"Dirty coagulation" technique as an alternative to microclips for control of bleeding from deep feeders during brain arteriovenous malformation surgery.

BACKGROUND: Meticulous haemostasis is one of the most important factors during microneurosurgical resection of brain arteriovenous malformation (AVM). Controlling major arterial feeders and draining veins with clips and bipolar coagulation are well-established techniques, while managing with bleeding from deep tiny vessels still proves to be challenging. This technical note describes a technique used by the senior author in AVM surgery for last 20 years in dealing with the issue highlighted. METHOD: "Dirty coagulation" is a technique of bipolar coagulation of small feeders carried out together with a thin layer of brain tissue that surrounds these fragile vessels. The senior author uses this technique for achieving permanent haemostasis predominantly in large and/or deep-seated AVMs. To illustrate the efficacy of this technique, we retrospectively reviewed the outcome of Spetzler-Martin (SM) grade III-V AVMs resected by the senior author over the last 5 years (2010-2015). RESULTS: Thirty-five cases of AVM surgeries (14 SM grade III, 15 SM grade IV and 6 SM grade V) in this 5-year period were analysed. No postoperative intracranial haemorrhage was encountered as a result of bleeding from the deep feeders. Postoperative angiograms showed complete resection of all AVMs, except in two cases (SM grade V and grade III). CONCLUSIONS: "Dirty coagulation" provides an effective way to secure haemostasis from deep tiny feeders. This cost-effective method could be successfully used for achieving permanent haemostasis and thereby decreasing postoperative haemorrhage in AVM surgery.

Vagoglossopharyngeal Neuralgia Occurred Concomitantly with Ipsilateral Hemifacial Spasm and Versive Seizure-Like Movement: A First Case Report.

Vagoglossopharyngeal neuralgia (VGPN) is a very rare condition. VGPN with convulsive like attack is even rarer All of the cases had their head turned to the opposite side of facial pain. Hemifacial spasm occurring concurrently with VGPN has never been reported. Herein, we present the first case of VGPN that had ipsilateral hemifacial spasm and versive seizure-like movement to the same side of facial pain. We reported a 71-year-old man presenting with multiple episodes of intermittent sharp shooting pain arising on the right middle neck, followed by hemifacial spasm on right face. Then the patient became syncope while his head and gaze turned to the same side of the painful neck. Electrocardiography showed sinus arrest. Interictal Electroencephalography was normal. This patient initially responded to pregabalin for two weeks, then the symptoms became worse. Microvascular decompression and carbamazepine resulted in the complete remission of all symptoms after six months of follow-up. We could not explain the pathophysiology of unilateral versive seizure like movement.

Prevalence of unruptured intracranial aneurysms among first-degree relatives of Thai patients who had aneurysmal subarachnoid hemorrhage.

BACKGROUND: The prevalence of familial unruptured intracranial aneurysm (UIA) in Thai population was unknown. METHODS: Our study population comprised first-degree relatives of patients who were diagnosed with aneurysmal subarachnoid hemorrhage (aSAH) in two cerebrovascular neurosurgical centers from January 2018 to December 2018. The volunteers underwent three-dimensional time-of-flight magnetic resonance angiography for screening intracranial aneurysms (IA). Those who were reported positive or suspected of IA then underwent computed tomography angiography for confirmation. RESULTS: We identified 12 patients who had 12 unruptured IAs (UIAs) from among 93 first-degree relatives. The prevalence of UIA among our study population was 12.9%. An estimated prevalence of UIA among Thai population was 9.05% (95% confidence interval [CI] 7.32-10.78). Of the 93 relatives, 84 had only one first-degree relative who suffered aSAH. Siblings posed a higher risk for UIA than offspring (16% vs. 9.5%), but the difference was not statistically significant (odds ratio 1.810, 95% CI 0.50-6.50, P = 0.274). The most common aneurysm location was the anterior cerebral artery territory (50%). CONCLUSION: The prevalence of familial UIA in a Thai population was relatively high. There was no significant between-group difference in the occurrence of UIA between the siblings and offspring of the aSAH patients.

Low-dose adenosine-induced transient asystole during intracranial aneurysm surgery.

BACKGROUND: Few studies have evaluated the adenosine dose that induces cardiac arrest during intracranial aneurysm surgery. We present our experiences with adenosine-induced transient asystole (AiTA) during intracranial aneurysm surgery and dosage recommendations. METHODS: We retrospectively reviewed the medical records of all patients who underwent intracranial aneurysm surgery between July 2016 and December 2018. Patients who experienced AiTA during intracranial aneurysm surgery were included in the study. RESULTS: Our study included nine intracranial aneurysm surgeries performed in eight patients. Thirteen episodes of AiTA were reported. Five of these were performed to facilitate bleeding control due to intraoperative aneurysm rupture (IAR), and adenosine doses were 9 mg (0.20 mg/kg), 12 mg (0.25 mg/kg), 12 mg (0.26 mg/kg), 18 mg (0.34 mg/kg), and 18 mg (0.39 mg/kg), resulted in transient asystole for 12, 14, 9, 44, and 18 s, respectively. For episodes without IAR, adenosine doses ranging from 6 to 18 mg (0.11-0.39 mg/kg) caused asystole for 8-33 s. In five episodes without IAR, low-dose adenosine (lower than 0.2 mg/kg) was used and caused asystole ranging from 8 to 12 s. Postoperatively, two patients had elevated cardiac troponin T levels but normal electrocardiograms. CONCLUSION: AiTA can facilitate the clipping of intracranial aneurysms at low-risk of serious cardiac complications. An adenosine dose of 0.2-0.4 mg/kg is safe and effective in both IAR and non IAR situations. In non IAR cases, we propose that low-dose AiTA is an option to facilitate aneurysm clipping. A starting dose of 6 mg or 0.1-0.2 mg/kg can adequately induce brief asystole by softening the aneurysmal sac during clip application.

Prevalence of intracranial aneurysms among acute ischemic stroke patients.

BACKGROUND: The prevalence of unruptured intracranial aneurysms varies with age, sex, and genetic diseases, including atherosclerotic diseases. The objectives of this study are to determine the prevalence of intracranial aneurysms among acute ischemic stroke patients and the clinical outcomes of the patients. METHODS: The authors included patients with acute ischemic stroke within 7 days of onset. Demographic data, stroke subtypes, risk factors, and modified Rankin scale (mRS) scores at 6 months after stroke were collected. Magnetic resonance angiography was performed to diagnose intracranial aneurysms. The occurrence of aneurysmal subarachnoid hemorrhage (aSAH) was recorded during the follow-up at 6 months. RESULTS: Thirteen (7%) of the 186 patients were found to have incidental intracranial aneurysms. Age and sex were not different between the patients with and without aneurysms (P > 0.999, P > 0.999). Ten patients (76.9%) had a saccular aneurysm. The most common site of the aneurysm was the cavernous part of the internal carotid artery (n = 6). Nine patients (69.2%) had very small (<4 mm) aneurysms. No aSAH was detected until 6 months after stroke. Favorable outcomes (mRS 0-2) at 6 months were not different between the patients with and without aneurysms (69.2% vs. 75.1%, P = 0.665). CONCLUSION: A higher prevalence of intracranial aneurysms was observed among acute ischemic stroke patients than among the general population. However, the variability of the general population should be considered. The functional outcomes of acute ischemic stroke patients are not affected by the presence of an intracranial aneurysm.

Are Fetal-Type Posterior Cerebral Arteries Associated With an Increased Risk of Posterior Communicating Artery Aneurysms?

BACKGROUND: Fetal-type posterior cerebral arteries (F-PCAs) might result in alterations in hemodynamic flow patterns and may predispose an individual to an increased risk of posterior communicating artery aneurysms (PCoAAs). OBJECTIVE: To determine the association between PCoAAs and the presence of ipsilateral F-PCAs. METHODS: We retrospectively reviewed the radiographic findings from 185 patients harboring 199 PCoAAs that were treated at our institution between 2005 and 2015. Our study population consisted of 4 cohorts: (A) patients with 171 internal carotid arteries (ICAs) harboring unilateral PCoAAs; (B) 171 unaffected ICAs in the same patients from the first group; (C) 28 ICAs of 14 patients with bilateral PCoAAs; and (D) 180 ICAs of 90 patients with aneurysms in other locations. We then determined the presence of ipsilateral F-PCAs and recorded all aneurysm characteristics. RESULTS: Group A had the highest prevalence of F-PCAs (42%) compared to 19% in group B, 3% in group C, and 14% in group D (odds ratio A : B = 3.041; A : C = 19.626; and A : D = 4.308; P < .001). PCoAAs were associated with larger diameters of the posterior communicating arteries (median value 1.05 vs 0.86 mm; P = .001). The presence of F-PCAs was associated with larger sizes of the aneurysm necks (median value 3.3 vs 3.0 mm; P = .02). CONCLUSION: PCoAAs were associated with a higher prevalence of ipsilateral F-PCAs. This variant was associated with larger sizes of the aneurysm necks but was not associated with the sizes of the aneurysm domes or with their rupture statuses.

Adenosine-induced cardiac arrest as an alternative to temporary clipping during intracranial aneurysm surgery.

OBJECTIVE The purpose of this study was to analyze the impact of adenosine-induced cardiac arrest (AiCA) on temporary clipping (TC) and the postoperative cerebral infarction rate among patients undergoing intracranial aneurysm surgery. METHODS In this retrospective matched-cohort study, 65 patients who received adenosine for decompression of aneurysms during microsurgical clipping were identified (Group A) and randomly matched with 65 selected patients who underwent clipping but did not receive adenosine during surgery (Group B). The matching criteria included age, Fisher grade, aneurysm size, rupture status, and location of aneurysms. The primary outcomes were TC time and the postoperative infarction rate. The secondary outcome was the incidence of intraoperative aneurysm rupture (IAR). RESULTS In Group A, 40 patients underwent clipping with AiCA alone and 25 patients (38%) received AiCA combined with TC, and in Group B, 60 patients (92%) underwent aneurysm clipping under the protection of TC (OR 0.052; 95% CI 0.018-0.147; p < 0.001). Group A required less TC time (2.04 minutes vs 4.46 minutes; p < 0.001). The incidence of postoperative lacunar infarction was equal in both groups (6.2%). There was an insignificant between-group difference in the incidence of IAR (1.5% in Group A vs 6.1% in Group B; OR 0.238; 95% CI 0.026-2.192; p = 0.171). CONCLUSIONS AiCA is a useful technique for microneurosurgical treatment of cerebral aneurysms. AiCA can minimize the use of TC and does not increase the risk of IAR and postoperative infarction.

The open access video collection project "Hernesniemi's 1001 and more microsurgical videos of Neurosurgery": A legacy for educational purposes.

BACKGROUND: Neurosurgical educational programs and courses are helpful to improve the quality of training. Moreover, nowadays, online activities may represent a very useful tool to globally enhance neurosurgical education. The "Hernesniemi's 1001 and more microneurosurgical videos" project aims to show the microsurgical style developed by the senior author and his TEAMs in more than 40 years of experience. METHODS: More than 1100 high-definition videos of microneurosurgical operations performed by the senior author were carefully edited. These videos illustrate the philosophy of "simple, clean, fast and preserving the normal anatomy" while offering a step by step guide of different neurosurgical procedures. RESULTS: All the aforementioned material is well organized in an electronic videobook, freely available in Surgical Neurology International. The book also includes comments of great current neurosurgeons and writings of the authors and editors. CONCLUSION: We are sure that our project will be able to instill in and spread across the neurosurgical community the microneurosurgical style of the senior author, thus representing an efficient educational tool for surgeons all around the world.

Microneurosurgical Management of Posterior Communicating Artery Aneurysm: A Contemporary Series from Helsinki.

OBJECTIVE: The objectives of this study were to analyze microsurgical techniques and to determine correlations between microsurgical techniques and the radiographic findings in the microneurosurgical treatment of posterior communicating artery aneurysms (PCoAAs). METHODS: We retrospectively analyzed radiographic findings and videos of surgeries in 64 patients with PCoAAs who underwent microsurgical clipping by the senior author from August 2010 to 2014. RESULTS: From 64 aneurysms, 30 (47%) had acute subarachnoid hemorrhage (SAH) that necessitated lamina terminalis fenestration (odds ratio [OR], 67.67; P < 0.001) and Liliequist membrane fenestration (OR, 19.62; P < 0.001). The low-lying aneurysms significantly necessitated the coagulation of the dura covering the anterior clinoid process (ACP) (OR, 7.43; P = 0.003) or anterior clinoidectomy (OR, 91.0; P < 0.001). We preferred straight clips in 45 (83%) of 54 posterolateral projecting aneurysms (OR, 45.0; P < 0.001), but preferred curved clips for posteromedial projecting aneurysms (OR, 6.39; P = 0.008). The mean operative time from the brain retraction to the final clipping was 17 minutes and 43 seconds. Postoperative computed tomography angiography revealed complete occlusion of 60 (94%) aneurysms. Three (4.6%) patients with acute SAH suffered postoperative lacunar infarction. CONCLUSIONS: For ruptured aneurysms, lamina terminalis and Liliequist membrane fenestration are useful for additional cerebrospinal fluid drainage. For low-lying aneurysms, coagulation of the dura covering the ACP or tailored anterior clinoidectomy might be necessary for exposing the proximal aneurysm neck. Type of clips depends on the direction of projection. The microsurgical clipping of the PCoAAs can achieve good immediate complete occlusion rate with low postoperative stroke rate.

Three distal anterior cerebral artery aneurysms in the same branch associated with five additional intracranial aneurysms.

BACKGROUND: Multiple distal anterior cerebral artery (DACA) aneurysms appear as rare findings. Simultaneous treatment of such lesions can be particularly challenging. A report of three aneurysms on the same parent artery has not been reported before. We report a case of three DACA aneurysms treated within one microsurgical operation in a patient with eight aneurysms. CASE DESCRIPTION: A 62-year-old woman incidentally presented with multiple various size saccular aneurysms, including tree on the left DACA. One of the DACA aneurysm was located on the A3 segment, and the other two were on the A4 and A5 segments. Ligation of all three of these aneurysms was planned in one operation. A standard anterior interhemispheric approach was utilized. Three aneurysms were successfully clipped using four clips. Intraoperative angiography confirmed aneurysm occlusion with parent artery patency preservation. The patient showed no new postoperative neurological deficit. CONCLUSION: Clipping multiple DACA aneurysms within a single microneurosurgical operation is a feasible treatment option. Meticulous analysis of preoperative imaging features is crucial for selecting the best, patient-specific treatment strategy.

Supracerebellar Infratentorial Paramedian Approach in Helsinki Neurosurgery: Cornerstones of a Safe and Effective Route to the Pineal Region.

OBJECTIVE: The supracerebellar infratentorial (SCIT) paramedian approach in sitting position represents one of the most used surgical routes for dealing with pineal region lesions. The purpose of this study is to determine the cornerstones to perform this approach in a simple, safe, and effective way, so that it could be easily reproduced in other neurosurgical centers, particularly in those with modest resources. METHODS: We reviewed and analyzed the surgical videos of 24 pineal region lesions that were operated on through an SCIT approach between June 2012 and October 2015. The SCIT approach may be divided into 3 main steps: 1) skin-muscle incision; 2) craniotomy; and 3) dura opening and access to the pineal region. RESULTS: Complete lesion removal was accomplished in 23 cases, and subtotal removal was accomplished in 1 case. The pineal region was effectively and safely reached through the SCIT approach in the sitting position with a mean time of 14 minutes, using a basic set of microsurgical instruments. Cornerstones and potential delaying events were carefully recorded for each of the 3 main steps of the approach. Moreover, we present in a short video a step-by-step guide to perform the SCIT approach in a fast and safe way. CONCLUSIONS: A correct application of microsurgical principles may allow to safely and rapidly perform the SCIT approach, therefore offering an effective and relatively atraumatic route for dealing with pineal region lesions.