Distal internal carotid artery dissection due to the carotid shunt during carotid endarterectomy.

We described two cases of shunt-related distal internal carotid artery (ICA) dissection from high cervical ICA stenosis. These cases suggest that for high cervical internal carotid endarterectomy, surgeons should reconsider using a carotid shunt to reduce the risk of ICA dissection.

Advantages of Staged Angioplasty in a Patient with Internal Carotid Artery Pseudo-Occlusion Besides Prevention of Cerebral Hyperperfusion Syndrome.

BACKGROUND: Staged angioplasty for carotid artery stenosis has been reported to be effective in preventing postoperative cerebral hyperperfusion syndrome (CHS) in patients with severe carotid stenosis; thus, it is also recommended for patients with internal carotid artery (ICA) pseudo-occlusion, the treatment strategy for which is controversial. CASE DESCRIPTION: This study reports the case of an Asian man in his 50s who had motor aphasia and right-side weakness caused by pseudo-occlusion of the left ICA. After medical treatment, he underwent a staged angioplasty. After the first stage of percutaneous transluminal angioplasty, anterograde blood flow to the left ICA increased but the distal ICA remained partially collapsed. Initially, the second stage of carotid artery stenting (CAS) was planned for 2 weeks after the first stage; however, hemorrhagic infarction was observed the day before the CAS, and it was postponed by 2 weeks, after adjustment of antiplatelet therapy. At the time of the CAS, the diameter of the initially collapsed left distal ICA was remodeled and it was fully dilated; thus, we used a balloon-type embolic protection device and conducted CAS successfully without apparent embolic complications. The postoperative course was uneventful. The patient did not develop CHS. CONCLUSIONS: Besides preventing CHS, staged angioplasty has advantages when used for treating patients with ICA pseudo-occlusions in that the extent of dilation of the distal ICA after percutaneous transluminal angioplasty can be confirmed and the development of a possible hemorrhagic infarction can be assessed before stent placement.

Left Sylvian Fissure Epidermoid Cyst Presenting with Progressive Aphasia.

INTRODUCTION: Epidermoid cysts within the sylvian fissure are extremely rare. Expressive aphasia and neurocognitive dysfunction because of mass effect have never been reported previously. CASE PRESENTATION: We discuss the case of a 53-year-old male who presented with an acute episode of expressive aphasia and vision changes along with progressive headaches and cognitive slowing over the 2.5 years prior to presentation. A detailed neurologic examination revealed subtle conductive aphasia, as well as mild short-term memory dysfunction. Magnetic resonance imaging revealed a cystic mass consistent with epidermoid cyst within the left sylvian fissure. High-definition fiber tractography showed that the arcuate fasciculus was stretched by the tumor. A left frontotemporal craniotomy allowed for near-total excision of the cyst and led to rapid and complete resolution of symptoms. CONCLUSION: Although rare, epidermoid cysts of the dominant sylvian fissure can present with progressive aphasia due to mass effect on the arcuate fasciculus. Despite the long-standing symptoms, surgical resection can lead to their complete resolution.

Mono-stereo-autostereo: the evolution of 3-dimensional neurosurgical planning.

BACKGROUND: In the past decade, surgery planning has changed significantly. The main reason is the improvements in computer graphical rendering power and display technology, which turned the plain graphics of the mid-1990s into interactive stereoscopic objects. OBJECTIVE: To report our experiences with 2 virtual reality systems used for planning neurosurgical operations. METHODS: A series of 208 operations were planned with the Dextroscope (Bracco AMT, Singapore) requiring the use of liquid crystal display shutter glasses. The participating neurosurgeons answered a questionnaire after the planning procedure and postoperatively. In a second prospective series of 33 patients, we used an autostereoscopic monitor system (MD20-3-D; Setred SA, Sweden) to plan intracranial operations. A questionnaire regarding the value of surgery planning was answered preoperatively and postoperatively. RESULTS: The Dextroscope could be integrated into daily surgical routine. Surgeons regarded their understanding of the pathoanatomical situation as improved, leading to enhanced intraoperative orientation and confidence compared with conventional planning. The autostereoscopic Setred system was regarded as helpful in establishing the surgical strategy and analyzing the pathoanatomical situation compared with conventional planning. Both systems were perceived as a backup in case of failure of the standard navigation system. CONCLUSION: Improvement of display and interaction techniques adds to the realism of the planning process and enables precise structural understanding preoperatively. This minimizes intraoperative guesswork and exploratory dissection. Autostereoscopic display techniques will further increase the value and acceptance of 3-dimensional planning and intraoperative navigation.

[Carotid dissection with cerebri media thrombosis due to a tonsillar lesion]. / Karotisdissektion mit Cerebri-media-Thrombose nach Tonsillenverletzung.

A 7-year-old boy suffered a tonsillar lesion due to trauma and presented to hospital with a GCS of 15. Some hours later he developed hemiparesis with loss of consciousness. Angiography displayed a left-sided carotid dissection associated with thrombosis of the arteria cerebri media. After initial treatment by heparinization, the increase of intracranial pressure was treated by craniectomy. The neurological deficits diminished partially after days and reimplantation of the skull cap was possible. The initial hemiparesis decreased slightly during rehabilitation after 5 weeks.