Advances in Cranial Surgery.

The landscape of the cranial neurosurgery has changed tremendously in past couple of decades. The main frontiers including introduction of neuro-endoscopy, minimally invasive skull base approaches, SRS, laser interstitial thermal therapy and use of tubular retractors have revolutionized the management of intracerebral hemorrhages, deep seated tumors other intracranial pathologies. Introduction of these novel techniques is based on smaller incisions with maximal operative corridors, decreased blood loss, shorter hospital stays, decreased post-operative pain and cosmetically appealing scars that improves patient satisfaction and clinical outcomes. The sophisticated tools like neuroendoscopy have improved light source, and better visualization around the corners. Advanced navigated tools and channel-based retractors help us to target deeply seated lesions with increased precision and minimal disruption of the surrounding neurovascular tissues. Advent of stereotactic radiosurgery has provided us alternative feasible, safe and effective options for treatment of patients who are otherwise not medically stable to undergo complex cranial surgical interventions. This paper review advances in treatment of intracranial pathologies, and how the neurosurgeons and other medical providers at the University of Missouri-Columbia (UMC) are optimizing these treatments for their patients.

Gamma Knife Radiosurgery in the Management of Hypothalamic Glioma: A Case Report with Long-Term Follow-Up.

BACKGROUND: Optic pathway/hypothalamic gliomas are rare pediatric brain tumors. The management paradigm for these challenging tumors includes chemotherapy, radiotherapy, or surgical resection, but the optimal management strategy remains elusive. Gamma knife radiosurgery (GKRS) has emerged as a promising treatment for such lesions as documented by a small number of cases in the literature. CASE PRESENTATION: We present a rare case of hypothalamic glioma in a 13-year-old girl who was referred to our service due to growth of an incidentally diagnosed hypothalamic lesion following head injury at the age of 8 years. The lesion demonstrated hypointensity on T1- and hyperintensity on T2-weighted imaging without contrast enhancement. Given the growth of the lesion on serial imaging, a stereotactic biopsy was performed demonstrating low-grade glioma. The patient underwent GKRS treatment with a marginal dose of 15 Gy at 50% isodose line for a tumor volume of 2.2 mL. Annual radiological surveillance over the next 17 years demonstrated a gradual shrinkage of the lesion until it completely disappeared. The patient is currently a healthy 31-year-old female without any visual, endocrine, or neurocognitive deficits. CONCLUSION: The outcome obtained after extended follow-up in our patient highlights the safety and efficacy of GKRS in the management of hypothalamic gliomas in pediatrics, which in turn can avoid potentially serious complications of surgery in this vulnerable patient population, especially in this sensitive location.

Outcomes of Mechanical Thrombectomy for Ischemic Stroke in Nonagenarians: A 10-Year Institutional Experience.

BACKGROUND: Nonagenarians have been underrepresented in stroke trials that established endovascular treatment as the standard for acute ischemic stroke (AIS). Evidence remains inconclusive regarding the efficacy of thrombectomy in this population. OBJECTIVES: To report our experience with thrombectomy in nonagenarians with stroke, and to identify predictors of mortality. We further investigated the effects of first-pass reperfusion and the addition of intravenous thrombolysis (IVT) on achieving better outcomes. MATERIALS AND METHODS: Data was collected for consecutively treated patients at three affiliated comprehensive stroke centers from 2010 to 2021. We included patients ≥90 years-old with AIS secondary to large vessel occlusion. Bivariate analyses were performed using the Mann-Whitney U test for continuous variables, and χ2 and Fisher's exact tests, respectively, for nominal and ordinal variables. RESULTS: Thirty-two nonagenarians underwent thrombectomy, of whom 25 (81%) had prestroke mRS ≤2. Thrombectomies were performed using stents (2, 6.7%), aspiration (8, 26.7%), or a combination of both (20, 66.7%). Successful recanalization was achieved in 97%. Procedural complications occurred in 2 (6.3%) and intracranial hemorrhage in 3 (9.4%). Sixteen patients (50%) were discharged home or to rehabilitation, 9 (28.2%) to nursing home or hospice, and 7 (21.9%) died during hospitalization. Only 2 (6%) patients had mRS ≤2 at discharge. No independent predictors of in-hospital mortality were identified, and neither first-pass reperfusion nor the addition of IVT correlated with improvement in clinical outcome. CONCLUSIONS: Although thrombectomy is safe for nonagenarian stroke and can achieve excellent recanalization, high mortality and poor functional status remain high given the advanced age and frailty of this population.

Compliance With Preferred Reporting Items for Systematic Review and Meta-Analysis Individual Participant Data Statement for Meta-Analyses Published for Stroke Studies.

Background and Purpose: Individual-participant data meta-analyses (IPD-MA) are powerful evidence synthesis studies which are considered the gold-standard of MA. The quality of reporting in these studies is guided by the 2015 Preferred Reporting Items for Systematic Review and Meta-Analysis of Individual Participant Data (PRISMA-IPD) guidelines. The growing number of IPD-MA published for stroke studies calls for an assessment of the compliance of these studies with the PRISMA-IPD statement. Methods: PubMed and EMBASE were searched for MA in stroke published between January 1, 2016, and March 30, 2020, in journals with impact factor >2. Literature reviews, scoping reviews, and aggregate MA were excluded. The final articles were scored using the 31-item PRISMA-IPD checklist. Results were depicted using descriptive statistics. Compliance with each item in PRISM-IPD guideline was recorded. The study was defined as compliant to IPD analyses if it satisfied all IPD specific items. Results: From an initial set of 321 articles, 31 met the final eligibility for data extraction. Only 4 (13%) described the use of PRISMA-IPD guidelines in their methodology, while 8/31 (26%) used the old PRISMA guidelines and 19/31 (61%) followed none. Regardless of mention of using IPD specific guidelines, 42% (n=13) of studies were compliant with all 4 IPD specific domains. The poorest areas of compliance were bias assessment within (32%) and across (39%) studies, reporting protocol and registration (42%), and reporting of IPD integrity (48%). The median journal impact factor was similar between the compliant (median, 8.1 [interquartile range, 5.4­39.9]) and noncompliant (median, 6 [interquartile range, 4.5­16.2]) groups (P=0.24). Similarly, the journal, country of correspondence, number of authors, number of studies included in MA, study sample size, and funding source were statistically similar between the groups. Conclusions: For the published IPD-MA stroke studies, the compliance with PRISMA-IPD statement and compliance with 4 IPD specific items was suboptimal. The journal, author, and study-related factors were not associated with compliance. Additional scrutiny measures to ensure adherence to mandated guidelines might increase the compliance. Several avenues to improve compliance and ensure optimal adherence are discussed.

Does preoperative embolization improve outcomes of meningioma resection? A systematic review and meta-analysis.

Current evidence regarding the benefit of preoperative embolization (POE) of meningiomas is inconclusive. This systematic review and meta-analysis aims to evaluate the safety profile of the procedure and to compare outcomes in embolized versus non-embolized meningiomas. PubMed was queried for studies after January 1990 reporting outcomes of POE. Pertinent variables were extracted and synthesized from eligible articles. Heterogeneity was assessed using I2, and random-effects model was employed to calculate pooled 95% CI effect sizes. Publication bias was assessed using funnel plots and Harbord's and Begg's tests. Meta-analyses were used to assess estimated blood loss and operative duration (mean difference; MD), gross-total resection (odds ratio; OR), and postsurgical complications and postsurgical mortality (risk difference; RD). Thirty-four studies encompassing 1782 preoperatively embolized meningiomas were captured. The pooled immediate complication rate following embolization was 4.3% (34 studies, n = 1782). Although heterogeneity was moderate to high (I2 = 35-86%), meta-analyses showed no statistically significant differences in estimated blood loss (8 studies, n = 1050, MD = 13.9 cc, 95% CI = -101.3 to 129.1), operative duration (11 studies, n = 1887, MD = 2.4 min, 95% CI = -35.5 to 30.8), gross-total resection (6 studies, n = 1608, OR = 1.07, 95% CI = 0.8-1.5), postsurgical complications (12 studies, n = 2060, RD = 0.01, 95% CI = -0.04 to 0.07), and postsurgical mortality (12 studies, n = 2060, RD = 0.01, 95% CI = 0-0.01). Although POE is relatively safe, no clear benefit was observed in operative and postoperative outcomes. However, results must be interpreted with caution due to heterogeneity and selection bias between studies. Well-controlled future investigations are needed to define the patient population most likely to benefit from the procedure.

Knobloch Syndrome, a Rare Cause of Occipital Encephalocele and Seizures: A Case Report.

BACKGROUND: Knobloch syndrome (KS) is a rare autosomal recessive disorder associated with multiple ocular and cranial abnormalities. Occult occipital skull defect or encephalocele should raise suspicion of this disease. It is never reported in neurosurgical literature, possibly due to a lack of clinician familiarity, leading to underdiagnosis and inadequate management. Our patient also had seizures, which is a sporadic presentation of this syndrome. CASE DESCRIPTION: Here, we report a clinico-radiologic finding of a 7-year-old boy who presented with seizures, cataracts, and an occipital bone defect along with bilateral subependymal heterotopias and polymicrogyria. CONCLUSIONS: This case highlights the importance of consideration of this syndrome in children with a midline occipital bone defect with or without encephalocele and seizures. Early recognition of this presentation is critical for obtaining access to appropriate genetic counseling and subsequent monitoring and prevention of complications by surgical intervention.

Efficacy and safety of gamma knife radiosurgery for posterior cranial fossa meningioma: a systematic review.

The management of posterior cranial fossa meningioma [PCFM] is challenging and many neurosurgeons advise gamma knife radiosurgery [GKRS] as a modality for its upfront or adjuvant treatment. Due to the varying radiosurgical response based on lesion location, tumor biology, and radiation dosage, we performed a pioneer attempt in doing a systematic review analyzing the treatment efficacy and safety profile of GKRS for PCFM based on current literature. A systematic review was performed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses [PRISMA] guidelines. A thorough literature search was conducted on PubMed, Web of science, and Cochrane data base; articles were selected systematically based on PRISMA protocol, reviewed completely, and relevant data was summarized and discussed. A total of 18 publications pertaining to GKRS for PCFM were included with a pooled sample size of 2131 patients. The median pre-GKRS tumor volume ranged from 2.28 to 10.5 cm [3]. Primary GKRS was administered in 61.1% of the pooled study cohorts, adjuvant treatment in 32.9%, and salvage therapy in 6.5% patients. Majority of the meningiomas were WHO grade 1 tumors (99.7%). The pooled mean marginal dose in the studies was 13.6 Gy (range 12-15.2 Gy) while the mean of maximum doses was 28.6 Gy (range 25-35 Gy). Most studies report an excellent radiosurgical outcome including the tumor control rate and the progression-free survival [PFS] of over 90%. The tumor control, PFS, and adverse radiation effect [ARE] rates in author's series were 92.3%, 91%, and 9.6%, respectively. The favorable radiosurgical outcome depends on multiple factors such as small tumor volume, absence of previous radiotherapy, tumor location, elderly patients, female gender, longer time from symptom onset, and decreasing maximal dose. GKRS as primary or adjuvant treatment modality needs to be considered as a promising management strategy for PCFM in selected patients in view of the growing evidence of high tumor control rate, improved neurological functions, and low incidence of ARE. The use of multiple isocenters, 3-D image planning, and limit GKRS treatment to tumors less than 3.5 cm help to avoid complications and achieve the best results. The treatment decisions in PCFM cases must be tailored and should consider the factors such as radiological profile, symptom severity, performance level, and patient preference for a good outcome.

An analysis of cross-continental scholarship requirements during neurosurgical training and national research productivity.

OBJECTIVE: Engagement in research and scholarship is considered a hallmark of neurosurgical training. However, the participation of neurosurgical trainees in this experience has only recently been analyzed and described in the United States, with little, if any, data available regarding the research environment in neurosurgical training programs across the globe. Here, the authors set out to identify requirements for research involvement and to quantify publication rates in leading neurosurgical journals throughout various nations across the globe. METHODS: The first aim was to identify the research requirements set by relevant program-accrediting and/or board-certifying agencies via query of the literature and published guidelines. For the second part of the study, the authors attempted to determine each country's neurosurgical research productivity by quantifying publications in the various large international neurosurgical journals-World Neurosurgery, Journal of Neurosurgery, and Neurosurgery-via a structured search of PubMed. RESULTS: Data on neurosurgical training requirements addressing research were available for 54 (28.1%) of 192 countries. Specific research requirements were identified for 39 countries, partial requirements for 8, and no requirements for 7. Surprisingly, the authors observed a trend of increased average research productivity with the absence of designated research requirements, although this finding is not unprecedented in the literature. CONCLUSIONS: A variety of countries of various sizes and neurosurgical workforce densities across the globe have instituted research requirements during training and/or prior to board certification in neurosurgery. These requirements range in intensity from 1 publication or presentation to the completion of a thesis or dissertation and occur at various time points throughout training. While these requirements do not correlate directly to national research productivity, they may provide a foundation for developing countries to establish a culture of excellence in research.

Resection of a posterior fossa arteriovenous malformation complicated by leaked Onyx: a case report and review of literature.

Extravasation of Onyx is a rare complication during embolization of arteriovenous malformations (AVM). We present a case of embolization that was complicated by leakage of Onyx into the cerebellum which was later encountered during surgical excision of the AVM. Our goal is to report this rare event and to outline successful treatment of this complication. The patient's records were reviewed for medical history, laboratory and radiologic workup, and outpatient clinical follow-up. A 62-year-old female presented with Hunt Hess grade 2 and modified Fisher grade 2 subarachnoid hemorrhage (SAH) secondary to ruptured left posterior inferior cerebellar artery (PICA) aneurysm associated with a superior cerebellar vermian AVM. Following endovascular intervention, the aneurysm was completely embolized; however, only 75% of the AVM could be safely obliterated. Extravasation of Onyx from the ruptured aneurysm was noted on her initial angiogram. Elective suboccipital craniectomy was subsequently planned for resection of the residual AVM where the extravasated Onyx posed an operative nuisance during resection. Post-op angiogram confirmed complete resection of the AVM, as well as the bulk of the extravasated Onyx. Patient did well post-operatively, remaining neurologically intact throughout her hospital course. Although infrequently reported in the literature, Onyx extravasation is a potential complication that neurosurgeons should be ready to face. Adherence of Onyx to surrounding parenchyma could hinder optimal surgical resection of AVM and increase complications. Therefore, careful surgical dissection should be performed with special care to delicate neurovasculature. In this case, complete resection of the AVM and Onyx mass was safely achieved.

Efficacy and safety of middle meningeal artery embolization in the management of refractory or chronic subdural hematomas: a systematic review and meta-analysis.

INTRODUCTION: Refractory or chronic subdural hematomas (cSDH) constitute a challenging entity that neurosurgeons face frequently nowadays. Middle meningeal artery embolization (MMAE) has emerged in the recent years as a promising treatment option. However, solid evidence that can dictate management guidelines is still lacking. METHODS: We conducted a systematic review and meta-analysis (MA) in compliance with the PRISMA guidelines to evaluate the efficacy and safety of MMAE compared with conventional treatments for refractory or cSDH. Databases were searched up to March 2019. Using a random-effects model, meta-analyses of proportions and risk difference were conducted recurrence, need for surgical rescue, and complications. RESULTS: Eleven studies (177 patients) were included. Majority (116, 69%) were males with a weighted mean age of 71 + -19.5 years. Meta-analysis of proportions showed treatment failure to be 2.8%, need for surgical rescue 2.7%, and embolization-related complications 1.2%. Meta-analysis of risk-difference between embolized and non-embolized patients showed a 26% (p < 0.001, 95% CI 21%-31%, I2 = 0) lower risk of hematoma recurrence in MMAE. Similarly, in the embolized group, the need for surgical rescue was 20% less (p < 0.001, 95% CI = 12%-27%, I2 = 12.4), and complications were 3.6% less (p = 0.008, 95% CI 1%-6%, I2 = 0) compared to conventional groups. CONCLUSIONS: Although MMAE appears to be a promising treatment for refractory or cSDH, drawing definitive conclusions remains limited by paucity of data and small sample sizes. Multicenter, randomized, prospective trials are needed to compare embolization to conventional treatments like watchful waiting, medical management, or surgical evacuation. More extensive research on MMAE could begin a new era in the minimally invasive management of cSDH.

Nocardia amikacinitolerans and cytomegalovirus: distinctive clinical and radiological characterization of the rare etiologies of brain abscesses: report of 2 cases.

Central nervous system infections in immunosuppressed patients are rare but potentially lethal complications that require swift diagnoses and intervention. While the differential diagnosis for new lesions on neuroradiological imaging of immunosuppressed patients typically includes infections and neoplasms, image-based heuristics to differentiate the two has been shown to have variable reliability.The authors describe 2 rare CNS infections in immunocompromised patients with atypical physical and radiological presentations. In the first case, a 59-year-old man, who had recently undergone a renal transplantation, was found to have multifocal Nocardia amikacinitolerans abscesses masquerading as neoplasms on diffusion-weighted imaging (DWI); in the second case, a 33-year-old man with suspected recurrent Hodgkin's lymphoma was found to have a nonpyogenic abscess with cytomegalovirus (CMV) encephalitis.As per review of the literature, this appears to be the first case of brain abscess caused by N. amikacinitolerans, a recently isolated superbug. Despite confirmation through brain biopsy later on in case 1, the initial radiological appearance was atypical, showing subtle diffusion restriction on DWI. Similarly, the authors present a case of CMV encephalitis that presented as a ring-enhancing lesion, which is extremely rare. Both cases draw attention to the reliability of neuroimaging in differentiating an abscess from a neoplasm.

Rheumatoid arthritis in review: Clinical, anatomical, cellular and molecular points of view.

Rheumatoid arthritis (RA) is the most common chronic autoimmune disease of the joints affecting close to 0.5-1.0% of the general population. Although the etiopathogenesis of RA remains elusive, the involvement of dendritic cells and type 17 T-helper cells appears to be pivotal in maintaining a state of chronic inflammation. RA is generally characterized by small joint involvement. A chronic inflammatory process leads to joint destruction and to tendon and ligament laxity and disintegration. These processes result in an imbalance of forces acting on the joints causing joint deformities including swan neck deformity, boutonniere deformity of the hands, flexion deformity of the wrist, lesser toe deformities, and others. In some instances, bony erosions subsequent to the RA disease process can result in life-threatening events including, for example, atlanto-axial subluxation, which can cause myelopathy and paralysis; and basilar invagination, which can cause brain stem injury and imminent death. Although less commonly involved, larger joints are not spared, as evidenced by the involvement of the elbow, hip, and shoulder joints in a sizable proportion of RA patients. The progression and prognosis of this disease entity are variable, guarded and dependent on the efficacy and response to treatment modalities employed. Inadequate management results in disease progression, which ultimately leads to joint erosion, destruction, deformities and substantial decrease in the functional quality of life. Clin. Anat. 31:216-223, 2018. © 2017 Wiley Periodicals, Inc.

Blood brain barrier: A review of its anatomy and physiology in health and disease.

The blood-brain barrier (BBB) is the principal regulator of transport of molecules and cells into and out of the central nervous system (CNS). It comprises endothelial cells, pericytes, immune cells, astrocytes, and basement membrane, collectively known as the neurovascular unit. The development of the barrier involves many complex pathways from all the progenitors of the neurovascular unit, but the timing of its formation is not entirely known. The coordinated activities of all the components of the neurovascular unit and other tissues ensure that materials required for growth and maintenance are allowed into the CNS while extraneous ones are excluded. This review summarizes current knowledge of the anatomy, development, and physiology of the BBB, and alterations that occur in disease conditions. Clin. Anat. 31:812-823, 2018. © 2018 Wiley Periodicals, Inc.

The newer classifications of the chiari malformations with clarifications: An anatomical review.

In 1891, Hans Chiari described a group of congenital hindbrain anomalies, which were eventually named after him. He classified these malformations into three types (Chiari malformations I, II, and III), and four years later added the Chiari IV malformation. However, numerous reports across the literature do not seem to fit Chiari's original descriptions of these malformations, so researchers have been encouraged to propose new classifications to encompass these variants (e.g., Chiari 0, Chiari1.5, and Chiari 3.5 malformations). Moreover, there is a continued misunderstanding and misuse of the term "Chiari IV malformation." Therefore, the current review intended to describe anatomical, pathophysiological, and clinical aspects of the newer classifications with clarifications of the Chiari malformations. We reviewed available literature about Chiari malformations and their variants using "PubMed" and "Google Scholar." We also looked into the term Chiari IV, clarifying its original description and citing examples where the term has been used erroneously. References in the reviewed articles were searched manually. Variants of the originally described Chiari malformations are termed Chiari 0, Chiari 1.5, and Chiari 3.5. Each has distinct anatomical characteristics and some of these are extremely rare and incompatible with life (e.g. Chiari 3.5). Chiari IV malformation has been further clarified. Some physicians might be unfamiliar with the newer classifications of Chiari malformations because these conditions are rare or even unique. Furthermore, care is needed in using the term "Chiari IV malformation", which must be consistent with Chiari's original description, i.e. an occipital encephalocele containing supratentorial contents. Clin. Anat. 31:314-322, 2018. © 2018 Wiley Periodicals, Inc.

Surgical anatomy, radiological features, and molecular biology of the lumbar intervertebral discs.

The intervertebral disc (IVD) is a joint unique in structure and functions. Lying between adjacent vertebrae, it provides both the primary support and the elasticity required for the spine to move stably. Various aspects of the IVD have long been studied by researchers seeking a better understanding of its dynamics, aging, and subsequent disorders. In this article, we review the surgical anatomy, imaging modalities, and molecular biology of the lumbar IVD. Clin. Anat. 30:251-266, 2017. © 2017 Wiley Periodicals, Inc.

Neuroanatomical variation in autism spectrum disorder: A comprehensive review.

Autism Spectrum Disorder (ASD) is a neurodevelopmental disorder characterized by impairments in socialization, communication, and behavior. Many investigators have described the anatomical abnormalities in autistic brains, in an attempt to correlate them with the manifestations of ASD. Herein, we reviewed all the available literature about the neuroanatomical findings in ASD available via "PubMed" and "Google Scholar." References found in review articles were also searched manually. There was substantial discrepancy throughout the literature regarding the reported presence and significance of neuroanatomical findings in ASD, and this is thoroughly discussed in the present review.

A modern history of neurosurgery and neurology in India: lessons for the world.

The compendia of medical knowledge of the great ancient Indian physicians Susruta, Caraka, Jivaka, and Vagbhata all attest to the practice of neurosurgery and neurology starting in the 1st millennium bce. Although a period of scientific stagnation ensued between the 12th and 20th centuries ce, Indian medical neurosciences once again flourished after India's independence from British rule in 1947. The pioneers of modern Indian neurosurgery, neurology, and their ancillary fields made numerous scientific and clinical discoveries, advancements, and innovations that proved influential on a global scale. Most importantly, the efforts of Indian neurosurgeons and neurologists were unified at the national level through the Neurological Society of India, which was established in 1951 and enabled an unprecedented degree of collaboration within the aforementioned medical specialties. The growth and success of the Indian model bears several lessons that can be applied to other nations in order to garner better collaboration among neurosurgeons, neurologists, and physicians in related fields. Here, the authors elaborate on the origins, growth, and development of neurosurgery and neurology in India and discuss their current state in order to glean valuable lessons on interdisciplinary collaboration, which forms the basis of the authors' proposal for the continued growth of societies dedicated to medical neurosciences across the world.

Gearing Up for the U.S. Medical Licensing Examination Step 1 Pass/Fail Transition, Evaluating the Role of Research Productivity as an Alternative During the Neurosurgical Residency Selection Process: An Overview.

Neurosurgery residency programs are the most competitive among the surgical specialties for applicants to match into. U.S. Medical Licensing Examination (USMLE) step 1 scores are staple and pivotal in narrowing down applicants for granting interviews and ranking in the match process. The upcoming transition from a numeric to binary step 1 scoring shifts the emphasis on using the status quo Step 2 Clinical Knowledge numeric scoring as the only objective measure. It can prove insubstantial for accurate assessment of competencies, further urging residency programs to widen their selection protocols to allow multiple assessments of competency. Research experience has consistently proved to result in higher successful match rates, and a positive correlation is seen with the number of research publications and Hirsch indices. However, with a predicted emphasis on research with the shift in scoring practices, these tools provide inadequate insight into authorship, contributions, type of publications, and community impact, warranting the need to include supplementary modifications, surrogates, or alternatives to such tools for a more comprehensive and equitable assessment of research. This study summarizes the role of research in the neurosurgical match process, describes nuances in research evaluation, and introduces novel Hirsch indices and additional strategies to address these nuances for equitable evaluation of research productions.

Surgical Resection and Clipping of an Atherosclerotic Partially Calcified Middle Cerebral Artery Trifurcation Aneurysm with Clipping of an Anterior Communicating Artery Aneurysm: 2-Dimensional Operative Video.

It is estimated within the western population that 10%-13% of patients possess multiple intracranial aneurysms1 and are linked to certain risk factors. Thrombotic aneurysms are a rare subgroup of complex aneurysms characterized by an organized intraluminal thrombus.2,3 They differ from typical saccular aneurysms in terms of morphology, natural history, symptomatology, and difficulty in treatment with conventional strategies.2,4 The risk of rupture is poorly characterized and assumed to be comparable with that of nonthrombotic aneurysms.2 A subset of thrombotic aneurysms can be treated surgically with conventional clipping, and direct clipping has been associated with the best surgical outcome.2 Despite its safety, endovascular treatment is associated with a high risk of recurrence and retreatment compared with surgical treatment,5 with recanalization rates up to 5× higher compared with nonthrombosed aneurysms.6,7 A 64-year-old male presented with headaches and dizziness for 6 months. He was neurologically intact. Imaging revealed a calcified thrombosed right middle cerebral artery aneurysm and an anterior communicating artery aneurysm, both of which underwent clipping. The patient consented to the procedure. Preservation of blood flow in branch arteries in thrombosed aneurysms is challenging. Thrombectomy and clip reconstruction in such cases can occlude the branch vessels, compromising blood flow. Achieving adequate proximal control and meticulous dissection of the branches is necessary before reconstruction. We present a 2-dimensional video demonstrating the surgical steps of clipping and reconstruction of the giant thrombosed middle cerebral artery aneurysm. Complete occlusion was achieved, and the patient tolerated the operation well with an uneventful postoperative course.