Transcervical access via direct neck exposure for neurointerventional procedures in the hybrid angiosuite

PURPOSE

A complicated course of the femoral route for neurointervention can prevent approaching the target. Thus, we determined whether transcervical access in the hybrid angiosuite is applicable and beneficial in real practice.

METHODS

From January 2014 to March 2017, this approach was used in 17 of 453 (3.75%) cases: 11 cerebral aneurysms (4 ruptured, 7 unruptured), 4 acute occlusions of the large cerebral artery, 1 proximal internal carotid artery (ICA) stenosis, and 1 direct carotid cavernous fistula (CCF).

RESULTS

All patients were elderly (mean age, 78.1 years). The main cause was severe tortuosity of the supra-aortic course or the supra-aortic and infra-aortic courses (eight and five cases, respectively), orifice disturbance (three cases), and femoral occlusion (one case). Through neck dissection, 6-8Fr guiding catheters were placed via subcutaneous tunneling to enhance device stability and support. All cerebral aneurysms were embolized (eight complete and three neck remnants) using the combination of several additional devices. Mechanical stent retrieval with an 8Fr balloon guiding catheter was successfully achieved in a few runs (mean, 2 times; range, 1-3) within the proper time window (mean skin to puncture, 17 ± 4 min; puncture to recanalization, 25 ± 4 min). Each stent was satisfactorily deployed in the proximal ICA and direct CCF without catheter kick-back. All puncture sites were closed through direct suturing without complications.

CONCLUSIONS

In the hybrid angiosuite, transcervical access via direct neck exposure is feasible in terms of device profile and support when the femoral route has an unfavorable anatomy.

Complications Following Transradial Cerebral Angiography : An Ultrasound Follow-Up Study

OBJECTIVE

The feasibility and usefulness of transradial catheterization for coronary and neuro-intervention are well known. However, the anatomical change in the catheterized radial artery (RA) is not well understood. Herein, we present the results of ultrasonographic observation of the RA after routine transradial cerebral angiography (TRCA).

METHODS

Patients who underwent routine TRCA with pre- and post-procedure Doppler ultrasonography (DUS) of the catheterized RA were enrolled. We then recorded and retrospectively reviewed the diameter and any complicated features of the RA observed on DUS, and the factors associated with the diameter and complications were analyzed.

RESULTS

A total of 223 TRCAs across 181 patients were enrolled in the current study. The mean RA diameter was 2.48 mm and was positively correlated with male gender (p<0.001) and hypertension (p<0.002). The median change in diameter after TRCA was less than 0.1 mm (range, -1.3 to 1.2 mm) and 90% of changes were between -0.8 and +0.7 mm. Across 228 procedures, there were 12 cases (5.3%) of intimal hyperplasia and 22 cases (9.6%) of asymptomatic local vascular complications found on DUS. Patients with abnormal findings on the first procedure had a smaller pre-procedural RA diameter than that of patients without findings (2.26 vs. 2.53 mm, p=0.0028). There was no significant difference in the incidence of abnormal findings for the first versus subsequent procedures (p=0.68).

CONCLUSION

DUS identified the pre- and post-procedural diameter and local complications of RA. Routine TRCA seems to be acceptable with regard to identifying local complications and changes in RA diameter.

The 360 photography: a new anatomical insight of the sphenoid bone. Interest for anatomy teaching and skull base surgery

Skull base architecture is tough to understand because of its 3D complex shape and its numerous foramen, reliefs or joints. It is especially true for the sphenoid bone whom central location hinged with most of skull base components is unique. Recently, technological progress has led to develop new pedagogical tools. This way, we bought a new real-time three-dimensional insight of the sphenoid bone that could be useful for the teacher, the student and the surgeon. High-definition photography was taken all around an isolated dry skull base bone prepared with Beauchêne's technique. Pictures were then computed to provide an overview with rotation and magnification on demand. From anterior, posterior, lateral or oblique views and from in out looks, anatomical landmarks and subtleties were described step by step. Thus, the sella turcica, the optic canal, the superior orbital fissure, the sphenoid sinus, the vidian canal, pterygoid plates and all foramen were clearly placed relative to the others at each face of the sphenoid bone. In addition to be the first report of the 360 Photography tool, perspectives are promising as the development of a real-time interactive tridimensional space featuring the sphenoid bone. It allows to turn around the sphenoid bone and to better understand its own special shape, numerous foramen, neurovascular contents and anatomical relationships. This new technological tool may further apply for surgical planning and mostly for strengthening a basic anatomical knowledge firstly introduced.

Can the angle between optic nerves indicate whether optic chiasm is prefixed, normofixed or postfixed? An anatomical study with radiologic and neurosurgical implications

PURPOSE

The objective of this study was to measure the angle (Interneural angle, INA) between intracranial segments of optic nerves (ISON), and to look for any relation between it and the relative anteroposterior location (RAPL) of the optic chiasm (OC)-viz. prefixed, normofixed and postfixed.

METHODS

The sample comprised of 100 autopsy specimens from South Indian population. INA was measured using software-aided processing of digital photographs. Length of the ISON was measured on each side using Vernier calipers. RAPL of the OC was noted during dissection. These were analysed with statistical methods.

RESULTS

RAPL of OC was found to be prefixed in 24 %, normofixed in 65 % and postfixed in 11 %. The INA had an overall mean of 69.9° (SD 9.29°). ANOVA confirmed statistically significant difference in INA among different groups; the corresponding mean value for the group was as follows: 79.61° (prefixed), 68.10° (normofixed) and 59.48° (postfixed). ROC curve was plotted for the use of various 'cut off' values of INA to 'diagnose' prefixed OC; an INA ≥71.4° was seen to diagnostically correlate with prefixed OC with 83.3 % sensitivity and 75 % specificity.

CONCLUSIONS

The INA is wider when OC is prefixed, intermediate when normofixed and narrowed when postfixed. This observation throws light on the possibility of using INA as a marker of RAPL of OC. As INA can be measured in axial MRI sections, it can be used in differentiation of the cases with prefixed OC from others during pre-operative work up for pituitary surgeries and to identify individuals 'at risk' during subfrontal approach for pituitary lesions.

Use of the 2.8 French Progreat microcatheter in diagnostic cerebral angiography

BACKGROUND

Tortuous vascular anatomy poses a significant challenge to performing diagnostic cerebral angiography.

OBJECTIVE

To report a new cerebral angiography technique for overcoming tortuous aortic and supra-aortic anatomy using a 2.8 French (F) Progreat microcatheter (0.028 inch (internal diameter) (Terumo; Somerset, New Jersey, USA) to obtain a diagnostic cerebral angiogram.

MATERIALS AND METHODS

A retrospective analysis of consecutive cases undergoing diagnostic cerebral angiography at our institution between 1 January 2013 and 30 November 2015 in which a 2.8F Progreat microcatheter was used. Clinical and operative notes were reviewed and correlated with imaging. Radiologic imaging, including CT, MRI, and digital subtraction angiography, was reviewed. Neurologic, systemic, and local complications were recorded on the basis of clinical follow-up results after each angiographic examination. Events that occurred within 24 h of the angiography were considered to be complications of the procedure.

RESULTS

Initial attempts at catheterization of the target vessel with various 4F and 5F catheters were unsuccessful owing to tortuosity, atherosclerotic disease, or occlusion of the catheter in the target vessel. Microcatheterization of the target vessel was successful in 59/62 (95%) target vessels. A diagnostic cerebral angiogram with a power injection was obtained in 59 (100%) of the successfully catheterized vessels. In one case, angiography proceeded to aneurysm coiling after over-the-wire exchange. In two cases, angiography proceeded to mechanical thrombectomy after over-the-wire exchange. No procedural complications were seen.

CONCLUSIONS

The 2.8F Progreat microcatheter can be used to obtain a diagnostic cerebral angiogram in patients with anatomic challenges limiting catheterization by standard techniques.

Feasibility of combined surgical and endovascular carotid access for interventional treatment of ischemic stroke

BACKGROUND

Rapid recanalization of occluded vessels is crucial for good clinical outcome in acute ischemic stroke. Endovascular treatment is usually performed via a transfemoral approach, but catheterization of the carotid arteries can be problematic in cases of difficult anatomy or vascular pathologies in some cases.

OBJECTIVE

To describe our experience with a technique involving surgical access to the carotid artery and consecutive transcarotid endovascular thrombectomy in patients with acute stroke.

METHODS

In a retrospective review of a prospectively maintained registry we identified 6 patients who underwent acute endovascular thrombectomy via a surgical access to the carotid artery.

RESULTS

Admission National Institute of Health Stroke Scale (NIHSS) ranged from 7 to 23. Intracranial recanalization (thrombolysis in cerebral infarction, TICI≥2b) was achieved in all patients (100%). Recanalization was achieved within 19±5 min after establishing carotid access. One patient developed a small neck hematoma, which was surgically removed without complications. No complications related to endovascular therapy were seen. At 3 months' follow-up, five patients had survived. Three patients (50%) had regained excellent neurological function (modified Rankin Scale, mRS 0-1).

CONCLUSIONS

Surgical carotid access for endovascular stroke treatment is feasible, with considerable advantages, in patients with expected problematic access or for whom transfemoral endovascular carotid access has failed.

A Technical Guide Describing the Use of Transradial Access Technique for Endovascular Interventions

Transradial arterial access (TRA) has been employed for transcatheter coronary procedures for more than 25 years, with numerous studies demonstrating improved patient safety as compared with transfemoral arterial access. However, TRA remains underused by the interventional radiology and vascular surgery communities. Advantages of TRA over transfemoral arterial access include easier accomplishment of postprocedure hemostasis, decreased risk of hemorrhagic complications, shorter patient recovery leading to immediate ambulation and decreased procedure-related costs, and increased patient satisfaction. In particular, TRA may be advantageous in the population of patients with obesity. The primary patient selection factor to consider before attempting TRA is whether the patient has adequate collateral perfusion to the hand; this is assessed using the Barbeau test. Limitations of TRA may include operator unfamiliarity or learning curve and unavailability of adequate length catheters. The most common complication, although still rare, is localized access site hematoma, which is often asymptomatic. Radial artery occlusion is rare and rarely symptomatic owing to collateral perfusion to the hand. Theoretical increased risk of cerebral embolism during TRA may be minimized by preferentially accessing the left wrist during below-diaphragm procedures, which limits transcatheter manipulation of the aortic arch. Transulnar artery access is under investigation for use in patients who cannot undergo TRA. Providing patients the option of TRA can lead to improved outcomes, potentially increasing safety and patient satisfaction while decreasing procedure costs.

Imaging of the pituitary and sella turcica

The pituitary gland is housed in the sella turcica and has vital endocrinologic functions. It lies in close proximity to numerous vital structures, including the optic chiasm, sphenoid sinus, cavernous sinus and hypothalamus. An understanding of the function, anatomy and embryology of the pituitary gland and its surrounding structures is vital to understanding its normal appearance, as well as in evaluating the broad spectrum of pathology that can involve the pituitary gland. Imaging of pathology in the sellar region, including pituitary adenomas, meningiomas, craniopharyngiomas and aneurysms, plays an important role in guiding treatment decisions. Modern imaging techniques are also important in evaluating the pituitary gland after surgery.

Anatomic study of the lamina terminalis: neurosurgical relevance in approaching lesions within and around the third ventricle

BACKGROUND

The lamina terminalis (LT) represents an important neurosurgical corridor by which to fenestrate the third ventricle into the subarachnoid space or to approach lesions of the third ventricle. However, a comprehensive review of its anatomy and approaches to it for various pathologies is lacking in the literature. We studied the anatomy of the LT in 21 cadavers and described the LT as observed in cadaveric dissections. We also reviewed the literature regarding the detailed anatomy and pathology of the LT. In addition, a case illustration that demonstrates the use of this structure as a corridor to third ventricular tumors is presented. Our aim was to explore the anatomy of the LT through cadaveric dissection, a review of the literature, and a case study.

METHODS

Twenty-one adult cadaver heads underwent microdissection of the LT with a focus on the working distance available to enter the third ventricle and related vascular structures.

RESULTS

Inferior to the anterior communicating artery was the safer region to open due to the lack of perforating arteries. A working distance of approximately 1 cm can be expected through the LT.

CONCLUSIONS

This information may aid neurosurgeons during approaches through and around the LT.

The subdiaphragmatic cistern: historic and radioanatomic findings

BACKGROUND

In the past, sporadic demonstrations of the existence of a subarachnoid subdiaphragmatic cistern have been published. The aim of this study was to evaluate the anatomical characteristics of the subdiaphragmatic cistern of the pituitary gland.

METHODS

After a complete review of the literature published on the topic, we report anatomical observations of the subdiaphragmatic cistern and its relationship to the pituitary gland and to the chiasmatic cistern. Ten cadaveric heads were studied using different techniques and surgical methods (plastination, plastic casts of the subarachnoid spaces, microscopic and transsphenoidal endoscopic approaches). Moreover, 3-T magnetic resonance images of ten healthy volunteers were analyzed to investigate the presence and anatomical variability of the subdiaphragmatic cistern.

RESULTS

By means of our qualitative radioanatomic study, we found that the roof of the subdiaphragmatic cistern is formed by the diaphragma sellae, the floor by the superior face of the pituitary gland, the lateral walls by the arachnoidea extending laterally through the medial walls of the cavernous sinus, and the medial walls by the infundibular stem. The subdiaphragmatic cistern communicates by means of the ostium of the diaphragm with the chiasmatic cistern.

CONCLUSION

We confirmed the existence of the subdiaphragmatic cistern. The overused term "suprasellar cistern" refers more to a complex of cisterns, formed by the subdiaphragmatic cistern, below the diaphragma sella, and by the chiasmatic cistern, above it, in direct communication with the lamina terminalis and carotid cisterns.

Pathophysiology of hypopituitarism in the setting of brain injury

The complex pathophysiology of traumatic brain injury (TBI) involves not only the primary mechanical event but also secondary insults such as hypotension, hypoxia, raised intracranial pressure and changes in cerebral blood flow and metabolism. It is increasingly evident that these initial insults as well as transient events and treatments during the early injury phase can impact hypothalamic-pituitary function both acutely and chronically after injury. In turn, untreated pituitary hormonal dysfunction itself can further hinder recovery from brain injury. Secondary adrenal insufficiency, although typically reversible, occurs in up to 50% of intubated TBI victims and is associated with lower systemic blood pressure. Chronic anterior hypopituitarism, although reversible in some patients, persists in 25-40% of moderate and severe TBI survivors and likely contributes to long-term neurobehavioral and quality of life impairment. While the rates and risk factors of acute and chronic pituitary dysfunction have been documented for moderate and severe TBI victims in numerous recent studies, the pathophysiology remains ill-defined. Herein we discuss the hypotheses and available data concerning hypothalamic-pituitary vulnerability in the setting of head injury. Four possible pathophysiological mechanisms are considered: (1) the primary brain injury event, (2) secondary brain insults, (3) the stress of critical illness and (4) medication effects. Although each of these factors appears to be important in determining which hormonal axes are affected, the severity of dysfunction, their time course and possible reversibility, this process remains incompletely understood.

Deep hypothermic circulatory arrest for thoracoabdominal aortic aneurysm repair in a patient with a large intracranial anterior communicating artery aneurysm

Abdominal aortic aneurysms occasionally occur concomitantly with an intracranial artery aneurysm (ICA). The association of an ICA with a thoracoabdominal aortic aneurysm (TAAA) is relatively rare. A patient with this condition is presented. Coiling of the ICA was not an option preoperatively because of the dissected false lumen of the TAAA, rendering a femoral artery approach impossible. The TAAA was repaired during deep hypothermic circulatory arrest.

Radial approach in the treatment of supraaortic arterial lesions

SUMMARY

Radial approach (mainly right) has been used in the treatment of 67 supraaortic lesions including 56 carotid, nine vertebral and two subclavian artery stenoses. This approach offers new possibilities and solves most of the remaining technical difficulties or impossibilities encountered in the endovascular treatment of supraaortic lesions. The current technique is described. The results of this first series have been very satisfactory without complication. MR angiography allows selection of patients suitable for radial approach.

Intraoperative angiography for neurovascular disease in the prone or three-quarter prone position

BACKGROUND

Intraoperative angiography for neurovascular disease has gained wide acceptance as a useful tool. There are few published cases of intraoperative angiography performed in the prone or three-quarter prone position, and the transradial approach has not previously been described for this situation.

METHODS

We retrospectively reviewed our last 177 consecutive cases of intraoperative angiography performed for neurovascular disease. Of these cases, 21 were performed in the prone or three-quarter prone position. Two different approaches were used: (1) a previously described extended femoral sheath approach (13 cases) and (2) a newly described transradial approach (8 cases).

RESULTS

All 21 intraoperative angiograms were successfully completed in the prone or three-quarter prone position. This enabled us to make additional surgical adjustments when necessary or to conclude the operation. One complication, a dissection of the brachial artery, occurred during one intraoperative angiographic procedure.

CONCLUSIONS

Intraoperative angiography can be performed in the prone or three-quarter prone position with good efficacy and safety. The transfemoral route has the advantage of familiarity but has disadvantages of poor sterility at access site, possible kinking or thrombosis of the sheath, and possible skin injury while resting on the tubing during long procedures. The transradial route has advantages of continuous access to the entry site throughout the surgical procedure and ease of catheterization of vertebral arteries for occipital and suboccipital lesions. However, the transradial route has the disadvantage of working from an unfamiliar approach, especially for spinal arteriovenous malformations.