Surgical Management of Acute Intracranial Hemorrhage, Surgical Aneurysmal and Arteriovenous Malformation Ablation, and Other Surgical Principles

Comparing Characteristics and Treatment of Brain Vascular Malformations in Children and Adults with HHT

Hereditary hemorrhagic telangiectasia (HHT) is a rare autosomal dominant disease characterized by the development of vascular malformations (VMs) in organs such as the brain and lungs, as well as telangiectases on mucosal surfaces. Prophylactic treatment of organ VMs may prevent potential complications, such as hemorrhage. However, brain VM treatment-surgical resection, embolization, and/or radiosurgery-is not recommended for all patients due to the associated risks. Given the scarcity of data regarding HHT-related brain VM presentation and treatment trends in pediatric patients, we aim to describe the clinical presentations and the patterns of treatment of HHT-related brain VMs in a pediatric cohort, and compare pediatric trends to those of adults. Demographic and clinical data were analyzed in 114 pediatric patients with HHT-related brain VMs and compared with a cohort of 253 adult patients enrolled in the multicenter Brain Vascular Malformation Consortium HHT Project. Our data demonstrated that a higher proportion of pediatric patients with HHT-related brain VMs were symptomatic at presentation (p = 0.004). Moreover, a higher proportion of pediatric patients presented with intracranial hemorrhage (p < 0.001) and seizure (p = 0.002) compared to adult patients. Surgical resection was the most common brain VM treatment modality in both children and adults. We conclude that pediatric patients may be more likely to present with symptoms and complications from brain VMs, supporting the case for screening for brain VMs in children with HHT.

A Novel Stereotactic Aspiration Technique for Intracerebral Hemorrhage

BACKGROUND

Minimally invasive surgery is effective and recommended for treatment of intracerebral hemorrhage; however, neurosurgeons in grass-root hospitals in underdeveloped countries lack effective and precise minimally invasive surgery techniques. The aim of this study was to present a technique of computed tomography angiography-based three-dimensional-printed navigation mold-guided stereotactic aspiration and demonstrate its clinical application using a hard needle in a series of patients.

METHODS

The novel stereotactic aspiration technique was performed in 18 patients with spontaneous intracerebral hemorrhage at our center, and clinical outcomes were reported. We compared the volume of hematoma measured by 3 different methods: ABC/2 formula, manual segmentation with OsiriX, and manual segmentation with 3D Slicer.

RESULTS

The surgery was completed safely within an average operative time of 15.11 minutes, achieving the goal of <15 mL residual clot volume or >70% clot removal in all patients. No intracranial rebleeding or infection was observed postoperatively. At the end of the 6-month follow-up, 61.11% (11/18) of patients achieved a modified Rankin Scale score <3. There was overall better agreement of hematoma measurement using segmentation with 3D Slicer rather than ABC/2 measurement or hematoma measurement using segmentation with OsiriX.

CONCLUSIONS

Our novel method of stereotactic aspiration benefited patients in this study with good percent clot removal, few surgery-related complications, and a favorable prognosis. Manual segmentation with 3D Slicer could be used to provide the neurosurgeon with dependable information about hematoma volume. This cheap and convenient technique may be applied in grass-root hospitals in underdeveloped countries. Assessment in multicenter prospective clinical trials is needed.

Hemodynamics Associated With Intracerebral Arteriovenous Malformations: The Effects of Treatment Modalities

The understanding of the physiology of cerebral arteriovenous malformations (AVMs) continues to expand. Knowledge of the hemodynamics of blood flow associated with AVMs is also progressing as imaging and treatment modalities advance. The authors present a comprehensive literature review that reveals the physical hemodynamics of AVMs, and the effect that various treatment modalities have on AVM hemodynamics and the surrounding cortex and vasculature. The authors discuss feeding arteries, flow through the nidus, venous outflow, and the relative effects of radiosurgical monotherapy, endovascular embolization alone, and combined microsurgical treatments. The hemodynamics associated with intracranial AVMs is complex and likely changes over time with changes in the physical morphology and angioarchitecture of the lesions. Hemodynamic change may be even more of a factor as it pertains to the vast array of single and multimodal treatment options available. An understanding of AVM hemodynamics associated with differing treatment modalities can affect treatment strategies and should be considered for optimal clinical outcomes.