Management of vascular malformations requires microcatheter manipulation through distal tortuous arterial feeders <1 mm in diameter to permit safe and effective embolization at the fistula or nidus ...location. The ASAHI CHIKAI 008 microguidewire (ACM) recently introduced in the United States was used to evaluate microcatheter torque, support, and safety in distal microcatheter navigation.
The use of the ACM in conjunction with flow-directed and over-the-wire microcatheters was evaluated in 25 neuroendovascular cases performed by a single operator for endovascular microcatheter embolization of intracranial vascular malformations over a 1-year period. The study evaluated angiographic evidence of distal microcatheter positioning, subsequent obliteration of the fistula at the location, and any complications.
The microguidewire was used in microcatheter embolization of 10 vein of Galen malformations, 11 brain and head and neck arteriovenous malformations, 2 spinal dural arteriovenous fistulas, and 2 cranial dural arteriovenous fistulas. Good flow-directed and over-the-wire microcatheter placement using the ACM was possible across the spectrum of cases achieving optimal catheterization and safe embolization in all. There were no microguidewire- or microcatheter-related vessel spasms, dissections, or perforations during combined or individual manipulation and no contrast or embolic extravasation on fluoroscopy or postembolization angiography.
The ACM is a safe, sturdy microguidewire that provides good torque in distal arterial anatomy, while providing microcatheter support and maintaining tip configuration on repeated use.
Objective: Indirect bypass surgeries for moyamoya disease have included modifications of procedures involving placement of the superficial temporal artery on the brain pial surface. We evaluate the ...functional and angiographic outcomes of patients treated with encephaloduroarteriomyosynangiosis (indirect) revascularization and examine the outcome in relation to demographic and radiological factors.
Materials and Methods: Patients treated surgically for moyamoya disease over a 14-year period were identified. Demographics, clinical presentation, and radiology were analyzed to assign a stage for the disease (Suzuki staging) and the extent of revascularization (Matsushima grade) at the last follow-up. A modified Rankin score was used to assess the clinical status at presentation and the functional outcome at follow-up.
Results: There were 46 patients operated on by a single surgeon over a 14-year period. A higher incidence of motor deficits, seizures, and speech deficits was seen in the pediatric population. Age, sex, preoperative Suzuki disease stage, and hemispheric involvement had no bearing on angiographic outcome at last follow-up. Three of 46 patients (6.5%) developed immediate postoperative complications. Among 43 patients on follow-up, 39 had stable disease or showed improvement in clinical symptoms with 90% event-free status at last follow-up.
Conclusions: Indirect revascularization procedures are an effective alternative to direct cerebral revascularizations in the early or advanced stages of moyamoya disease. This is effective in a predominant ischemic presentation as noted in our series.
Revascularization surgery is a safe and effective surgical treatment for symptomatic moyamoya disease (MMD) and has been shown to reduce the frequency of future ischemic events and improve quality of ...life in affected patients. The authors sought to investigate the occurrence of acute perioperative occlusion of the contralateral internal carotid artery (ICA) with contralateral stroke following revascularization surgery, a rare complication that has not been previously reported.
This study is a retrospective review of a prospective database of a single surgeon's series of revascularization operations in patients with MMD. From 1991 to 2016, 1446 bypasses were performed in 905 patients, 89.6% of which involved direct anastomosis of the superficial temporal artery (STA) to a distal branch of the middle cerebral artery (MCA). Demographic, surgical, and radiographic data were collected prospectively in all treated patients.
Symptomatic contralateral hemispheric infarcts occurred during the postoperative period in 34 cases (2.4%). Digital subtraction angiography (DSA) was performed in each of these patients. In 8 cases (0.6%), DSA during the immediate postoperative period revealed associated new occlusion of the contralateral ICA. In each of these cases, revascularization surgery involved direct anastomosis of the STA to an M4 branch of the MCA. Preoperative DSA revealed moderate (n = 1) or severe (n = 3) stenosis or occlusion (n = 4) of the ipsilateral ICA and mild (n = 2), moderate (n = 4), or severe (n = 2) stenosis of the contralateral ICA. The baseline Suzuki stage was 4 (n = 7) or 5 (n = 1). The collateral supply originated exclusively from the intracranial circulation in 4/8 patients (50%), and from both the intracranial and extracranial circulation in the remaining 50% of patients. Seven (88%) of 8 patients improved symptomatically during the acute postoperative period with induced hypertension. The modified Rankin Scale (mRS) score at discharge was worse than baseline in 7/8 patients (88%), whereas 1 patient had only minor deficits that did not affect the mRS score. At the 3-year follow-up, 3/8 patients (38%) were at their baseline mRS score or better, 1 patient had significant disability compared with preoperatively, 2 patients had died, and 1 patient was lost to follow-up. Three-year follow-up is not yet available in 1 patient.
Acute occlusion of the ICA on the contralateral side from an STA-MCA bypass is a rare, but potentially serious, complication of revascularization surgery for MMD. It highlights the importance of the hemodynamic interrelationships that exist between the two hemispheres, a concept that has been previously underappreciated. Induced hypertension during the acute period may provide adequate cerebral blood flow via developing collateral vessels, and good outcomes may be achieved with aggressive supportive management and expedited contralateral revascularization.
•Scalp cirsoid aneurysms are subcutaneous arteriovenous fistulae fed by the external carotid artery.•High-flow cirsoid aneurysms and lesions larger than 4 cm require combined endovascular and ...surgical modalities of management•Data published in the past 25 years showed a female preponderance (2.2:1)and a frontal location (45 %) fed by the superficial temporal artery.•Recurrences and complications are more common in the endovascular group than the surgical group. Our minor complication rate was 2 in 6 (33 %)
Scalp cirsoid aneurysms are subcutaneous arteriovenous fistulae fed by branches of the external carotid artery. They present with progressive scalp swelling and cosmetic deformities in addition to neuro-vascular symptoms. We evaluate the treatment and outcome of this rare vascular lesion with surgery and adjunctive endovascular embolisation performed by a dual-trained neurosurgeon.
A retrospective analysis of 6 cases operated over a 16 year-period was performed which comprised of clinical data, radiology including angiography and pre-operative embolisation, surgical approaches, outcomes and complications.
6 patients with ages ranging between 26 and 51 years were operated in the study period. All the patients underwent surgical excision of the lesion, of which 2 had undergone pre-operative embolisation of the feeders. There was no recurrence in the follow-up period (Mean 4.7 years) following total excision of the lesions. One patient had post-operative wound dehiscence and another had migration of embolic material to lungs.
Surgery is the predominant treatment method for scalp cirsoid aneurysms. Various adjunctive endovascular procedures can be performed pre-operatively to minimise operative blood loss.Though lower recurrence is seen with surgery for the scalp AV fistula, embolisation performed in select cases can achieve curative results with appropriate techniques.
Minimally invasive techniques of hematoma evacuation with or without the use of thrombolytic agents to lyse the clots have shown promising outcomes compared to open surgical evacuation. However, ...there is a dearth of literature in developing nations. The objective in this study was to evacuate spontaneous hypertensive basal ganglionic hemorrhages using computed tomography (CT)–guided catheter insertion, hematoma aspiration, and lysis with thrombolytic agents and analyze the efficacy and outcomes.
Ten patients with spontaneous basal ganglionic hemorrhage underwent CT-guided clot catheter insertion, followed by aspiration of hematoma and clot lysis using 25,000 IU urokinase instilled every 12 hours. Details including symptoms, clinical and radiologic findings, efficacy of the technique, functional outcomes during follow-up, length of stay, and cost were recorded. Relevant details for 12 age- and sex-matched conservatively treated patients were compared.
Functional outcome in the catheter group at 6 months was better than the medically managed group, with improved mean Glasgow Outcome Scale score (0.4 vs. 0.08), reduced modified Rankin scale score (−0.8 vs. −0.25), and reduced National Institutes of Health Stroke Scale score (−6.8 vs. −1.5 points). However, it was not statistically significant. Average hematoma volume reduction in the catheter group was 83.14%. In the medically managed group, 2 of 12 patients (16.6%) had hematoma expansion, 6 patients (50%) developed hydrocephalus, and 2 patients (16.6%) died. In the catheter group, 4 of 10 patients (40%) developed mild pneumocephalus that resolved.
The evacuation of hypertensive basal ganglionic hematomas is feasible with basic neurosurgical instruments and existing resources (e.g., CT scan) with improved functional outcome compared with conservative treatment alone.
Abstract
Objectives
Distal anterior cerebral artery (DACA) aneurysms are a subset of aneurysms located in the anterior circulation but away from the circle of Willis. We analyze the clinical ...presentation and outcomes of two treatment groups—surgical and endovascular—for DACA aneurysms managed by a dual-trained neurosurgeon.
Material and Methods
A retrospective evaluation of radiological and operative/interventional data of 34 patients with 35 DACA aneurysms over a 12-year period was analyzed. Twenty-seven patients underwent surgery, whereas seven underwent endovascular coiling of the aneurysms. Modified Fisher grade and World Federation of Neurosurgical Societies scale (WFNS) were used to note the subarachnoid hemorrhage (SAH) severity.
Statistical Analysis
Categorical data were presented as frequency and percentage, while noncategorical data were represented as mean ± SD. Statistical significance for difference in outcome between the two groups was analyzed using Chi-square test, and
p
< 0.05 was considered statistically significant.
Results
Of 34 patients, 33 presented with a bleed and 23.5% patients were noted to have another aneurysm in addition to the DACA aneurysm. Patients who underwent clipping for another aneurysm along with the DACA aneurysm in a single surgical exercise had a poor outcome compared with those who underwent surgery for the lone DACA aneurysm (7 vs. 20,
p
= 0.015). Most patients in both surgical (70.37%) and endovascular (85.71%) groups had good outcome (mRS ≤ 2).
Conclusions
A good outcome can be achieved with either surgery or endovascular coiling in the management of DACA aneurysms. In patients with multiple aneurysms, SAH with aneurysmal rupture of DACA should be managed first; the other unruptured aneurysm may be operated after an interval to avoid morbidity.
Vertebro-vertebral fistula involving the V3 segment of the vertebral artery is a rare vascular pathology which is either spontaneous or traumatic in origin. We describe a post-operative traumatic ...vertebro-vertebral fistula in a 47-year old lady with NF-1. We review reported cases of V3 segment vertebrovertebral fistula for their incidence, aetiology, clinical presentation, treatment and outcomes using an illustrative case. Traumatic V3 segment vertebrovertebral fistula is predominantly managed with parent vessel occlusion. Per the algorithm presented, we suggest endovascular management of non-traumatic fistula be based on the anatomical variance of the contralateral vertebral artery.
Abstract
BACKGROUND
Poor natural history of hemorrhagic Moyamoya disease (MMD) is related to high rehemorrhage rates between 32% and 61%. Postrevascularization, rehemorrhage rates reportedly decrease ...to 12% to 17%.
OBJECTIVE
To evaluate long-term functional outcomes and rehemorrhage rates of hemorrhagic MMD patients treated with surgical revascularization and examine these in relation to clinical and radiological factors.
METHODS
Patients treated surgically for hemorrhagic MMD over a 26-yr period were identified. Modified Rankin scale (mRS) was used to assess clinical status at presentation and functional outcomes. Multivariable regression analyses were performed to evaluate the risk factors associated with rehemorrhage rates and functional outcomes.
RESULTS
A total of 104 patients (mean age: 38.04 yr) were identified. The mean mRS score at baseline was 1.3. Of 172 revascularized hemispheres, 157 (91.3%) were direct superficial temporal artery (STA)-middle cerebral artery (MCA) bypasses and the rest indirect. Over the mean follow-up of 61.4 mo, 8 of 104 patients (7.7%) experienced rehemorrhage with rehemorrhage rate per person-years of 1.9%. A total of 4 patients died with 1 related to rehemorrhage. At the last follow-up, mean mRS score improved to 1.1. No significant risk factors were identified in relation to the rehemorrhage rates (P < .05). The patients’ initial mRS score was positively associated with mRS scores at the final follow-up (P < .001). STA-MCA direct bypass was associated with better performance status (P = .033).
CONCLUSION
Rehemorrhage rate following surgical revascularization of the hemorrhagic MMD patients at 7.7% is lower compared with much higher natural history rates. Surgical revascularization improved patients' performance status. These outcomes support performing revascularization procedure with a preference for direct STA-MCA bypasses.
Graphical Abstract
Graphical Abstract
Abstract
Objective
We present our experience in the management of frontal bone fractures using the previously described radiologic classification of frontal bone fractures.
Methodology
A ...retrospective study was conducted, which reviewed the medical records and computed tomographic (CT) scan images of patients with frontal bone fracture from January 2016 to February 2019. Patients with complete medical records and a follow-up of minimum 1 year were included in the study. Demographic details, mechanism of injury, associated intracranial injuries, maxillofacial fractures, management, and complications were analyzed. CT scan images were used to classify the frontal bone fractures using the novel classification given by Garg et al (2014). The indications for surgical treatment were inner table frontal sinus fracture with cerebrospinal fluid (CSF) leak, intracranial hematoma with significant mass effect requiring surgical evacuation, and outer table comminuted fracture that is either causing nasofrontal duct obstruction or for cosmetic purpose.
Results
A total of 55 patients were included in the study. Road traffic accidents as the commonest cause of frontal bone fractures. The most common fracture pattern was type 1 followed by type 5 and depth B followed by depth A. Four patients presented with CSF rhinorrhea. CSF rhinorrhea was more frequent with fracture extension to the skull base (depth B, C, D), which was statistically significant (
p
< 0.001).
Conclusion
Frontal bone fracture management has to be tailor-made for each patient based on the extent of the fracture, presence of CSF leak, and associated intracranial and maxillofacial injuries.
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