches were patent. CONCLUSION: Therefore, endovascular treatment is an appropriate choice for arterial fenestration combined with tandem aneurysms, once the aneurysms have ruptured.


Assuntos
Aneurisma Roto , Angiografia Cerebral/métodos , Artérias Cerebrais , Embolização Terapêutica/métodos , Procedimentos Endovasculares/métodos , Procedimentos Neurocirúrgicos/métodos , Hemorragia Subaracnóidea , Adulto , Aneurisma Roto/diagnóstico , Aneurisma Roto/fisiopatologia , Aneurisma Roto/cirurgia , Angiografia Digital/métodos , Artérias Cerebrais/diagnóstico por imagem , Artérias Cerebrais/patologia , Artérias Cerebrais/cirurgia , Angiografia por Tomografia Computadorizada/métodos , Humanos , Aneurisma Intracraniano/complicações , Aneurisma Intracraniano/diagnóstico por imagem , Masculino , Hemorragia Subaracnóidea/diagnóstico por imagem , Hemorragia Subaracnóidea/etiologia , Hemorragia Subaracnóidea/cirurgia , Resultado do Tratamento
12.
Stroke ; 51(6): 1868-1872, 2020 06.
Artigo em Inglês | MEDLINE | ID: mdl-32397927

RESUMO

Background and Purpose- Absence of arterial wall enhancement (AWE) of unruptured intracranial aneurysms (UIA) has shown promise at predicting which aneurysms will not rupture. We here tested the hypothesis that increased enhancement during follow-up (increased intensity, extension, or thickness or appearance of de novo enhancement), assessed using vessel wall magnetic resonance imaging, was associated with higher rates of subsequent growth. Methods- Patients with UIA were included between 2012 and 2018. Two readers independently rated AWE modification on 3T vessel wall magnetic resonance imaging, and morphological changes on time-of-flight magnetic resonance angiography during follow-up. Results- A total of 129 patients harboring 145 UIA (mean size 4.1 mm) met study criteria, of which 12 (8.3%) displayed morphological growth at 2 years. Of them, 8 demonstrated increased AWE during follow-up before or concurrently to morphological growth, and 4 had preexisting AWE that remained stable before growth. In the remaining 133 (nongrowing) UIAs, no AWE modifications were found. In multivariable analysis, increased AWE, not size, was associated with UIA growth (relative risk, 26.1 [95% CI, 7.4-91.7], P<0.001). Sensitivity, specificity, positive predictive value, and negative predictive value for UIA growth of increased AWE during follow-up were, respectively, of 67%, 100%, 96%, and 100%. Conclusions- Increased AWE during follow-up of conservatively managed UIAs predicts aneurysm growth over a 2-year period. This may impact UIA management towards closer monitoring or preventive treatment. Replication in a different setting is warranted.


Assuntos
Angiografia Cerebral , Artérias Cerebrais , Bases de Dados Factuais , Aneurisma Intracraniano , Angiografia por Ressonância Magnética , Idoso , Artérias Cerebrais/diagnóstico por imagem , Artérias Cerebrais/fisiopatologia , Feminino , Seguimentos , Humanos , Aneurisma Intracraniano/diagnóstico por imagem , Aneurisma Intracraniano/fisiopatologia , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos
13.
BMC Surg ; 20(1): 104, 2020 May 14.
Artigo em Inglês | MEDLINE | ID: mdl-32408864

RESUMO

BACKGROUND: Long term results of endovascular coiling are yet scarce. This study reviews the impact of comorbidities on the success of endovascular coiling of both ruptured and unruptured intracranial aneurysms. Endovascular treatment has become thetreatment of choice after the ISAT trials. Independent risk factors that influence recovery are age, sex, smoking, and hypertension. METHODS: This is a 3-year retrospective analysis, performed to assess the clinical and radiological outcome of patients with cerebral aneurysms treated with detachable coils in an Asian population with relation to comorbidities including smoking and hypertension with age and gender as mediators. From July 2015 to August 2018, a total of 297 consecutive patients (mean age: 45.5 years) with cerebral aneurysms both ruptured and unruptured who were treated at a single center with endovascular coiling procedures are included in the study. Clinical information and radiological outcomes were evaluated on regular follow-ups and telephonic interviews. A modified Rankin Scale was used to measure the clinical outcomes in patients. RESULTS: We have found that smoking harmed clinical outcome, with smokers 35% less likely to recover, while hypertension played a smaller role with only 15%. It was found that while aneurysms are more prevalent in women than men, women not only have a higher chance of getting an aneurysm but also have poorer outcomes. Similarly, patients who were above the age of 40 had a lower chance of recovery compared to younger patients due to comorbidities irrespective of gender. CONCLUSION: Asian sub-continent has different genetic markers that lead to poorer outcomes of aneurysms in women, while outcomes are similar in men and women in developed nations. Smoking does not play a major role in women's recovery. Men with comorbidity seemed to be at higher risk and age played a major role in their recovery.


Assuntos
Aneurisma Roto/terapia , Embolização Terapêutica/métodos , Procedimentos Endovasculares/métodos , Aneurisma Intracraniano/terapia , Adulto , Fatores Etários , Aneurisma Roto/diagnóstico por imagem , Grupo com Ancestrais do Continente Asiático , Angiografia Cerebral , Feminino , Humanos , Hipertensão/complicações , Aneurisma Intracraniano/diagnóstico por imagem , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Fatores de Risco , Fatores Sexuais , Fumar/efeitos adversos , Resultado do Tratamento , Adulto Jovem
15.
World Neurosurg ; 139: 558-566, 2020 07.
Artigo em Inglês | MEDLINE | ID: mdl-32376373

RESUMO

BACKGROUND: Anatomical variations of the course of the internal carotid artery (ICA) may complicate surgical clipping of posterior communicating artery (PCoA) aneurysms by narrowing the retrocarotid window. We evaluated the efficacy of the periclinoid surgical maneuvers for expanding the retrocarotid window and analyzed computed tomography angiography (CTA) data from patients with PCoA aneurysms to define parameters for low-coursing ICAs. METHODS: Using cadaveric specimens, standard pterional craniotomies were fashioned and extradural or intradural periclinoid surgical maneuvers-cutting of the meningo-orbital band, anterior clinoidectomy, and cutting of the distal dural ring (DDR)-were performed, and their relative advantages for expanding the retrocarotid window were assessed. Additionally, preoperative CTA data from 24 patients with PCoA aneurysms used to calculate the angles of the ICA relative to the skull base. RESULTS: Periclinoid maneuvers, especially the anterior clinoidectomy, provided additional exposure of the retrocarotid space. Cutting of the DDR allowed for partial mobilization of the ICA and widened the retrocarotid surgical window, enhancing maneuverability. The anterior clinoidectomy with cutting of the DDR allowed for enhanced exposure of the medial, middle, and posterolateral aspects of the retrocarotid space. Cutting the anterior petroclinoid fold and mobilizing cranial nerve III provided wide exposure of the lateral aspect of retrocarotid space. CONCLUSION: When clipping PCoA aneurysms in the presence of normal-coursing ICAs (approximately ≥30° ICA angle), a standard pterional craniotomy with anterior clinoidectomy and cutting of the DDR allows for substantial expansion of the retrocarotid window.


Assuntos
Velocidade do Fluxo Sanguíneo/fisiologia , Artéria Carótida Interna/diagnóstico por imagem , Angiografia por Tomografia Computadorizada/métodos , Aneurisma Intracraniano/diagnóstico por imagem , Aneurisma Intracraniano/cirurgia , Instrumentos Cirúrgicos , Idoso , Artéria Carótida Interna/fisiopatologia , Humanos , Aneurisma Intracraniano/fisiopatologia , Masculino
16.
Comput Biol Med ; 120: 103759, 2020 05.
Artigo em Inglês | MEDLINE | ID: mdl-32421656

RESUMO

BACKGROUND: Computational fluid dynamics(CFD) of intracranial aneurysms requires flow boundary conditions(BCs) as inputs. Patient-specific BCs are usually unavailable and substituted by literature-derived generic BCs. Therefore, we investigated inter-patient BC variations and their influence on middle cerebral artery aneurysmal hemodynamics. METHOD: We retrospectively collected CT angiography and 7-T Phase-Contrast(PC)-MRI data from eight middle-cerebral-artery bifurcation aneurysms to reconstruct the geometry and measure the arterial flowrates, respectively. The coefficient of variation(CoV) was calculated for the inlet flowrate and the pulsatility index(PI). The outflow split estimated by Murray's law was compared with PC-MRI measurements. For each aneurysm, we performed seven simulations: "baseline" using PC-MRI-derived BCs and the other six with changing BCs to explore the influence of BC variations on hemodynamics. RESULTS: From PC-MRI, the inlet flowrate was 1.94 ± 0.71 cm3/s(CoV = 36%) and PI was 0.37 ± 0.13(CoV = 34%). The outflow split estimated by Murray's law deviated by 15.3% compared to PC-MRI. Comparing to "baseline" models, ±36% variations in inlet flowrate caused -61% to +89% changes in time-averaged wall shear stress(WSS), -37% to +32% in normalized WSS(NWSS; by parent-artery), and -42% to +126% in oscillatory shear index(OSI). The ±34% variations in PI caused, -46% to +67% in OSI. Applying ±15% variations in outflow split led to inflow jet deflection and -41% to +52% changes in WSS, -41% to +47% in NWSS, and -44% to +144% in OSI. CONCLUSION: Inflow rate and outflow split have a drastic impact on hemodynamics of intracranial aneurysms. Inlet waveform has a negligible impact on WSS and NWSS but major impact on OSI. CFD-based models need to consider such sensitivity.


Assuntos
Hemodinâmica , Aneurisma Intracraniano/diagnóstico por imagem , Artéria Cerebral Média/diagnóstico por imagem , Velocidade do Fluxo Sanguíneo , Circulação Cerebrovascular , Angiografia por Tomografia Computadorizada , Simulação por Computador , Meios de Contraste , Humanos , Hidrodinâmica , Imageamento Tridimensional , Aneurisma Intracraniano/patologia , Aneurisma Intracraniano/fisiopatologia , Angiografia por Ressonância Magnética , Artéria Cerebral Média/patologia , Artéria Cerebral Média/fisiopatologia , Modelos Cardiovasculares , Imagem Multimodal , Fluxo Pulsátil , Estudos Retrospectivos
17.
BMC Neurol ; 20(1): 199, 2020 May 20.
Artigo em Inglês | MEDLINE | ID: mdl-32434485

RESUMO

BACKGROUND: Direct evidence of intimal flaps, double lumen and intramural haematomas (IMH) is difficult to detect on conventional angiography in most intracranial vertebrobasilar dissecting aneurysms (VBDAs). Our purpose was to assess the value of three-dimensional high-resolution magnetic resonance vessel wall imaging (3D HRMR VWI) for identifying VBDAs. METHODS: Between August 2013 and January 2016, consecutive patients with suspicious VBDAs were prospectively enrolled to undergo catheter angiography and VWI (pre- and post-contrast). The lesion was diagnosed as definite VBDA when presenting direct signs of dissection; as possible when only presenting indirect signs; and as segmental ectasia when there was local dilation and wall thickness similar to adjacent normal artery's without mural thrombosis. RESULTS: Twenty-one patients with 27 lesions suspicious for VBDAs were finally included. Based on findings of VWI and catheter angiography, definite VBDA was diagnosed in 25 and 7 lesions (92.6%, vs 25.9%, p <  0.001), respectively; possible VBDA in 0 and 20 (0 vs 74.1%), respectively; and segmental ectasia in 2 and 0 (7.4% vs 0%), respectively. On VWI and catheter angiography, intimal flap was detected in 21 and 7 lesions (77.8% vs 25.9%, p = 0.001), respectively; double lumen sign in 18 and 7 (66.7% vs 25.9%, p = 0.003), respectively; and IMH sign in 14 and 0 (51.9% vs 0), respectively. CONCLUSIONS: 3D HRMR VWI could detect direct dissection signs more frequently than catheter angiography. This may help obtain definite diagnosis of intracranial VBDAs, and allow accurate differentiation between dissecting aneurysm and segmental ectasia as well. Further prospective study with larger sample was required to investigate the superiority of HRMR VWI for definite diagnosis of intracranial VBDAs than catheter angiography.


Assuntos
Aneurisma Dissecante/diagnóstico por imagem , Imageamento Tridimensional/métodos , Aneurisma Intracraniano/diagnóstico por imagem , Adulto , Idoso , Aneurisma Dissecante/complicações , Artéria Basilar/diagnóstico por imagem , Angiografia Cerebral/métodos , Feminino , Hematoma , Humanos , Aneurisma Intracraniano/complicações , Imagem por Ressonância Magnética/métodos , Masculino , Pessoa de Meia-Idade , Doenças do Sistema Nervoso , Estudos Prospectivos
19.
J Stroke Cerebrovasc Dis ; 29(7): 104853, 2020 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-32389556

RESUMO

Giant thrombosed middle cerebral artery (MCA) aneurysms are difficult to treat and sometimes require complex revascularization using allografts. We describe a technical method using revascularization with a natural Y-shaped graft that provides a normal variation for a complex MCA aneurysm. A 65-year-old man with a giant thrombosed MCA aneurysm presented with right hemiparesis and aphasia. The patient had a history of clipping surgery for the ipsilateral side of the MCA aneurysm 25 years before, and a de novo aneurysm developed over the previous 18 years. For the giant thrombosed aneurysm, trapping and revascularization were performed. A natural radial artery Y-graft was used as the graft and anastomosed to both M2 trunks. The symptoms improved after surgery, and the patient was discharged 3 weeks later. This is the first report of a double-barrel bypass using a natural Y-graft. This method attained a normal variation, and the flow of the Y-graft was physiological. For the radical cure of giant thrombosed MCA aneurysms, multiple revascularizations might be required. With this natural Y-graft, complex transpositions could be avoided.


Assuntos
Bioprótese , Implante de Prótese Vascular/instrumentação , Prótese Vascular , Revascularização Cerebral/instrumentação , Aneurisma Intracraniano/cirurgia , Trombose Intracraniana/cirurgia , Artéria Cerebral Média/cirurgia , Artéria Radial/transplante , Idoso , Humanos , Aneurisma Intracraniano/diagnóstico por imagem , Aneurisma Intracraniano/fisiopatologia , Trombose Intracraniana/diagnóstico por imagem , Trombose Intracraniana/fisiopatologia , Masculino , Artéria Cerebral Média/diagnóstico por imagem , Artéria Cerebral Média/fisiopatologia , Artéria Radial/diagnóstico por imagem , Artéria Radial/fisiopatologia , Resultado do Tratamento
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