Urgent treatment of severe subarachnoid hemorrhage caused by ruptured traumatic aneurysm of the cavernous internal carotid artery using coil embolization followed by superficial temporal artery-middle cerebral artery anastomosis: A case report

Pseudoaneurysm of the Internal Carotid Artery After Craniofacial Traumatism: Series of Cases and Integrative Literature Review

The present study aims to develop an integrative review about pseudoaneurysms after traumatic facial trauma, through the analysis of its etiology, type of fracture, signs and symptoms, time elapsed between the trauma and the exposure of signs and symptoms, and treatment performed in these cases. Furthermore into the report, there are 3 clinical cases that occurred in the Buccomaxillofacial Surgery and Traumatology service of Hospital da Restauração Recife/PE. The study was carried out in 2 phases, first, a digital research about post-traumatic craniofacial pseudoaneurysm was performed in the following databases "MEDLINE/PubMed," "Scielo" and "Scopus," in September 2019, with 5 articles being included. In the second, 3 cases of patients with high-impact facial trauma who developed pseudoaneurysm of the internal carotid artery were reported. The average age of the patients was 35.6 years, all patients were male (100%), the majority (60%) being victims of an automobile accident, 3 patients (60%) suffered craniofacial trauma and 2 (40%) had trauma only to the face, most of them had symptoms later on due to the trauma, in 80% of cases the therapy instituted was embolization. Cases of high-impact craniofacial traumas, which present epistaxis and/or ophthalmological alterations correlated to fractures, should be carefully evaluated, determining a better prognosis for the patient.

Diagnosis and Treatment of Traumatic Cerebrovascular Injury: Pitfalls in the Management of Neurotrauma

Traumatic cerebrovascular injury (TCVI) is an uncommon clinical entity in traumatic brain injury (TBI), yet it may cause devastating brain injury with high morbidity and mortality. Early recognition and prioritized strategic treatment are of paramount importance. A total of 1966 TBI patients admitted between 1999 and 2015 in our tertiary critical care center were reviewed. Screening of TCVI was based on the Guidelines for the Management of Severe Head Injury in Japan. TCVI was confirmed in 33 (1.7%) patients; 29 blunt and 4 penetrating injuries. The primary location of the injury included 16 cervical, 6 craniofacial, and 11 intracranial lesions. On arrival, 15 patients presented with hemorrhage, 5 of these arrived in shock status with massive hemorrhage. Ten presented with ischemic symptoms. Sixteen patients underwent surgical or endovascular intervention, 13 of whom required immediate treatment upon arrival. Surgical procedures included clipping or trapping for traumatic aneurysms, superficial temporal artery - middle cerebral artery bypass, carotid endarterectomy, and direct suture of the injured vessels. Endovascular intervention was undertaken in 7 patients; embolization with Gelfoam (Pharmacia and Upjohn Company, Kalamazoo, MI, USA) or coil for 6 hemorrhagic lesions and stent placement for 1 lesion causing ischemia. Patients’ outcome assessed by the Glasgow Outcome Scale at 3 months were good recovery in 8, moderate disability in 3, severe disability in 9, persistent vegetative state in 1, and death in 12, respectively. In order to rescue potentially salvageable TCVI patients, neurosurgeons in charge should be aware of TCVI and master basic skills of cerebrovascular surgical and endovascular procedures to utilize in an emergency setting.

Penetrative Injury to the Face Resulting in Delayed Death After Rupture of a Cavernous Sinus Aneurysm on the Contralateral Side

Delayed deaths after assault give rise to medicolegal issues such as whether the assault was directly responsible, did it contribute or was it totally unrelated to the death. We present the case of a patient who sustained penetrative trauma to the face resulting in the formation of a contralateral, carotid-cavernous fistula, which resulted in aneurysm formation, delayed rupture, and death. A literature search failed to find a similar case.

4D flow preliminary investigation of a direct carotid cavernous fistula due to a ruptured intracavernous aneurysm

Inadequate information is available about the cerebral blood flow and surgical strategies of a direct aneurysmal carotid cavernous fistula (daCCF). We report a quantitative analysis of flow velocity and volume using preoperative time-resolved phase-contrast MRI (four-dimensional (4D) flow MRI) in a daCCF. This is the first report of 4D flow findings with a daCCF. A 55-year-old woman developed a sudden headache and bruit of the right orbit, and MRI suggested the presence of a daCCF. Quantitative analysis using preoperative 4D flow MRI revealed the flow volume of the right internal carotid artery. The daCCF was successfully treated by high-flow bypass using a radial artery graft and internal carotid artery trapping. Postoperative angiography showed a complete obliteration of the daCCF. Studies to collect data from additional cases are required so that 4D flow findings can be further used in the management of daCCFs.

Effectiveness of suturing training with 10-0 nylon under fixed and maximum magnification (×20) using desk type microscope

BACKGROUND

Microvascular anastomosis using 10-0 nylon needs a higher level of technical dexterity compared with routine neurosurgical maneuvers. Although this technique remains an important part of treating complex intracranial aneurysms or cerebrovascular disease, the surgeon's clinical experience in using this technique is not so common.

METHODS

To improve dexterity and maneuverability in the limited clinical case volume, we developed an easily accessible training system, using commercially available desk type microscope and simply suturing neighboring fibers of the gauze with 10-0 nylon under fixed and highest (x 20) magnification.

RESULT

This training system is somewhat of a drawback compared to the simulation of a real clinical setting. However, because of the extremely easy availability and accessibility of the dark type microscope repeated training and the accumulation of more than 10000 stitches, on average, was accomplished. This resulted in a steep learning curve of the technique.

CONCLUSION

For residency and post-residency year young neurosurgeons, who need to brush up their skills due to lower surgical case volume compared with what senior neurosurgeons have experienced this easily available training would contribute to establishing daily and long-lasting microsurgical practice.