Treatment of non-saccular vertebrobasilar aneurysms remains highly challenging despite significant recent advances in endovascular techniques. Establishing the natural history of this heterogeneous ...disease, as best as currently available data allows, is crucial to help guide counseling and management.
A review of the literature was conducted to identify publications describing the presentation and natural history of vertebrobasilar dolichoectasia and non-saccular aneurysms.
Nine studies of 440 patients met the analysis inclusion criteria. The majority of patients presented with ischemia, mass effect, or incidentally; hemorrhage was uncommon and overlapped with the population of vertebrobasilar dissection. Overall mortality was ~40% after 7 years of follow-up, with 43% of these deaths resulting from non-neurologic causes. Neurologic course was dominated by ischemic stroke rather than hemorrhage. Mass effect prognosis was especially poor, with 40% mortality after ~4 years. Incidentally discovered lesions which remain morphologically stable have a favorable long term course.
Initial clinical presentation is a strong predictor of subsequent disease course. Although overall prognosis is poor, nearly half of all deaths resulted from non-neurologic causes, underscoring the importance of comprehensive medical management. Aneurysms characterized by expansion, established mass effect, or hemorrhage have a poor natural history, and may be considered for invasive treatment, which is increasingly endovascular in nature. Lesions presenting with ischemia or incidentally are likely best addressed with aggressive neurologic and overall medical management.
Neurovascular training models include animal models, synthetics, or computer simulation. In vivo models are expensive and require significant resources. Synthetic/computer models do not reflect ...the elasticity of fresh vessels. We describe an endovascular and microsurgical training model using a chicken thigh/leg.
A total of 20 chicken thigh/leg models were obtained. Angiography was used to understand the anatomy. Proximal cannulation with a 5-French catheter was achieved and connected to a hemostatic valve with a pump to simulate pulsatile flow. Aneurysms were created at the thigh-leg junction. For clipping training, 3 types of aneurysms were created to reproduce anatomy seen in middle cerebral, anterior communicating, and posterior communicating aneurysms.
The average cost per specimen was $1.70 ± $0.30. The diameter of the proximal femoral artery was 2.4 mm ± 0.2 mm. The length from the proximal femoral artery to the aneurysm was 9.5 cm ± 0.7 cm. Distal catheterization was successful in all cases (n = 6). Successful deployment of coils and a stent was achieved under fluoroscopic guidance. Gross oversizing of coils and other mistakes led to aneurysm rupture. Each examiner performed an exploration of the pulsatile aneurysm, application and reapplication of a variety of clips, and then the final inspection of branching vessels to confirm patency.
The chicken thigh/leg model provides training opportunities in microsurgical suturing, endovascular techniques for aneurysm obliteration, and microsurgical reconstruction of aneurysms. It combines affordability, time efficiency, and reproducibility. Further studies measuring improvement in technical aneurysm management and comparison with other training models are warranted.
Abstract
BACKGROUND
The supraorbital craniotomy (SOC) is classically performed through a skin incision in the patient's eyebrow. A variant with a skin incision in the patient's eyelid has become ...increasingly popular in recent years.
OBJECTIVE
To compare the transpalpebral and the transciliary variants of the SOC with regard to their potential role in aneurysm surgery.
METHODS
We carried out cadaveric dissections and virtual craniotomies on computerized tomography datasets. The skin incision, the craniotomy location and size, the working angles, and the achievable exposure of neurovascular structures were assessed and compared for both variants of the SOC.
RESULTS
The skin incision measured 4 cm for the transpalpebral and 3 cm for the transciliary variant. The skin could be retracted 1.5 cm upward from the lower edge of the orbital rim with the transpalpebral and 2.5 cm upward with the transciliary variant. The craniotomy size was 2.5 × 1.5 cm for both variants, given that the transpalpebral variant included an orbital osteotomy. The bony opening in the transpalpebral variant was 1 cm more caudal; this restricted the craniocaudal working angles and, thereby, limited the achievable exposure of neurovascular structures in the paraclinoid area and along the sphenoid ridge.
CONCLUSION
If the orbital rim and the anterior aspect of the orbital roof are removed, then the transpalpebral variant of the SOC enables a bony opening that is just as large as that of the transciliary variant. Nonetheless, the more caudal location of the bony opening alters the available working angles and may impede exposure of key structures during aneurysm surgery.
Abstract
BACKGROUND:
The International Study of Intracranial Aneurysms found that for patients with no previous history of subarachnoid hemorrhage, small (< 7 mm) anterior circulation and posterior ...circulation aneurysms had a 0% and 2.5% risk of subarachnoid hemorrhage over 5 years, respectively.
OBJECTIVE:
To determine whether cerebral aneurysms shrink with rupture.
METHODS:
The clinical databases of 7 sites were screened for patients with imaging of cerebral aneurysms before and after rupture. Inclusion criteria included documented subarachnoid hemorrhage by imaging or lumbar puncture and intracranial imaging before and after cerebral aneurysm rupture. The patients were evaluated for aneurysm maximal height, maximal width, neck diameter, and other measurement parameters. Only a change of ≥ 2 mm was considered a true change.
RESULTS:
Data on 13 patients who met inclusion criteria were collected. The median age was 60, and 11 of the 13 patients (84.6%) were female. Only 5 patients had posterior circulation aneurysms. None of the aneurysms had a significant decrease in size. One aneurysm decreased by 1.8 mm in maximum size after rupture (7.7%). Six aneurysms had an increase in maximum size of at least 2 mm after rupture (46.2%) with a mean increase of 3.5 mm (± 0.5 mm).
CONCLUSION:
Unruptured aneurysms do not shrink when they rupture. The large percentage of ruptured small aneurysms in previous studies were likely small before they ruptured.
The Publisher regrets that this article is an accidental duplication of an article that has already been published, DOI of original article: http://dx.doi.org/10.1016/j.wneu.2014.08.046 . The ...duplicate article has therefore been withdrawn. The full Elsevier Policy on Article Withdrawal can be found at http://www.elsevier.com/locate/withdrawalpolicy.
Abstract
Sidewall aneurysm treatment often requires complex management strategies. These can include advanced clipping techniques or stent-assisted coiling techniques. Endovascular coiling alone has ...been associated with high recurrence rates and is often not feasible.1-4 Flow-diversion embolization has recently become a standard of care for many aneurysms, demonstrating high occlusion rates.4,5 However, the third generation of coil-assist stents can be delivered with 0.0165” microcatheters, being an ideal adjunct to manage this group of aneurysms in more distal locations.
In this video, a 16-yr-old teenager with Parry-Romberg syndrome and congenital adrenal hyperplasia had an incidental finding of a 6.5-mm sidewall aneurysm arising off the angular branch of the left middle cerebral artery, found during the work-up of complex partial seizures. The patient consented to the procedure. Due to his young age and aneurysm size, a decision was made to treat the aneurysm through an endovascular approach. Under general anesthesia, a transfemoral approach was carried out using a 6-French short sheath. A 6-French guiding catheter was left in the distal cervical left internal carotid artery; a 0.0165” microcatheter was used to first deploy a 3.0 × 15 mm Neuroform Atlas stent, completely covering the length of the aneurysm. Then, the stent was traversed with the microcatheter to coil the aneurysm. Follow-up cerebral angiogram confirmed complete occlusion of the aneurysm.
Cerebral aneurysms in the pediatric population are rare and optimal treatment strategies are not as well characterized as in adults. The Pipeline embolization device (PED) is an endoluminal flow ...diverter that is commonly used to treat aneurysms in adults, but experience with this device in children is limited. The authors sought to further characterize PED use and outcomes in this specific population by performing both a systematic review of patient-level data from studies reporting the use of the PED to treat pediatric aneurysms and a retrospective review of their experience.
A systematic review of the PubMed, Embase, and Scopus databases was performed to identify studies reporting the use of the PED in pediatric patients (age ≤ 18 years). Disaggregated data regarding demographics, aneurysm characteristics, treatment, and outcomes were collected. Retrospective data from the authors' two institutions were also included.
Thirty studies comprising patient-level data on 43 pediatric patients with 47 aneurysms were identified. An additional 9 patients with 9 aneurysms were included from the authors' institutions for a total of 52 patients with 56 aneurysms. The mean patient age was 11.1 years. Presentations included aneurysm rupture (17.3%) and symptomatic mass effect (23.1%). Aneurysms were located in the anterior circulation in 55.4% of cases, and 73.2% were described as nonsaccular. Imaging follow-up was available for 89.3% with a mean follow-up of 13.3 months. Aneurysm occlusion was reported in 75%, with 1 case each (1.8%) demonstrating significant in-stent stenosis and parent vessel occlusion. Clinical follow-up was reported in 90.4% with a mean follow-up of 14.7 months. Good functional outcomes (modified Rankin Scale score of 0-1 or Glasgow Outcome Scale score of 5) were reported in 65.4% of the total population. Two major complications were reported, including 1 death.
Despite substantial differences in aneurysm location and type between published pediatric and adult patient populations treated with the PED, the use of the PED in the pediatric population appears to be safe. While the short-term effectiveness is also similar to that of adults, additional studies are needed to further characterize the long-term outcomes and better define the use of this device in pediatric patients.
Background
By 2030, nonacute subdural hematomas (NASHs) will likely be the most common cranial neurosurgery pathology. Treatment with surgical evacuation may be necessary, but the recurrence rate ...after surgery is as high as 30%. Minimally invasive middle meningeal artery embolization (MMAE) during the perioperative period has been posited as an adjunctive treatment to decrease the potential for recurrence after surgical evacuation. We evaluated the safety and efficacy of concurrent MMAE in a multi-institutional cohort.
Methods
Data from 145 patients (median age 73 years) with NASH who underwent surgical evacuation and MMAE in the perioperative period were retrospectively collected from 15 institutions. The primary outcome was the rate of recurrence requiring repeat surgical intervention. We collected clinical, treatment, and radiographic data at initial presentation, after evacuation, and at 90-day follow-up. Outcomes data were also collected.
Results
Preoperatively, the median hematoma width was 18 mm, and subdural membranes were present on imaging in 87.3% of patients. At 90-day follow-up, median NASH width was 6 mm, and 51.4% of patients had at least a 50% decrease of NASH size on imaging. Eight percent of treated NASHs had recurrence that required additional surgical intervention. Of patients with a modified Rankin Scale score at last follow-up, 87.2% had the same or improved mRS score. The total all-cause mortality was 6.0%.
Conclusion
This study provides evidence from a multi-institutional cohort that performing MMAE in the perioperative period as an adjunct to surgical evacuation is a safe and effective means to reduce recurrence in patients with NASHs.
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