Depiction of Cerebral Aneurysm Wall by Computational Fluid Dynamics (CFD) and Preoperative Illustration

Introduction  Preoperative illustration is a part of an important exercise to study the configuration, direction, and presence of any perforations, and is the weakest point in the wall of the cerebral aneurysm. The same illustration is used to study the surrounding brain structures to decide the best and safe surgical approach prior to any surgical procedure. With the evolution of the aneurysm wall study and study of flow dynamic within the involved artery and its aneurysm wall using computational fluid dynamics (CFD), a better surgical plan can be formulated to improve the flow dynamics. As one of the clinical applications of CFD, we propose a study using a composite image that combines preoperative illustration and CFD, which is traditionally widely used in neurosurgery.

Methods and Materials  We study the use of illustrations of the unruptured cerebral aneurysm of internal carotid-posterior communicating (ICPC) artery and anterior communicating artery (AcomA) treated at our hospital. The combinations of both preoperative illustrations and CFD images by using “ipad Pro” were used.

Result and Conclusion  Medical illustration in the preoperative study of unruptured cerebral aneurysm with combinations of CFD and surrounding brain structures is helpful to decide the surgical approaches and successful surgical treatments.

The Use of Fusion Images as a Diagnostic and Neurosurgical Planning Tool in Microvascular Decompression

Preoperative assessment of surgery using high-quality images can help surgeons to achieve best result of treatment. With the advances in computer technology, interactive multimodality fusion images have been developed. The use of fusion images as a preoperative planning tool is described with its examples in illustrative cases of trigeminal neuralgia and hemifacial spasm microvascular decompression (MVD). Interactive computer graphics such as multimodality fusion method is a useful tool to preoperatively predict the need of bone exposure and configuration of blood vessels with its correlation to cranial nerves in MVD.

Cell and platelet composition assays by flow cytometry: basis for new platelet-rich fibrin methodologies

Platelet-rich plasma (PRP) and platelet-rich fibrin (PRF) are selective blood fractions obtained by cen¬trifugation. They act locally on inflammation and immunity as adjuvant homeostatic modulators during tissue regeneration. In recent years, many methods for achieving these blood concentrates have emerged, whose parameters of time and force of centrifugation presented themselves as critical, conflicting, and poorly understood points. Thus, the present study aimed to evaluate the effect of different centrifugal experimental parameters on the concentration of cells and platelets in samples of anticoagulated blood. Blood samples were centrifuged by forces of 200, 400 and 800 x g for 5, 10 and 15 minutes of centrifugation times to obtain three fractions: a) platelet-poor plasma (PPP), b) leukocyte-rich plasma (L- PRP) and c) red blood cell sed¬iment (RBC). The leukocyte and platelet content of each centrifuged fraction was measured by automated flow cytometry associated with the peroxidase reaction for differential leukocyte count. The application of 200 x g generated a more significant dispersive content of leukocytes and platelets in the supernatant fraction of PPP when compared to the other two strength ranges. However, it presented the highest concentration of platelets in the sediment (P <0.05 ANOVA), representing a loss of total mass during processing. The 400 and 800 x g forces showed leukocytes and platelets condensed in the L-PRP fraction and lower levels in the sedi¬ment, demonstrating the greater effectiveness of buoyancy in the resuspension of these sedimented elements. Our experimental data showed that the concentration and organization of leukocytes and platelets in the centrifuged blood matrices are very sensitive to variations in g force and centrifugation time, thus generating products with different biological composition and characteristics, and with specific potential therapeutic effects. The present study did not focus on comparing authoring methods, but on presenting the impact of methodological variations on the biological nature of centrifuged blood matrices. Further in vivo studies are needed to assess the specific clinical effect of each methodological change.

High-Flow Bypass with Radial Artery Graft for Cavernous Carotid Aneurysms: A Case Series

Background:

The incidence of cavernous carotid aneurysms (CCAs) of intracranial aneurysms is low. Majority of cases presented as incidental findings with benign natural progression. The most common presenting symptoms are multiple cranial neuropathies among symptomatic patients. The treatment modalities for symptomatic patients include direct surgical clipping, endovascular coil embolization, or placement of flow diverter, or indirect procedures such as occlusion of parent artery with and without revascularization techniques. The advancement in the microsurgical treatments and endovascular devices have enable a high success rate in the treatment of patients with CCAs with low morbidity and mortality rates.

Objective:

To study the surgical outcomes of patients with cavernous aneurysm who underwent high-flow bypass between 2015 and 2020 in our institution.

Materials and Methods:

A total of six patients in a single institution presented with CCAs who were treated with high-flow bypass surgery were included in this case-series. A single-case illustration was presented focusing on the details of surgical case management of CCA. The intraoperative middle cerebral artery (MCA) pressure monitoring during bypass surgery was also described.

Results:

All five female patients and one male patient who were diagnosed with cavernous carotid aneurysms were studied. The mean age was 68.8 years old (range: 24-84 years old) and the mean size of the aneurysm was 19.6mm (range: 9.7 – 30mm). There were successfully treated with high flow bypasses using radial artery graft without any neurological sequelae.

Conclusion:

The surgical treatments of cavernous carotid aneurysms should be limited to experienced neurosurgeons in view of significant risk of morbidity and mortality. Endovascular procedures may be the main stay of treatments. The success shown in this case series with parent artery occlusion and bypass surgery may provide an safe alternative to the endovascular treatment.

Intradural versus extradural location of paraclinoid aneurysms: Preoperative red flag markers

Background:

Exact preoperative confirmation of the distal dural ring and intradural location of a paraclinoid internal carotid aneurysm has been an age old dilemma. This study was aimed at identifying anatomical landmarks in cases of paraclinoid aneurysms, which were relatively consistent, and would help in predicting the possibility of an extradural inaccessible location of these aneurysms for surgical clipping.

Methods:

Ninety surgically managed unruptured paraclinoid aneurysms were retrospectively analyzed with preoperative computerized tomography. Axial relation of the aneurysm neck to the ophthalmic artery (OA), optic strut (OS), and anterior clinoid process (ACP) in terms of vertical distance and the direction of projection were analyzed and tabulated for all 90 cases. Intradural and extradural (inaccessible) aneurysms were compared.

Results:

Seven out of the 8 inaccessible necks were medially directed and 1 was ventrally placed (P = 0.053). The OA level when compared to the neck had a positive correlation with inaccessible aneurysms for clipping (P = 0.002) The OS location above the level of the neck had significant correlation with inaccessibility of clipping and extradural location (P < 0.001). The tip of the ACP had no statistical significance with inaccessibility (P = 0.351).

Conclusions:

Medially projecting aneurysms with necks below the level of the OS and origin of the OA should be managed with a high index of suspicion and an alternate method of treatment should be sought. The relation of the neck to the ACP does not seem to have significant statistical bearing with decision making.

EC-IC Bypass; Our Experience of Cerebral Revascularization with Intraoperative Dual-Image Video Angiography (Diva)

Background:

Extracranial-intracranial (EC-IC) arterial bypass has been used in the treatment of various cerebrovascular ischemic disease due to atherosclerosis or Moyamoya disease, skull base tumors encasing large IC artery or complex IC aneurysms.

Aim:

The aim is to analyze surgical technique (EC-IC bypass) and its outcome with intraoperative use of dual image video angiography (DIVA) and Doppler ultrasound.

Materials and Methods:

We studied in this article a series of 23 patients operated in Banbuntane Hotokukai Hospital, Fujita Health University, for which a superficial temporal artery-middle cerebral artery anastomosis was done for steno-occlusive disease, giant IC aneurysm or Moyamoya disease. The study was conducted between 2018 and 2020. We used dual-image video angiography (DIVA) and Doppler ultrasound to assess the luminal patency of anastomosis during the procedure.

Results:

In this study, three patients presented with Moyamoya disease, 4 had aneurysm, whereas 16 patients presented with the vascular steno-occlusive disease. The patients were divided into three categories (steno-occlusive disease, Moyamoya, and flow replacement for giant aneurysm). Dual image video angiography, along with intraoperative Doppler, helped us in the assessment of luminal patency of the anastomosis.

Conclusion:

Hemodynamic recovery after cerebrovascular bypass brings about a better outcome in ischemic stroke. The result of surgery improves with proper selection of patients with hemodynamic impairment (in Stage 2). With various modalities such as intraoperative Doppler, DIVA (Dual-image Video Angiography) and improved surgical techniques may aid in the reduction of complications and improve clinical outcome.

Institutional Experience of Microsurgical Management in Posterior Circulation Aneurysm

Introduction:

Posterior circulation aneurysm constitutes 15%–20% of all intracerebral aneurysms. With the advancement of endovascular techniques, the microsurgery for posterior circulation aneurysms has been pushed back a little. Even the International Subarachnoid Aneurysmal Trial gave support to the concepts of endovascular procedures, but microsurgical modality should not be discouraged. We present our institutional experience of microsurgical techniques on posterior circulation aneurysms.

Materials and Methods:

We performed a retrospective analysis of 37 patients of posterior circulation aneurysm from 2015 to 2019, referred to Bantane Hospital, Japan. We included all posterior circulation aneurysms such as basilar tip, basilar trunk, and vertebral artery-posterior inferior cerebellar artery (VA-PICA) aneurysms, admitted and treated with clipping or bypass and trapping. We assessed the outcome as measured by modified Rankin Score (mRS), complications, and mortality.

Results:

Out of 37 patients, 10 cases were a basilar tip, one case was the basilar trunk, and 26 cases were VA-PICA aneurysm. Intraoperatively, neuromonitoring, indocyanine green dye, dual-image videoangiography (DIVA), and neuro endoscope were used. Two patients of basilar tip aneurysm developed third cranial nerve paresis and six patients of VA-PICA aneurysm developed lower cranial nerve paresis which resolved spontaneously. All the patients were discharged with mRS of 0 or 1. No mortality was recorded in our study.

Conclusion:

Microsurgical clipping of posterior circulation aneurysm is safe in unruptured aneurysm with a very low risk of mortality and morbidity under experienced hands. All postoperative complications in our study were transient and resolved with time with no residual deficits. Preoperative simulation, intraoperative neuromonitoring, DIVA, and neuro endoscope help achieve complete obliteration of aneurysmal sac and avoid complications.

Analysis of the Surgical Outcome of Unruptured Intracranial Saccular Aneurysms in Octogenarians (80-89 Years)

Background:

The prevalence of unruptured intracranial aneurysms is increasing in elderly population in Japan. Octogenarians (80–89 years) are more prone to complications due to increased age, comorbidities, increased risk of vasospasm, and treatment risks.

Aim:

The aim is to study the surgical outcome of unruptured intracranial saccular aneurysms in elderly patients aged between 80 and 89 years.

Patients and Methods:

A retrospective study was conducted involving all the cases of unruptured intracranial saccular aneurysms operated surgically in elderly patients aged between 80 and 89 years. All the cases operated between January 2017 and October 2019 were included in the study. The preoperative neurological status was assessed using the Glasgow Coma Scale (GCS). The comorbidities and risk factors involved were assessed. Postoperative neurological status was assessed by (1) postoperative GCS score and by the (2) presence or absence of the motor weakness of limbs.

Results:

Thirty-three aneurysms were operated in 27 patients. Two patients were operated two times at separate occasions for different aneurysms during the study period and hence making a total of 29 surgeries. The age range was 80–88 years, with a mean of 82.4 years ± 2.64 standard deviation (SD). There were 7 (24.1%) males and 22 (75.86%) females. All the patients had a preoperative GCS score of 15/15 without focal neurological deficit. The mean size (mm) of the aneurysms was 6.57 ± 4.04 SD. There were 31 (93.94%) aneurysms in the anterior circulation and 2 (6.06%) aneurysms in the posterior circulation. The comorbidities and risk factors were analyzed and found to be not influencing the outcome of the patients. Clipping was done in 32 aneurysms. One case of posterior inferior cerebellar artery (PICA) aneurysm underwent occipital artery to PICA bypass surgery. The postoperative complications include chronic subdural hematoma (CSDH) in 7 (24.13%) patients, extradural hematoma in 1 (3.4%), meningitis in 1 (3.4%), and lower cranial nerve palsy in 1 (3.4%) patient. All the patients were discharged with GCS score 15/15 without motor weakness of the limbs. The mean duration of stay was 16.62 days ± 9.98 SD.

Conclusion:

Surgery for unruptured saccular aneurysms in octogenarians has got a good result in the tertiary care facility. Advanced age alone should not be considered for preferring coiling over clipping. Octogenarians are more prone to developing postoperative CSDH.

Unusually Located Proximal Middle Cerebral Artery Saccular Aneurysm

Middle cerebral aneurysms constitute almost one-third of all anterior circulation aneurysms. Most of the saccular aneurysms originate from the arterial branching sites, but origins other than at the branching site are extremely rare. In this article, we are describing a unique M1 segment middle cerebral artery aneurysm which is not related with any branching site. Our literature search suggests that atherosclerotic changes in the arterial wall and local hemodynamic forces play an important role in the development of these types of aneurysm. Surgical management is not so unique in this type of aneurysm, but due to atherosclerotic parent arterial wall and thin-walled aneurysm sac, a neurosurgeon should be more cautious.

Surgical Management of Complex Middle Cerebral Artery Aneurysms: An Institutional Review

Background:

Complex middle cerebral artery (MCA) aneurysms are defined as large (≥10 mm) or giant (≥25 mm) aneurysms with M2 branches arising from the aneurysm rather than M1 segments and usually require some form of reconstruction of the bifurcation. Their management is difficult and surgery is preferred over endovascular modalities because of their peculiar angioarchitecture and association with critical branch points or perforators.

Objectives:

The study was aimed at analyzing surgically managed complex MCA aneurysms and discussing characteristics not favorable for endovascular management, surgical nuances and clipping strategies, patient outcomes, and newer diagnostic modalities which help improve management.

Methods:

Nine cases of surgically operated complex MCA aneurysms were identified from January 2017 to July 2019. The aneurysm characteristics, surgical nuances, clipping strategies, patient outcomes and points not favoring endovascular management were tabulated and analyzed.

Results:

The mean maximum aneurysm diameter was 13.4 mm and the mean fundus/neck ratio was 1.6. The average microscope time was 124 min, and the most common method was clip reconstruction. The average number of clips used was 2.7 and the mean follow-up was 13 months. All patients have good postoperative outcome (Modified Rankin Score 0-2). The complete occlusion rate was 88.9% with one intraoperative voluntary residual sac which was coated. Computational fluid dynamic study results done preoperatively correlated with intraoperative findings.

Conclusions:

MCA aneurysms pose a significant challenge for endovascular treatment because of various factors such as luminal thrombi, complex angio-architecture, precarious branch/perforator locations, broad necks, and fusiform characteristics. Surgical management in experienced hands can tackle all these problems with an armamentarium of clipping techniques and bypass procedures.

Endoscopic Microvascular Decompression for Hemifacial Spasm

Introduction and Objective

Hemifacial spasm (HFS) is a condition, characterized by painless, involuntary unilateral tonic or clonic contractions of the facial muscles innervated by the ipsilateral facial nerve. HFS starts with contractions in the orbicularis oculi muscle with subsequent eyelid closure and/or eyebrow elevation, but may spread to involve muscles of the frontalis, platysma, and orbicularis oris muscles. Microvascular decompression (MVD) is reliable and accepted surgical treatment for HFS. MVD is the standard surgical technique now for HFS treatment with long-term success rates.

Materials and Methods

We performed fully endoscopic MVD technique for 1 patient with HFS (a 83-year-old female) at our institution. HFS was diagnosed based on the clinical history and presentation, a neurologic examination, and additional imaging findings. Respectively, the durations of HFS were 3 years, respectively. The patient had been previously treated with repeated botulinum toxin injections. Preoperative evaluation was done with magnetic resonance imaging; three-dimensional computed tomography fusion images examinations had identified the anterior inferior cerebellar artery (AICA) as the offending vessel in this patient.

Results

The patient with HFS was treated by fully endoscopic MVD technique. The AICA, which had been identified as the offending vessel by preoperative magnetic resonance imaging, was successfully decompressed. No surgery-related complications occurred and had excellent outcomes with the complete resolution of HFS immediately after the operation.

Conclusions

Endoscopic surgery can provide a more panoramic surgical view than conventional microscopic surgery. Fully endoscopic MVD is both safe and effective in the treatment of HFS. This method minimizes the risks of brain retraction and extensive dissection often required for microscopic exposure. Endoscopic MVD is safe and has advantage over microscope in terms of visualization of structure, identification of neurovascular conflict, but it has a learning curve and technically challenging.

Endoscopic-assisted paramedian infratentorial supracerebellar approach for pineal cyst - How I do it Video clip

Background:

The endoscopic supracerebellar-infratentorial (SCIT) approach is a viable method to access pathology of the posterior incisura, but a narrow working space and frequent instrument conflict can potentially limit its surgical efficacy. We planned an endoscopic-assisted paramedian infratentorial supracerebellar approach for pineal cyst.

Case Description:

Patient was placed in prone position under general anesthesia. His head was rotated to the left side slightly. The location of the transverse sinus was detected with navigation system. A 5 cm linear skin incision was performed, and a 2 cm craniectomy was performed about 2 cm left of the median. The transverse sinus was little bit exposed. Dura was incised in a U-shaped incision with the transverse sinus at the base. The endoscope was advanced along with the culmen. At that time, we observed inferior and superior vermian vein. After reaching to the thick arachnoid near by galenic system, the arachnoid membrane was incised and the CSF was evacuated. After that, the cerebellum became soft and the surgical corridor became large. The arachnoid membrane was incised widely. Pineal cyst, precentral cerebellar vein, bilateral internal occipital vein and great vein of galen were exposed. There were some small veins on the pineal cyst, but the adhesion was not so severe. The cyst was dissected from these small veins. There was no adhesion between the cyst and surrounding brain except for the pineal recess. Bilateral ICV was seen behind the cyst. There was feeding artery and draining vein on the antero-lateral part of the cyst. These vessels were coagulated and cut, then the cyst was removed. After the removal, we confirmed complete removal of the cyst and hemostasis.

Conclusion:

Endoscopic-assisted paramedian SCIT approach for pineal cyst in prone position is a reasonable and efficient access for posterior third ventricular lesions. The learning curve, maneuverability in small space, and instrument conflict limit efficacy.

Minimally Invasive Anterolateral Approach for C2 Neurofibroma in Elderly Patient

Conventionally ventrally located spinal tumor is approached through anterior vertebrectomy which requires bony fixation and then immobilization for a couple of months. The alternative route to deal with such type of tumor is anterolaterally to avoid the surgical and nonsurgical complications. We are reporting a minimally invasive anterolateral approach for C2 neurofibroma in an 84-year-old patient. Postoperatively this patient did not require cervical brace and postoperative discomfort was minimal. It was observed that dumbbell-shaped cervical tumor with no intradural pathology and wide neural foramina could also be taken care through the anterolateral route which did not require bony fusion or immobilization, but the expertise of the surgeon is necessary for performing these types of minimally invasive procedure to achieve the best results.

Rare Cases of Contrast-Induced Encephalopathies

Cortical blindness (CB) due to contrast-induced encephalopathy is a rare complication in endovascular procedure. Although exact mechanism is not known, disruption of blood–brain barrier (BBB) by contrast agent is supposed to be caused. We report two cases of contrast-induced encephalopathies after coil embolization of unruptured aneurysm. A 68-year-old woman with unruptured basilar artery aneurysm was treated with endovascular stent-assisted coil embolization. The procedure was successfully accomplished within 172 min using about 160 ml of contrast medium (iopamidol). However, she manifested with CB 3 h after the procedure and seizure on the next day. Immediate computed tomography revealed the cortical enhancement in both occipital lobes. Diffusion-weighted imaging–magnetic resonance imaging and fluid-attenuated inversion recovery sequence 1 day after the procedure revealed edema in both occipital lobes with no findings of ischemia or hyperperfusion. Electroencephalography showed sharp and slow waves in both occipital lobes. She required endotracheal intubation on day 2 to maintain airways and breathing. Her sensorium improved 4 days after the procedure with administration of steroid and anticonvulsant. She was extubated on day 4 after the procedure. She was discharged with persisting CB as a sequel.

Demystifying White Matter Injury in the Unconscious Patients with Diffusion Tensor Imaging

Background

Diffusion tensor imaging (DTI) and diffusion tensor tractography (DTT) provide a noninvasive window to study the neural connectivity and reconstruct the tracts. Detection of white matter injury (WMI) by DTT is a recent application being used in stroke, diffuse axonal injury, and neurodegenerative disorders. Fiber tracking in patients with brain hemorrhage can detect loss of fibers and anatomical disruption of the tracts, which can be useful in the prognostication of patient outcome.

Materials and Methods

DTI and fiber tracking was done in four patients admitted at Fujita Health University Banbuntane Hospital, Japan, with decreased consciousness following brain hemorrhage (3 patients with aneurysmal subarachnoid hemorrhage and one patient with bifrontal hemorrhage), and WMI was analyzed. We also reviewed the literature on tractography in patients with brain hemorrhage and its correlation with consciousness.

Results

We found significant frontal WMI in the form of thinning and anatomical disruption in all four cases. The frontal white matter tracts form an important component of the limbic system and ascending reticular activating system and frontal WMI correlated with the poor conscious level and cognitive dysfunction. Structural damage to the fiber tracts demonstrated as thinning, reduction in the volume or absence on tractography with corresponding reduction in the mean fractional anisotropy values in the frontal white matter of the affected side.

Conclusion

DTI can be useful as a critical tool for revealing the anatomical basis for the cognitive dysfunction and unconsciousness and can be possibly used to prognosticate patient recovery. Early detection of WMI by DTI can also help in tailored rehabilitation. The authors believe that DTT could have a crucial role in the future for detecting structural changes which lead to cognitive dysfunction and further studies are needed to arrive at a specific protocol for detecting WMI.

The Keyhole Approach in Anterior Circulation Aneurysm - Current Indication and Limitation with Review of Literature

Introduction:

The keyhole approach has been an emerging technique for cerebral aneurysm surgery in the past two decades. The preoperative simulation and tailored-made approach for each patient make feasible to clip many cerebral aneurysms via keyhole approach. In our study, we reviewed the previous experiences of the keyhole approach, related specifically for anterior circulation aneurysm.

Material and Methods:

The comprehensive literature review was performed on PubMed, Google Scholar, ScienceDirect, and various neurosurgery and neurology journals. Then, each manuscript's reference list was reviewed for the potential relevant article. The data of total 17 articles, which met our inclusion criteria included for the final review.

Results:

It was found that the anterior communicating artery, middle cerebral artery, and internal carotid- posterior communicating aneurysms were the most common locations treated by keyhole approach. The size of an aneurysm was <10 mm in most of the studies. Many studies treated multiple aneurysms by single keyhole approach.

Conclusion:

The keyhole approach has shown benefit in term of satisfactory aneurysmal occlusion rate, short operative time, less blood loss, short hospital stay, and good overall surgical outcome.

Hearing Outcomes after Microvascular Decompression for Hemifacial Spasm: An Institutional Experience

Introduction

Hearing loss following microvascular decompression (MVD) for hemifacial spasm is one of the most dreaded complications. Several factors such as stretching of VIII cranial nerve, vasospasm of labyrinthine artery, and acoustic trauma due to drill noise may be considered in its causation. We evaluated the incidence and severity of hearing loss following MVD in hemifacial spasm and the factors which might be responsible for this complication.

Methods

A retrospective analysis of 30 patients operated for hemifacial spasm between January 1, 2014, and December 31, 2018, with at least 3 months of follow-up were included in the study. Retromastoid craniotomy was made, and Teflon was placed between involved vessel and VII nerve.

Results

Freedom from hemifacial spasm was noted in 27 of 30 patients. Moderate spasm persisted in one patient, which was controlled with medications. The recurrence was noted in 3 patients at 6 months follow-up. Postoperatively, hearing loss was found in one female patient. The offending vessel was both anterior inferior cerebellar artery (AICA) and posterior inferior cerebellar artery (PICA) loop, which was transpositioned during surgery, and the patient was spasm free postoperatively.

Conclusion

The incidence of hearing loss following MVD can be minimized using proper surgical techniques and various intraoperative adjuncts such as brainstem auditory evoked responses monitoring, use of endoscope, and indocyanine green or dual-image video angiography.

Recurrence of Previously Clipped Anterior Communicating Aneurysm: The Surgical Techniques and Strategies: A Case Series

Background:

Microsurgical aneurysm (MSA) clipping is considered as the standard therapy with the endovascular coiling. Microsurgical clipping is considered superior to endovascular in terms of the recurrence rate. The management of recurrent aneurysm following previous microsurgical clipping is challenging. The management of recurrent aneurysm following previous microsurgical clipping is challenging. This study aims to explore the management of recurrent aneurysm of the anterior communicating artery (ACoM).

Materials and Methods:

This is a case series of three elder women who had a recurrence of ACoM aneurysm after MSA clipping. All the three patients were operated with microsurgical clipping. We studied the preoperative images of the first surgery of all the patients. The detailed case-by-case analysis was performed based on preoperative, postoperative, and follow-up radiologic examinations and operative findings.

Results:

All three patients who had a recurrence after MSA clipping of ACoM aneurysm and were asymptomatic. At presentation, they were diagnosed at the postoperative imaging at follow-up. The earliest recurrence was 1 year while in one patient; the recurrence was detected 8 years after the initial MSA clipping. The cerebral aneurysms were posteriorly directed in the initial preoperative images in all the cases.

Conclusion:

This study revealed the recurrence as the residual neck or the enlargement of the aneurysm even after MSA in these cases of ACoM aneurysm. Even with the complete clipping, there can be recurrence at the clip site due to the change in hemodynamics over the time. We should follow-up the patients regularly even after microsurgical clipping.

Comparative Outcome Analysis of Enterprise and Neuroform Stent-Assisted Coiling of Cerebral Aneurysms: A Review of the Literature

Introduction

One of the popular treatment strategies for complex cerebral aneurysms with wide necks or low dome-to-neck ratios is stent-assisted coiling. The most widely used intracranial stents for stent-assisted coiling are Neuroform (NF) and Enterprise (EP) stents. The purposes of this study are to review the recent literature of the past 5 years to compare outcomes between the EP and NF stent-assist coiling systems so as to comment on the safety, efficacy, complications, and recurrence rate of stent-assisted coiling in general.

Methods

PubMed was used to search for all published literature of NF or EP stent-assisted coiling of unruptured cerebral aneurysms from January 2014 to August 2019 with the search terms of "Enterprise stent-assisted coiling," "Neuroform stent," and "Neuroform vs. Enterprise stent."

Results

Twenty two publications met the inclusion criteria which encompass 1764 patients and 1873 aneurysms. Out of these 1873 aneurysms, 1007 aneurysms were treated with EP stent and 866 aneurysms were treated with NF stent. The overall outcome was low rates of thromboembolic complications (4.37%) and intracranial hemorrhage (1.13%), low permanent morbidity (1.70%) and mortality (0.40%), and lower rate of recanalization (11%). Data analysis shows an overall higher rate of complication and recurrence of aneurysm and lower overall rate of aneurysmal occlusion in the patients where EP stent was used in comparison to NF stent. However, this difference was not statistically significant.

Conclusions

The review of two stent-assisted coiling devices using EP and NF stents including 1873 aneurysms in 1764 patients revealed that overall, it is safe and effective with comparable outcomes.

Temporal arteritis with focal pachymeningitis: a deceptive association

Temporal arteritis is an immunological disorder mostly affecting the elderly population. This frequently occurs in association with other rheumatological diseases of the elderly. The symptoms of Temporal arteritis overlap with other symptoms of commonly occurring diseases in that population. Focal pachymeningitis in association with temporal arteritis is a rare finding and a literature review revealed less than ten cases of similar associations being published. In such instances, this finding can be mistaken for aseptic meningitis and treated erroneously. We present our case, discuss the management and summarize a review of literature about focal pachymeningitis along with temporal arteritis which was managed successfully with steroids and Toclizumab.

Anterior Temporal Approach and Clipping of a High-Riding Basilar Tip Aneurysm: Case Report and Review of the Surgical Technique

Basilar apex aneurysms constitute 5%–8% of all intracranial aneurysms. Microsurgical clipping of basilar tip aneurysms is still advocated for as it is safe, especially for unruptured basilar tip aneurysms which have a low risk of postoperative mortality or morbidity. Careful patient preparation is needed preoperatively because the risk of intraoperative rupture is significant. Good surgical techniques should be applied. The skill will need to be preserved as endovascular surgery becomes more popular. This is a case of basilar tip aneurysm managed by clipping through the anterior temporal approach, followed by a review of the literature.

Management of Recurrent Aneurysms after Endovascular Coiling: A Fujita Experience

Introduction:

Microsurgical clipping and Endovascular coiling (EC) are both effective alternatives in the management of intracranial aneurysms. EC has been shown to be associated with the risk of recurrent aneurysm (RA) growth. Considering the minimally invasive nature of this procedure, the management of intracranial aneurysms has been skewed toward EC, especially in the developed world. In this scenario, there has been an upsurge of RAs after EC. Since the optimal management of these RAs has not been defined, they pose a unique challenge to the treating surgeons.

Aims and Objectives:

The aim of this study is to elucidate the optimal management of RAs after EC.

Materials and Methods:

Medical records of all patients who underwent surgery for RAs were reviewed from the period January 2014 to March 2019. The demographic and angiographic patterns of the patients and operative techniques and complications were studied. The outcome was dichotomized into good and bad depending on the Glasgow outcome scale (GOS).

Results:

There were four cases of RAs operated in our institution between the above-mentioned period. There were varied differences between the initial coiling and time to recurrences. All four patients were operated under neuromonitoring. Three underwent clipping and one patient underwent clipping with bypass. All four patients had good outcome with a GOS of 5/5.

Conclusion:

Operations for RAs constitute many technical challenges and require a lot of expertise. Such surgeries are recommended in high-volume centers, with sufficient experience in both clipping and cerebral bypass.

Atypical Symptomatic Bilateral Spontaneous Cavernous Carotid Aneurysm with Systemic Vessel Wall Pathology in Young Female: A Rare Case Report

Bilateral cavernous carotid aneurysm (CCA) is a rare entity. Its association with connective tissue disorder makes the diagnosis and treatment of symptomatic patient an enigma. We present a case report of a 25-year-old female medical student presented to us with bilateral spontaneous atypically symptomatic CCA with incidentally diagnosed case of Ehlers–Danlos syndrome. Both surgical and endovascular options of treatment were weighed and were ultimately treated satisfactorily by high-flow bypass with carotid artery ligation with an insurance bypass.

P4760New minimally invasive and tailor-made strategy for cryoballoon ablation in patients with paroxysmal atrial fibrillation

Background

Currently, cryoballoon ablation (CBA) has proven to be highly effective in achieving free from atrial fibrillation (AF), especially paroxysmal AF. However, the optimal freezing protocol for each patient to achieve successful pulmonary vein isolation by only CBA is still uncertain. The aim of this study was to evaluate the clinical implications of a reduction in the freezing duration (<180s) during CBA guided by the time to target temperature.

Methods

From November 2015 to August 2018, 286 consecutive paroxysmal AF patients undergoing CBA were enrolled. We compared 107 patients undergoing a tailor-made CBA procedure (Group A; August 2017-August 2018) to 179 patients with a standard CBA procedure (Group B; November 2015–July 2017). In Group A, the freezing duration was reduced to 150s when the temperature reached ≤−40°C within 40s. Furthermore, we reduced it to 120s when it reached ≤−50°C within 60s. In the other patients, the freezing time was 180s except for excessive freezing over −60°C and/or emergent situations while monitoring the esophageal temperature and for phrenic nerve injury as in Group B.

Results

The baseline clinical characteristics were similar between two groups. In Group A, 89 patients (83%) underwent CBA with a reduction in the freezing time. The rate of having reduction time in left inferior PV (LIPV) and right inferior PV (RIPV) was lower compared with left superior PV (LSPV) and right superior PV (RSPV) (respectively 17%, 29%, 56%, and 63.5%). However, for right inferior PV, in 31 patients having the reduced freezing time, none of them required touch-up ablation. Although the procedure time and frequency of touch-up ablation did not differ between the 2 groups, total freezing time for each PV was significantly shorter in Group A than Group B as shown in figure (LSPV: 164±28s vs. 216±67s; p<0.001, LIPV: 187±44s vs. 218±69s; p<0.001, RSPV: 147±31s vs. 192±51s; p<0.001, RIPV: 180±50 vs. 218±73s; p<0.001). The AF free survival rate during the follow-up period (356±167 days) was similar between the 2 groups (log-rank test, p=0.38). Furthermore, the complication rate was similar 2 groups.

The freezing time for each PV

Conclusion

The safety and efficacy of the new tailor-made CBA strategy were non-inferior to the standard procedure. This study showed that the unnecessary freezing time could be reduced in most of paroxysmal AF patients.

A 5-Year Follow-up of Intracranial Arterial Dolichoectasia: A Case Report and Review of Literature

A patient with multiple dolichoectasia of the intracranial cerebral artery was followed sequentially with clinical and radiological progression of disease in the past 5 years. The patient was treated in multiple stages in the past 5 years with the endovascular and microsurgical clipping method. The maximum diameter of each major intracranial artery segment was recorded and compared in the follow-up year. The progression in size of the dolichoectatic segment was observed in spite of surgical intervention. In review diagnostic criteria, etiopathogenesis and treatment options have been discussed.

P2694Early and late restenosis after excimer laser coronary angioplasty and paclitaxel-coated balloon combination therapy for drug-eluting stent restenosis

Background

Drug-eluting stent restenosis (DES-ISR) is associated with poorer outcomes than those of bare-metal stent restenosis after treatment with paclitaxel-coated balloon (PCB), and late restenosis after PCB angioplasty for DES-ISR is a residual problem. Excimer laser coronary angioplasty (ELCA) is thought to be advantageous for ISR treatment by removing neointima. However, whether the combination of ELCA and PCB angioplasty is more effective than the use of PCB only angioplasty in DES-ISR has not been studied so far.

Purpose

We evaluated the efficacy of ELCA and PCB combination therapy for DES-ISR at mid-and late-term after revascularization.

Methods

From January 2014 to March 2016, 166 DES-ISR lesions were treated with ELCA and no-ELCA prior to PCB. Two serial angiographic follow-ups were planned for the patients (at 6–12 and 18–24 months after procedure). Acute procedural and follow-up angiographic results were assessed by quantitative coronary angiography. ELCA and no-ELCA group included 74 lesions and 92 lesions, respectively.

Results

There was no significant difference between the two groups in the clinical characteristics except the prevalence of hemodialysis, the rate of first-generation DES (37.9% vs 36.8%, p=0.897), previous stent size (2.90±0.39 mm vs 2.77±0.39 mm, p=0.063), and reference vessel diameter (2.65±0.46 mm vs 2.60±0.65 mm, p=0.593). Early follow-up angiography was performed in 66 lesions (89.1%) of ELCA group, and was done in 76 lesions (82.6%) of no-ELCA group. In the ELCA group, percentage diameter stenosis (%DS) just after procedure and at 6–12 months later were significantly smaller than those of no-ELCA group. Besides, target lesion revascularization (TLR) rate at 6–12 months after procedure was tended to be lower in the ELCA group. Late follow-up angiography was performed for 93 lesions (81.6%) of the remaining 114 lesions (excluding TLR lesion), late restenosis was found 9 lesions (18.6%) in the ELCA group and 11 lesions (24.4%) in the no-ELCA group (p=0.504). Late luminal loss was similar in both groups (0.37±0.71 mm vs 0.24±0.82 mm, p=0.438), and %DS at 12–18 months after revascularization was not different between the two groups.

Changes of %DS and TLR rate

Conclusions

%DS in the ELCA group was smaller at just after procedure and the advantage was kept even after 1-year. However, late restenosis and TLR at 2-year after revascularization for DES-ISR could not be reduced by ELCA and PCB combination therapy.

Patent Persistent Fibrous Tract in a Patient with Disconnected Lumboperitoneal Shunt

Disconnection of proximal or distal catheter is seen more frequently in the complication of the lumboperitoneal (LP) shunt. A connective tissue sheath that forms around the peritoneal catheter of silicone shunt tubing is a normal biological response to foreign material. The literature did not establish whether the disconnected LP shunt can allow passage of cerebrospinal fluid (CSF) through the disconnected portion. However, proof of the passage of CSF through these sheaths has been reported in only one published study to date. We present a case of a young patient with disconnected LP shunt who reported patent persistent fibrous tract around the tube shunt. In conclusion, asymptomatic patients with shunt disconnection should be evaluated with shuntography for patency of fibrous sheath before removal of the shunt to avoid the possible complications.

Review of Avoidance of Complications in Cerebral Aneurysm Surgery: The Fujita Experience

Avoidance of complications during cerebral aneurysm surgery marks the future outcome in the patient. Various modalities such as adequate opening of the Sylvian fissure, motor-evoked potential, endoscope-assisted microsurgery, indocyanine green dye, and dual image video angiography are available to reduce these complications during surgery, either by prevention of injury to the small perforators or the parent artery. We present our experience at the Fujita Health University Banbuntane Hospital, Japan, of the cerebral aneurysm surgery along with the use of these modalities in our patients from September 2014 to December 2016 along with a brief review of the various techniques for avoidance of complications.

Microsurgical Treatment of Paraclinoid Aneurysms by Extradural Anterior Clinoidectomy: The Fujita Experience

Introduction:

Paraclinoid aneurysms pose technical difficulty in their approach, mainly because of their close proximity to neurovascular structures, deeper location, and a smaller corridor. Extradural anterior clinoidectomy is a highly beneficial technique in such cases, making more space to deal with these aneurysms. We describe our method of performing extradural anterior clinoidectomy in such patients.

Materials and Methods:

A total of 33 cases of paraclinoid internal carotid artery aneurysms presenting to Fujita Health University Banbuntane Hospital, Japan, were included. Females comprised the majority with 32 cases; the mean age was 54.8 years (range: 35–74 years). The mean size of the paraclinoid aneurysm was 5.3 mm (range: 3–12 mm).

Results:

Nine paraclinoid aneurysms were found projecting dorsally, 7 laterally, and 17 medially (Kazuhiko Kyoshim et al's. classification). An immediate complete occlusion rate of 100% was present. Visual disturbance was found in 6.2% of our patients. One of our patients developed permanent loss of vision.

Conclusion:

Extradural anterior clinoidectomy enables a better exposure to paraclinoid aneurysms. Precise anatomical knowledge along with microsurgical tactics is required to prevent and manage potential complications to achieve good outcomes.

Use of our protocol of multimodality tools to aid in the safe microsurgical clipping of unruptured anterior circulation aneurysms

Objectives:

The aim of this study is to analyze the effectiveness of our protocol of the use of multimodality tools, namely indocyanine green-dual image video angiography, neuroendoscope, neuromonitoring with motor-evoked potential, micro-Doppler in the microsurgical clipping of unruptured anterior circulation aneurysms, operated at our institute from January 2016 to December 2018.

Materials and Methods:

We performed a retrospective analysis of all cases of unruptured anterior circulation aneurysms, operated at Fujita Health University Banbuntane-Hotokukai Hospital, Japan, from January 2016 to December 2018. We assessed outcome at immediate postoperative, at discharge, and at 3 months follow-up by defining permanent morbidity as drop in Modified Rankin Scale (MRS) by 1 at 3 months follow-up and transient morbidity as temporary deficit that improved at discharge or follow-up. Postoperative events, namely seizures, infection that did not affect/change. Preoperative MRS and discharge timing were excluded. We concluded poor outcome as MRS ≥3 and good outcome as MRS < 3 (0–2). All patients had a minimum of 3 months follow-up before outcome conclusion.

Results:

In 2016, a total of 98 cases were operated with no mortality or permanent morbidity (i.e., change in preoperative MRS), only transient morbidity was seen in (two cases) 2.04%. In 2017, a total of 119 cases were operated with no mortality or morbidity. In 2018, a total of 130 cases were operated with no mortality or permanent morbidity, only transient morbidity 0.7%. Summarizing from January 2016 to December 2018, a total of 347 cases of anterior circulation aneurysms were operated. Mostly, in the female sex (73.3%), the most common was middle cerebral artery aneurysm (39.1%). The mean size was 5.3 mm with no mortality or permanent morbidity with only transient morbidity in 0.9%. No poor outcome (MRS ≥3) was seen in our series.

Conclusion:

In our center for most unruptured anterior circulation aneurysms, microsurgical clipping is the treatment of choice. We believe our protocol of the intra-operative usage of multimodality tools have aided in the safe microsurgical clipping and have consistently resulted in good operative outcomes. Hence, we recommend and continue to use our Fujita-Bantane Protocol in all cases of micro-surgical clipping of aneurysms to consistently achieve good operative outcomes.

Staged deep brain stimulation of ventral intermediate nucleus of the thalamus for suppression of essential tremors

Deep brain stimulation (DBS) of the ventral intermediate nucleus (VIM) of the thalamus is a powerful surgical option in the treatment of essential tremors (ETs). However, its therapeutic efficacy depends on the tremor distribution. DBS is highly efficient in the relief of distal appendicular tremor but not other types of tremor. We report a case of staged DBS of ventral intermediate nucleus (VIM) of thalamus for the suppression of ETs.

Multiples of multiple: Case series of mirror aneurysms and review of literature

•

Incidentally detected unruptured mirror intracranial aneurysms are on the rise due to advanced imaging modalities.

•

Further studies are required to elucidate theories of development, inheritance pattern and the need for screening of 1st-degree relatives with twin aneurysms.

•

Treatment strategy for mirror aneurysms should be customised based on the location, size, morphology and clinical manifestations of each patient.

•

Randomised control trials that compare [single/multistage] clipping and coiling of mirror aneurysms are necessary to decide the best intervention strategy.

Introduction

Mirror aneurysms are a rare subtype of multiple aneurysms, located in identical or adjacent arterial segment bilaterally. We report a case series of 3 such patients amongst whom one of them had 3 sets of mirror aneurysms and the other patient had 2 sets of mirror aneurysm on the same arterial segment which has not been reported till date.

Methods

A retrospective analysis of 3 patients with incidentally detected multiple mirror aneurysms, who were treated with microsurgical clipping and coiling, was conducted. A systematic search was performed using the PUBMED database and relevant articles were reviewed with particular attention to incidence, associated conditions, risk factors and management strategies. Written informed consent was obtained from all of the patients for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request. This research work has been reported in line with the PROCESS criteria (Agha et al., 2018).

Results

All the 3 patients were females with incidentally detected multiple mirror aneurysms. All the 3 patients were known Hypertensives. All the aneurysms were successfully clipped by a multistage, bilateral craniotomy except the one in the cavernous ICA, for which an endovascular procedure is planned. All of them had an uneventful postoperative course with the CT angiogram showing obliteration of all the clipped aneurysms except the one in the cavernous ICA.

Conclusions

Multiple mirror aneurysms represent a rare occurrence of a diverse pathology. Both these described types of cases have not been reported so far in the literature. The treatment strategy for mirror aneurysms should be determined individually based on the location, size, and morphology of the aneurysms, as well as, on the clinical manifestations of each patient.

Extracranial Internal Carotid Artery Aneurysm - Challenges in the Management: A Case Report and Review Literature

Extracranial internal carotid artery aneurysms (EICA) are rare. Incidence is <1% of all an arterial aneurysm. This aneurysm being rare but is important because it is associated with a high risk of neurological thromboembolic events, cranial nerve compression, and rupture. The causes of the EICA are congenital, trauma leading to the pseudoaneurysm, atherosclerosis, infections, and fibromuscular dysplasia. Here, we describe a case report of a 69-year-old female with progressive enlargement of the right neck mass accompanied by dyspnea on exertion. The patient had been diagnosed as right EICA and underwent the endovascular procedure as parent vessel occlusion 4 years ago. There was still enlargement of the size of the right neck mass and was causing troublesome to the patient. We performed selective embolization of the various feeders to the mass, but after this also, it was still enlarging. Three-dimensional reconstruction of the computed tomography scan showed fusiform dilatation of the right proximal EICA. We made the diagnosis of the thrombosed EICA and hence we planned to undergo surgical management. We performed removal of the intraluminal thrombus and ligation of the EICA. The size of the swelling decreased significantly.

Combined Endovascular and Microsurgical Hybrid Management of Cerebral Aneurysms: The Preliminary Fujita Experience

Introduction:

A subgroup of complex aneurysms demands multimodal treatment by microscopic and endovascular means. Partial obliteration or remnant postprocedure demands to go further to the other modality.

Materials and Methods:

All patients between July 2016 and January 2017 who had to undergo multimodality measures for complete obliteration of the aneurysms were included in the study. The patients who had either undergone clipping or coiling for their aneurysms, but with incomplete obliteration of the aneurysm, were also included in the study.

Results:

Between July 2016 and January 2017, a total of three patients had to undergo coiling after clipping of the aneurysm for complete obliteration. Two patients had to go for clipping following coiling. All five patients had complete obliteration of the aneurysm sac.

Conclusion:

Both microscopic and endovascular means are complementary measures instead of competing procedures. It is important to realize the technical difficulties when surgical therapy follows initial endovascular treatment. Similarly, coiling a previously clipped aneurysm can be difficult, if the clip obscures normal working projections.

Superficial Temporal Artery: Middle Cerebral Artery Bypass, Our Series of 20 Cases, Surgical Technique and Indications with Illustrative Cases

The first extracranial-intracranial (EC-IC) bypass surgery was performed by professor Yasargil in 1967 since then this procedure has been widely used in vascular neurosurgery and sometimes, in tumors excision when a vascular sacrifice is necessary. In this article, we will illustrate the surgical technique of the superficial temporal artery-middle cerebral artery (STA-MCA) bypass with two cases; a 59-year-old male and 64-year-old female who presented with an occlusion of the MCA. The male presented also with a posterior communicating artery-IC aneurysm which was clipped in the same sitting. We also studied in this paper a series of 20 patients operated in Banbuntane Hotokukai Hospital, Fujita Health University, for which a low-flow STA-MCA anastomosis was done for steno-occlusive disease or moyamoya disease. In Banbuntane Hotokukai Hospital, Fujita Health University, 20 patients were operated since 2015, 12 patients were male. Five patients presented with moyamoya disease, while 15 patients presented with vascular steno-occlusive disease. The steno-occlusion was found in internal carotid artery in nine patients. The patients were divided into two categories (steno-occlusive disease and moyamoya). STA-MCA bypass is now one of the basic techniques to master in vascular neurosurgery. It requires to perform the anastomosis correctly within the permissible time. The goal is to have a long-term patency for the anastomosed vessel.

Endoscopic Approach to Subcortical (Lobar) Hemorrhage

Objective

To highlight the basic points of brain endoscopic procedure for Subcortical (Lobar) Hemorrhage to achieve repeatability and reproducibility in the results among the new brain endoscopic surgeons.

Method

Sharing the experience of 10 years as an endoscopic surgeon to bring out the basic insight into the method, challenges, points which need special attention during the surgery and discussion of recent advancements in the endoscopic equipment for safe surgery.

Conclusion

Procedure of endoscopic evacuation of brain hematoma is simple with learning curve. In the beginning new endoscopic surgeons should operate in the presence of experience surgeon. They should follow standard technique to achieve the good surgical outcome and uniformity in the result every time they perform the surgery.

Endoscopic Approach to Putaminal Bleed

Objective:

To highlight the basic points of brain endoscopic procedure for Putaminal Bleed to achieve repeatability and reproducibility in the results among the new brain endoscopic surgeons.

Method:

Sharing the experience of 10 years as an endoscopic surgeon to bring out the basic insight into the method, challenges, points which need special attention during the surgery and discussion of recent advancements in the endoscopic equipment for safe surgery.

Conclusion:

Procedure of endoscopic evacuation of brain hematoma is simple with learning curve. In the beginning new endoscopic surgeons should operate in the presence of experience surgeon. They should follow standard technique to achieve the good surgical outcome and uniformity in the result every time they perform the surgery.

Endoscopic Approach to Cerebellar and Large Putaminal Bleed

Objective:

To highlight the basic points of brain endoscopic procedure for Cerebellar and Large Putaminal Hemorrhage to achieve repeatability and reproducibility in the results among the new brain endoscopic surgeons.

Method:

Sharing the experience of 10 years as an endoscopic surgeon to bring out the basic insight into the method, challenges, points which need special attention during the surgery and discussion of recent advancements in the endoscopic equipment for safe surgery.

Conclusion:

Procedure of endoscopic evacuation of brain hematoma is simple with learning curve. In the beginning new endoscopic surgeons should operate in the presence of experience surgeon. They should follow standard technique to achieve the good surgical outcome and uniformity in the result every time they perform the surgery.

Endoscopic Approach to Thalamic and Intraventricular Hemorrhage

Objective

To highlight the basic points of brain endoscopic procedure for Thalamic and Intraventricular Hemorrhage to achieve repeatability and reproducibility in the results among the new brain endoscopic surgeons.

Method

Sharing the experience of 10 years as an endoscopic surgeon to bring out the basic insight into the method, challenges, points which need special attention during the surgery and discussion of recent advancements in the endoscopic equipment for safe surgery.

Conclusion

Procedure of endoscopic evacuation of brain hematoma is simple with learning curve. In the beginning new endoscopic surgeons should operate in the presence of experience surgeon. They should follow standard technique to achieve the good surgical outcome and uniformity in the result every time they perform the surgery.

A Retrospective Study in Microsurgical Procedures of Large and Giant Intracranial Aneurysms: An Outcome Analysis

OBJECTIVE

Intracranial aneurysms are considered large if >10 mm and giant if >25 mm. The risk of aneurysmal rupture compounds with increase in size of the aneurysm, thus, warranting appropriate intervention. In this study, we have analyzed the outcome and effectiveness of microsurgical procedures in large and giant aneurysms.

METHODS

A retrospective analysis of all the patients who underwent microsurgical procedures for large and giant cerebral aneurysms from 2014-2018 in our institute was conducted. There were a total of 52 patients, in which direct clipping was performed in 42 (80.7%) patients, proximal trapping in 3 (5.7%) patients, trapping with bypass in 3 (5.7%) patients, suction decompression in 3 (5.7%) patients, and 1 (1.9%) patient underwent surgical reconstruction.

RESULTS

Among the 52 patients, in the postoperative period, 1 (1.9%) patient became comatose, 1 (1.9%) patient developed hemiplegia, 1 (1.9%) patient had a transient hemiparesis, and 1 (1.9%) patient had transient lower cranial nerve palsy. Two (3.8%) patients had chronic subdural hematoma during the 3-month follow-up. There was no mortality in our series.

CONCLUSIONS

There are several treatment strategies available to manage large and giant cerebral aneurysms. In this study, we had minimal morbidity (3.8%), favorable outcome (96.1%), and no mortality. Therefore, we would like to conclude that appropriate microsurgical procedures, in experienced hands, can be considered as first line in the management for large and giant intracranial aneurysms, especially those with complex anatomy, wide neck, mass effect, partial thrombosis, and the presence of critical perforating vessels from the aneurysm wall.

Microvascular Revascularization for Recurrent A1 Anterior Cerebral Artery Aneurysm Postendovascular Treatment: A Case Report and Review of the Literature

The recurrence of aneurysms postcoil embolization is a common occurrence. Endovascular coiling has been noted to be more effective for small lesions rather than the giant aneurysms. A postembolization recurrent aneurysm is a difficult condition to manage. We present a case of a recurrent giant aneurysm of the anterior cerebral arteries (ACAs) first segment (A1). It was managed by superficial temporal artery to A3 segment of anterior cerebral artery bypass anastomotic revascularization plus distal A1- segment clipping. A literature review is presented for the management of giant A1 artery aneurysms.

Tumors of the Orbit: Case Report and Review of Surgical Corridors and Current Options

Tumors that involve the orbit can be classified into two major groups: primary tumors of the orbit and tumors that extend into the orbit from other sites. The most frequent primary orbital lesions in adults include cavernous hemangiomas, lymphoid tumors, and meningiomas. The most common tumors that extend into the orbit are meningiomas, followed by sinonasal carcinomas. In this article, we report a case of intraconal orbital lesion operated at our center and a review of the surgical approaches to the orbit.

Prognostic Factors Influencing Outcome in Unruptured Anterior Communicating Artery Aneurysm after Microsurgical Clipping

Anterior communicating artery (A.com. A) aneurysm projection is an important factor in determining the outcome of aneurysm clipping. The objective of this study was to analyze the outcome of A.com.A aneurysm projection and prognostic factors influencing it and comparing them with Glasgow outcome scale. A retrospective analysis of 47 patients from hospital records who have got admitted in the Banbuntanke Hotokokai Hospital, Nagoya, Japan, from 2014 to 2017, with unruptured A.com.A aneurysm and subsequently operated in the hospital. Demographic factors such as age, sex, and associated with other aneurysms and the morphological characteristics such as aneurysm size, projection, and height were analyzed with postoperative complications and Glasgow outcome scale. Totally 47 cases have been operated in which 26 (55.3%) are female and 21 (44.6%) are male, and the median age is 68 years, 7 (14.89%) patients had middle cerebral artery aneurysm along with A.com.A aneurysm and 1 had internal carotid artery-posterior communicating artery junction aneurysm. Four (8.5%) had chronic subdural hematoma and 1 (2.12%) had epilepsy, 1 (2.12%) case got reoperated, and 1 (2.12%) had hydrocephalus. Moreover, the overall complication rate is 14.89%. For six patients, motor-evoked potential monitoring was used. Forty-six patients had Glasgow outcome scale of 5 and 1 patient had Glasgow outcome scale of 4. There was no mortality in this study. Mean size of the aneurysm was 6.68 mm and the range was 2–25 mm. Mean height was 4.14 mm, 26 (56.52%) A.com.A aneurysm were anteriorly projecting, 9 (19.56%) were superiorly projecting, 8 (17.32%) were inferiorly projecting, and 3 (6.38%) were posteriorly projecting. Morphological parameters such as size, height, and projection were not only highly associated with A.com.A aneurysm rupture and also complications due to clipping of aneurysm.

Unilateral Fenestrated A1 Segment of Anterior Cerebral Artery Multiple Aneurysms: Case Reports and Literature Review

The fenestration of the cerebral arteries is infrequent anomaly mostly occurring in the posterior communicating artery, the vertebral artery, the basilar artery, and the middle cerebral artery.^[1] We report a case of unilateral A1 fenestration associated saccular aneurysm, focusing on its features of surgical treatment.

Surgical Management of Unruptured Cerebral Aneurysms in the Elderly: An Institution Experience

Background and Purpose:

The elderly population is increasing in the world, especially in developed countries. The gain in life expectancy is remarkable in Japan, consequently incidence of aneurysms increases in this population. The purpose of this study is to evaluate the surgical treatment and outcome of patients aged more than 75 years treated for unruptured intracranial aneurysms.

Patients and Methods:

We conducted a retrospective study for unruptured cerebral aneurysms operated between September 2014 and August 31, 2018, in Fujita Health University, Banbuntane Hotokukai Hospital, for people aged more than 75 years. A demographic study was done. We also studied aneurysm location, aneurysm size, outcome, duration of stay, and complications.

Results:

About 61 patients aged more than 75 years were operated in 4 years, comprising 12 males and 45 females. The mean age was 79.32 ± 3.29 years. Mean size of the aneurysm was 6.22 ± 3.28. Aneurysm location (P = 0.0037), associated risk factors (P = 0.006), and association of hypertension and diabetes (P = 0.0362) influence outcome. Length of stay is directly correlated with outcome (P = 0.009).

Conclusions:

Elder patients with hypertension and diabetes or associated risk factors having a posterior circulation aneurysm have a poor diagnosis.

Timing of Surgery and Surgical Strategies in Symptomatic Brainstem Cavernomas: Review of the Literature

Brainstem cavernomas (BSCs) are angiographically occult, benign low flow vascular malformations that pose a significant surgical challenge due to their eloquent location. The present study includes an extensive review of the literature and three illustrative cases of BSC with emphasis on the timing of surgery: surgical approaches, usage of intraoperative monitoring, and complication avoidance. A systematic search was performed using the PubMed database was from January 1, 1999, to June 2018. The relevant articles were reviewed with particular attention to hemorrhage rates, timing of surgery, indications for surgery, surgical approaches, and outcome. Along with this, a retrospective analysis of three cases of symptomatic BSC, who were operated for the same, during the year 2018 in our institute was conducted. All the three patients presented with at least 1 episode of hemorrhage before surgery. Of these, one patient was operated immediately due to altered sensorium whereas the other two were operated after at least 4 weeks of the hemorrhagic episode. The patients who were operated in the subacute phase of bleed were seen to have liquefaction of hematoma, thus providing a good surgical demarcation and thereby reduced surgery-related trauma to the surrounding eloquent structures. Two patients improved neurologically during the immediate postoperative period, whereas one had transient worsening of neurological deficits during the immediate postoperative period in the form of additional cranial nerve palsies which completely improved on follow-up after 2 months. Radical resection is recommended in all patients with symptomatic BSCs. Surgery should be considered after the first or the second episode of hemorrhage as multiple rebleeds can cause exacerbation of deficits and sometimes mortality as well. Considering surgical timing, anywhere between 4 and 6 weeks or the subacute phase of the hemorrhage is considered appropriate. The aims of surgical intervention must be to improve preoperative function, minimize surgical morbidity and to reduce hemorrhagic rates. In spite of the significant surgical morbidity associated with BSCs, appropriate patient selection, meticulous surgical planning with adjuncts such as intraoperative monitoring and neuronavigation will go a long way in avoidance of major postoperative complications.

Carotid Endarterectomy: The Need for In vivo Optical Spectroscopy in the Decision-Making on Intraoperative Shunt Usage - A Technical Note

Background:

Carotid endarterectomy (CEA) is the surgical excision of the atherosclerotic plaque in patients with severe carotid artery stenosis. It is a common surgical technique required by neurosurgeons that should be mastered. In this article, we provide an outline of the technique and multimodality adjuncts involved in performing an effective CEA with a better surgical outcome.

Materials and Methods:

We have operated a total of 14 patients in our institute from 2015 to 2018. The male to female ratio is 13:1. Four (28.5%) patients were symptomatic and 10 (71.5%) were asymptomatic; with an average percentage of carotid stenosis being 81.2% in symptomatic and 76.6% in asymptomatic patients. Two patients have undergone bilateral CEA. Intraoperative monitoring was done with continuous in vivo optical spectroscopy (INVOS). Furui's double balloon shunt system was used to maintain blood flow from common carotid artery to the internal carotid artery, thus preventing cerebral ischemia in selected cases with significantly lateralized cerebral oximetry (CO) recordings.

Results:

Of the 14 patients with 16 CEA procedures, continuous INVOS monitoring was used in 12 CEA procedures. Of the 12 cases, only 5 (41.6%) needed a shunt. Furui's shunt was not used in 7 (58.3%) CEA procedures, where there were no changes in the intraoperative CO and these patients had an uneventful postoperative period. INVOS monitoring not only reduced the use of routine intraoperative shunt but also reduced the total surgical time and thus aided in preventing neurological complications.

Conclusion:

CEA should be strongly considered for symptomatic patients with >70% of carotid stenosis and in patients with 50%–69% stenosis if no other etiological basis for the ischemic symptoms can be identified. Continuous INVOS monitoring is mandatory for the decision of the use of intraoperative shunt, which reduces the perioperative morbidity and mortality significantly.