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Sternbach S, Nguyen VN, Sizdahkhani S, Abedi A, Rennert RC, Atai NA, Khahera AS, Carey JN, Russin JJ. Open Surgical Treatment of Middle Cerebral Artery Aneurysms: A Single-Center Series in the Endovascular Era. World Neurosurg 2024; 184:e577-e585. [PMID: 38336208 DOI: 10.1016/j.wneu.2024.01.172] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2023] [Revised: 01/31/2024] [Accepted: 01/31/2024] [Indexed: 02/12/2024]
Abstract
OBJECTIVE We review the outcomes of open surgical treatment of middle cerebral artery aneurysms (MCAAs) at a single center, focusing on aneurysm obliteration rates and functional outcomes at the most recent follow-up. These findings can be used for future comparisons of surgical outcomes with MCAAs. METHODS We retrospectively reviewed cases from a prospectively maintained database of patients receiving open surgical treatment for ruptured or unruptured MCAAs between July 2014 and December 2022. We utilized patients' modified Rankin Scale (mRS) score and Glasgow Outcome Scale score as functional outcome measures. Means, standard deviations, medians, and interquartile ranges were calculated, and a student's t test or its nonparametric equivalent was used to compare subgroups. RESULTS One hundred fifty patients (114 women, 76%; mean age 55.0 ± 14.7 years) with a total of 156 MCAAs comprised 152 cases; 85 (56%) ruptured and 71 (46%) unruptured. Bypass was performed in 34 cases (22.4%); 18 ruptured (51.4%) and 16 unruptured (48.6%). Intraoperative rupture occurred in 5 (5%) ruptured and 1 (2%) unruptured cases. Onwe hundred forty-five patients (95.4%) had aneurysm obliteration with initial surgery, with 98.4% of patients having complete occlusion at 40.2± 65.5 weeks of follow-up. Intrahospital mortality occurred in 7 (6.9%) ruptured versus 1 (2.0%) unruptured case. Fifty-two (51.5%) of the ruptured compared to 43 (86%) unruptured patients were discharged home, with the remaining patients requiring inpatient rehabilitation or long-term hospitalization. The ruptured group had a mean hospital stay of 18.4 ± 10.5 days versus. 5.7 ± 6.0 days for unruptured. Length of stay, discharge mRS/ Glasgow Outcome Scale, and mRS at 4-6 weeks favored unruptured cases (P < 0.0001-0.0336). Mean change in mRS from presentation to last follow-up favored ruptured cases (-0.7 ± 1.2 vs. -0.04 ± 1.2, P = 0.0215). CONCLUSIONS Open surgery remains a safe and definitive treatment option for MCAAs in the endovascular era.
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Affiliation(s)
- Sarah Sternbach
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Vincent N Nguyen
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Saman Sizdahkhani
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Aidin Abedi
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California, USA; Neurorestoration Center, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Robert C Rennert
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Nadia A Atai
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California, USA; Neurorestoration Center, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Anadjeet S Khahera
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Joseph N Carey
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Jonathan J Russin
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California, USA; Neurorestoration Center, Keck School of Medicine, University of Southern California, Los Angeles, California, USA.
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Rennert RC, Atai NA, Nguyen VN, Abedi A, Sternbach S, Chu J, Carey JN, Russin JJ. Three-Vessel Anastomosis for Direct Multiterritory Cerebral Revascularization: Case Series. Oper Neurosurg (Hagerstown) 2024; 26:423-432. [PMID: 38084991 DOI: 10.1227/ons.0000000000001013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Accepted: 09/29/2023] [Indexed: 03/16/2024] Open
Abstract
BACKGROUND AND OBJECTIVE Cerebral revascularization of multiple territories traditionally requires multiple constructs, serial anastomoses, or a combination of direct and indirect approaches. A novel 3-vessel anastomosis technique allows for direct, simultaneous multiterritory cerebral revascularization using a single interposition graft. We herein present our experience with this approach. METHODS Retrospective review of perioperative data and outcomes for patients undergoing multiterritory cerebral revascularization using a 3-vessel anastomosis from 2019 to 2023. RESULTS Five patients met inclusion criteria (median age 53 years [range 12-73]). Three patients with complex middle cerebral artery aneurysms (1 ruptured) were treated with proximal ligation or partial/complete clip trapping and multiterritory external carotid artery-M2-M2 revascularization using a saphenous vein interposition graft. Two patients with moyamoya disease, prior strokes, and predominately bilateral anterior cerebral artery hypoperfusion were treated with proximal superficial temporal artery-A3-A3 revascularization using a radial artery or radial artery fascial flow-through free flap graft. No patients experienced significant surgery-related ischemia. Bypass patency was 100%. One patient had new strokes from vasospasm after subarachnoid hemorrhage. One patient required a revision surgery for subdural hematoma evacuation and radial artery fascial flow-through free flap debridement, without affecting bypass patency or neurologic outcome. On hospital discharge, median Glasgow Outcome Scale and modified Rankin Scale scores were 4 (range 3-5) and 2 (range 0-5), respectively. On follow-up, 1 patient died from medical complications of their presenting stroke; Glasgow Outcome Scale and modified Rankin Scale scores were otherwise stable or improved. CONCLUSION The 3-vessel anastomosis technique can be considered for simultaneous revascularization of multiple intracranial territories.
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Affiliation(s)
- Robert C Rennert
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles , California , USA
| | - Nadia A Atai
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles , California , USA
- Neurorestoration Center, Keck School of Medicine, University of Southern California, Los Angeles , California , USA
| | - Vincent N Nguyen
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles , California , USA
| | - Aidin Abedi
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles , California , USA
- Neurorestoration Center, Keck School of Medicine, University of Southern California, Los Angeles , California , USA
| | - Sarah Sternbach
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles , California , USA
| | - Jason Chu
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles , California , USA
- Department of Neurosurgery, Children's Hospital Los Angeles, Los Angeles , California , USA
| | - Joseph N Carey
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Keck School of Medicine, University of Southern California, Los Angeles , California , USA
| | - Jonathan J Russin
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles , California , USA
- Neurorestoration Center, Keck School of Medicine, University of Southern California, Los Angeles , California , USA
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Rawanduzy CA, Winkler-Schwartz A, Budohoski KP, Couldwell WT. Occipital artery-to-PICA bypass: how I do it. Acta Neurochir (Wien) 2023; 165:3737-3741. [PMID: 37256439 DOI: 10.1007/s00701-023-05633-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Accepted: 05/07/2023] [Indexed: 06/01/2023]
Abstract
BACKGROUND Posterior inferior cerebellar artery (PICA) aneurysms are uncommon, and their management is challenging because of the complex angioarchitecture of the PICA and the frequently nonsaccular aneurysm presentation. Endovascular therapy may not be feasible. METHODS We describe our technique of clip trapping with occipital artery (OA)-to-PICA bypass to treat a PICA aneurysm. Because the aneurysm affected the ipsilateral, dominant PICA, an OA-PICA bypass was chosen to ensure adequate flow and reduce risk to the contralateral PICA supply. CONCLUSION The OA-PICA anastomosis is a safe and effective method to successfully achieve flow preservation with bypass reconstruction and aneurysm trapping.
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Affiliation(s)
- Cameron A Rawanduzy
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, 175 N. Medical Drive East, Salt Lake City, UT, 84132, USA
| | - Alexander Winkler-Schwartz
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, 175 N. Medical Drive East, Salt Lake City, UT, 84132, USA
| | - Karol P Budohoski
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, 175 N. Medical Drive East, Salt Lake City, UT, 84132, USA
| | - William T Couldwell
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, 175 N. Medical Drive East, Salt Lake City, UT, 84132, USA.
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Rennert RC, Russin JJ. Commentary: Common Carotid Artery to Middle Cerebral Artery Bypass With Radial Interposition Graft for Internal Carotid Artery (ICA) Occlusion After Stent-Coil Embolization of Giant ICA Terminus Aneurysm: 2-Dimensional Operative Video. Oper Neurosurg (Hagerstown) 2023; 24:e291-e292. [PMID: 36715997 DOI: 10.1227/ons.0000000000000621] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2022] [Accepted: 11/11/2022] [Indexed: 01/31/2023] Open
Affiliation(s)
- Robert C Rennert
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Jonathan J Russin
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California, USA.,Neurorestoration Center, University of Southern California, Los Angeles, California, USA
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Zhao L, Xue B, Guo G, Wu R, Gao T, Liu Y, Sun Y, Hernesniemi J, Andrade Barazarte H, Li T, Li C. Case Report: Curative effect of OA-PICA protected bypass in severe PICA-complicated vertebral artery stenosis treatment: Results in 3 cases. Front Surg 2023; 10:1074438. [PMID: 36860943 PMCID: PMC9968787 DOI: 10.3389/fsurg.2023.1074438] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2022] [Accepted: 01/02/2023] [Indexed: 02/16/2023] Open
Abstract
Objectives We aimed to explore the results of OA-PICA-protected bypass grafting in patients with severe stenosis of the vertebral artery combined with PICA. Methods Three patients with vertebral artery stenosis involving the posterior inferior cerebellar artery, treated by the Department of Neurosurgery of Henan Provincial People's Hospital from January 2018 to December 2021, were retrospectively analyzed. All the patients underwent Occipital Artery-Posterior Inferior Cerebellar Artery (OA-PICA) bypass surgery followed by elective vertebral artery stenting. Intraoperative indocyanine green fluorescence angiography (ICGA) showed patency of the bridge-vessel anastomosis. Postoperatively, the ANSYS software was used to assess the flow pressure changes and vascular shear in combination with the reviewed DSA angiogram. CTA or DSA was reviewed 1-2 years postoperatively, and the prognosis was evaluated by the modified Rankin Scale (mRS) one year postoperatively. Results OA-PICA bypass surgery was completed in all patients, with intraoperative ICGA showing a patent bridge anastomosis, followed by stenting of the vertebral artery, and a review of the DSA angiogram. We also employed ANSYS software evaluation of the bypass vessel, which showed stable pressure and low turnover angle, suggesting a low rate of long-term occlusion of the vessel. All patients had no procedure-related complications during their hospitalization, and were followed up for a mean of 24 months postoperatively, with a good prognosis (mRS score of 1) at 1 year postoperatively. Conclusion OA-PICA-protected bypass grafting is an effective treatment for patients with severe stenosis of the vertebral artery combined with PICA.
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Affiliation(s)
- Liming Zhao
- Department of Neurosurgery, Zhengzhou University People's Hospital, Henan Provincial People's Hospital, Zhengzhou, China
| | - Bingqian Xue
- Department of Neurosurgery, Henan University People's Hospital, Henan Provincial People's Hospital, Zhengzhou, China
| | - Gaochao Guo
- Department of Neurosurgery, Zhengzhou University People's Hospital, Henan Provincial People's Hospital, Zhengzhou, China
| | - Ruiyu Wu
- Department of Neurosurgery, Henan University People's Hospital, Henan Provincial People's Hospital, Zhengzhou, China
| | - Tao Gao
- Department of Neurosurgery, Zhengzhou University People's Hospital, Henan Provincial People's Hospital, Zhengzhou, China
| | - Yang Liu
- Department of Neurosurgery, Zhengzhou University People's Hospital, Henan Provincial People's Hospital, Zhengzhou, China
| | - Yuxue Sun
- Department of Neurosurgery, Zhengzhou University People's Hospital, Henan Provincial People's Hospital, Zhengzhou, China
| | - Juha Hernesniemi
- Department of Neurosurgery, Zhengzhou University People's Hospital, Henan Provincial People's Hospital, Zhengzhou, China
| | - Hugo Andrade Barazarte
- Department of Neurosurgery, Zhengzhou University People's Hospital, Henan Provincial People's Hospital, Zhengzhou, China
| | - Tianxiao Li
- Department of Neurosurgery, Zhengzhou University People's Hospital, Henan Provincial People's Hospital, Zhengzhou, China
| | - Chaoyue Li
- Department of Neurosurgery, Zhengzhou University People's Hospital, Henan Provincial People's Hospital, Zhengzhou, China,Correspondence: Chaoyue Li
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Rennert RC, Nguyen VN, Abedi A, Atai NA, Carey JN, Tenser M, Amar A, Mack WJ, Russin JJ. Combined open revascularization and endovascular treatment of complex intracranial aneurysms: case series. Front Neurol 2023; 14:1102496. [PMID: 37153667 PMCID: PMC10160605 DOI: 10.3389/fneur.2023.1102496] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2022] [Accepted: 03/29/2023] [Indexed: 05/10/2023] Open
Abstract
Background and purpose The treatment of complex intracranial aneurysms can be challenging with stand-alone open or endovascular techniques, particularly after rupture. A combined open and endovascular strategy can potentially limit the risk of extensive dissections with open-only techniques, and allow for aggressive definitive endovascular treatments with minimized downstream ischemic risk. Materials and methods Retrospective, single-institution review of consecutive patients undergoing combined open revascularization and endovascular embolization/occlusion for complex intracranial aneurysms from 1/2016 to 6/2022. Results Ten patients (4 male [40%]; mean age 51.9 ± 8.7 years) underwent combined open revascularization and endovascular treatment of intracranial aneurysms. The majority of aneurysms, 9/10 (90%), were ruptured and 8/10 (80%) were fusiform in morphology. Aneurysms of the posterior circulation represented 8/10 (80%) of the cases (vertebral artery [VA] involving the posterior inferior cerebellar artery [PICA] origin, proximal PICA or anterior inferior cerebellar artery/PICA complex, or proximal posterior cerebral artery). Revascularization strategies included intracranial-to-intracranial (IC-IC; 7/10 [70%]) and extracranial-to-intracranial (EC-IC; 3/10 [30%]) constructs, with 100% postoperative patency. Initial endovascular procedures (consisting of aneurysm/vessel sacrifice in 9/10 patients) were performed early after surgery (0.7 ± 1.5 days). In one patient, secondary endovascular vessel sacrifice was performed after an initial sub-occlusive embolization. Treatment related strokes were diagnosed in 3/10 patients (30%), largely from involved or nearby perforators. All bypasses with follow-up were patent (median 14.0, range 4-72 months). Good outcomes (defined as a Glasgow Outcomes Scale ≥4 and modified Rankin Scale ≤2) occurred in 6/10 patients (60%). Conclusion A variety of complex aneurysms not amenable to stand-alone open or endovascular techniques can be successfully treated with combined open and endovascular approaches. Recognition and preservation of perforators is critical to treatment success.
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Affiliation(s)
- Robert C. Rennert
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, United States
| | - Vincent N. Nguyen
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, United States
| | - Aidin Abedi
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, United States
- Neurorestoration Center, Keck School of Medicine, University of Southern California, Los Angeles, CA, United States
| | - Nadia A. Atai
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, United States
- Neurorestoration Center, Keck School of Medicine, University of Southern California, Los Angeles, CA, United States
| | - Joseph N. Carey
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, United States
| | - Matthew Tenser
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, United States
| | - Arun Amar
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, United States
| | - William J. Mack
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, United States
| | - Jonathan J. Russin
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, United States
- Neurorestoration Center, Keck School of Medicine, University of Southern California, Los Angeles, CA, United States
- *Correspondence: Jonathan J. Russin,
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7
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Rennert RC, Russin JJ. Rethinking Cerebral Bypass Surgery. Neurosurg Clin N Am 2022; 33:403-417. [DOI: 10.1016/j.nec.2022.05.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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8
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Yang Z, Song J, Quan K, Li P, An Q, Shi Y, Liu P, Yu G, Tian Y, Zhou L, Zhu W. Microsurgical treatment of posterior inferior cerebellar aneurysms based on angioarchitecture supplemented by high-resolution vessel wall MRI: a case series report. Stroke Vasc Neurol 2022; 7:337-344. [PMID: 35387894 DOI: 10.1136/svn-2021-001115if:9.893q1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2021] [Accepted: 02/07/2022] [Indexed: 05/27/2023] Open
Abstract
BACKGROUND Surgical treatment of posterior inferior cerebellar artery (PICA) aneurysms is challenging because many are nonsaccular and atherosclerotic. We report our tailored approach to PICA aneurysms, which is based on angioarchitecture supplemented by high-resolution vessel wall MRI (HR-VW MRI) findings. METHODS From March 2010 to September 2020, 27 patients with 29 PICA aneurysms underwent surgical treatment in our institution. Since October 2016, HR-VW MRI has been used for aneurysmal wall assessment. Clinical characteristics, radiological data and surgical outcomes were analysed. RESULTS Nineteen proximal PICA aneurysms (vertebral artery (VA), P1, P2 and P3) were treated using the far-lateral approach. Ten distal PICA aneurysms (P4, P5) were treated using the suboccipital midline approach. Direct clipping or clip reconstruction was achieved in 19 aneurysms. Ten were trapped in conjunction with extracranial-intracranial or intracranial-intracranial bypass, including three occipital artery-PICA reimplantations, three PICA-VA reimplantations, two PICA-PICA side-to-side anastomoses, one PICA-PICA reimplantation and one PICA-PICA reanastomosis. All aneurysms were eventually completely obliterated and all bypasses remained patent. At the last follow-up, 26 patients (96.2%) achieved a good outcome (modified Rankin Scale score <3). Eight patients underwent HR-VW MRI. Among these, the six aneurysms with focal wall enhancement required bypass and the two with negative enhancement were successfully clipped. CONCLUSION PICA aneurysms have a higher frequency of complex features such as large or giant size and fusiform or dissecting morphology. Favourable outcomes were achieved with individualised microsurgical strategies based on angioarchitecture. HR-VW MRI may be used as a promising technique to predict aneurysmal atherosclerosis.
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Affiliation(s)
- Zixiao Yang
- Department of Neurosurgery, Huashan Hospital Fudan University, Shanghai, China
- National Center for Neurological Disorders, Shanghai, China
- Neurosurgical Institute of Fudan University, Shanghai, China
- Shanghai Clinical Medical Center of Neurosurgery, Shanghai, China
| | - Jianping Song
- Department of Neurosurgery, Huashan Hospital Fudan University, Shanghai, China
- National Center for Neurological Disorders, Shanghai, China
- Neurosurgical Institute of Fudan University, Shanghai, China
- Shanghai Clinical Medical Center of Neurosurgery, Shanghai, China
| | - Kai Quan
- Department of Neurosurgery, Huashan Hospital Fudan University, Shanghai, China
- National Center for Neurological Disorders, Shanghai, China
- Neurosurgical Institute of Fudan University, Shanghai, China
- Shanghai Clinical Medical Center of Neurosurgery, Shanghai, China
| | - Peiliang Li
- Department of Neurosurgery, Huashan Hospital Fudan University, Shanghai, China
- National Center for Neurological Disorders, Shanghai, China
- Neurosurgical Institute of Fudan University, Shanghai, China
- Shanghai Clinical Medical Center of Neurosurgery, Shanghai, China
| | - Qingzhu An
- Department of Neurosurgery, Huashan Hospital Fudan University, Shanghai, China
- National Center for Neurological Disorders, Shanghai, China
- Neurosurgical Institute of Fudan University, Shanghai, China
- Shanghai Clinical Medical Center of Neurosurgery, Shanghai, China
| | - Yuan Shi
- Department of Neurosurgery, Huashan Hospital Fudan University, Shanghai, China
- National Center for Neurological Disorders, Shanghai, China
- Neurosurgical Institute of Fudan University, Shanghai, China
- Shanghai Clinical Medical Center of Neurosurgery, Shanghai, China
| | - Peixi Liu
- Department of Neurosurgery, Huashan Hospital Fudan University, Shanghai, China
- National Center for Neurological Disorders, Shanghai, China
- Neurosurgical Institute of Fudan University, Shanghai, China
- Shanghai Clinical Medical Center of Neurosurgery, Shanghai, China
| | - Guo Yu
- Department of Neurosurgery, Huashan Hospital Fudan University, Shanghai, China
- National Center for Neurological Disorders, Shanghai, China
- Neurosurgical Institute of Fudan University, Shanghai, China
- Shanghai Clinical Medical Center of Neurosurgery, Shanghai, China
| | - Yanlong Tian
- Department of Neurosurgery, Huashan Hospital Fudan University, Shanghai, China
- National Center for Neurological Disorders, Shanghai, China
- Neurosurgical Institute of Fudan University, Shanghai, China
- Shanghai Clinical Medical Center of Neurosurgery, Shanghai, China
| | - Liangfu Zhou
- Department of Neurosurgery, Huashan Hospital Fudan University, Shanghai, China
- National Center for Neurological Disorders, Shanghai, China
- Neurosurgical Institute of Fudan University, Shanghai, China
- Shanghai Clinical Medical Center of Neurosurgery, Shanghai, China
| | - Wei Zhu
- Department of Neurosurgery, Huashan Hospital Fudan University, Shanghai, China
- National Center for Neurological Disorders, Shanghai, China
- Neurosurgical Institute of Fudan University, Shanghai, China
- Shanghai Clinical Medical Center of Neurosurgery, Shanghai, China
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Wolfswinkel EM, Ravina K, Rennert RC, Landau M, Strickland BA, Chun A, Wlodarczyk JR, Abedi A, Carey JN, Russin JJ. Cerebral Bypass Using the Descending Branch of the Lateral Circumflex Femoral Artery: A Case Series. Oper Neurosurg (Hagerstown) 2022; 22:364-372. [DOI: 10.1227/ons.0000000000000144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2021] [Accepted: 11/08/2021] [Indexed: 11/19/2022] Open
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10
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Yang Z, Song J, Quan K, Li P, An Q, Shi Y, Liu P, Yu G, Tian Y, Zhou L, Zhu W. Microsurgical treatment of posterior inferior cerebellar aneurysms based on angioarchitecture supplemented by high-resolution vessel wall MRI: a case series report. Stroke Vasc Neurol 2022; 7:337-344. [PMID: 35387894 PMCID: PMC9453843 DOI: 10.1136/svn-2021-001115] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2021] [Accepted: 02/07/2022] [Indexed: 11/03/2022] Open
Abstract
BACKGROUND Surgical treatment of posterior inferior cerebellar artery (PICA) aneurysms is challenging because many are nonsaccular and atherosclerotic. We report our tailored approach to PICA aneurysms, which is based on angioarchitecture supplemented by high-resolution vessel wall MRI (HR-VW MRI) findings. METHODS From March 2010 to September 2020, 27 patients with 29 PICA aneurysms underwent surgical treatment in our institution. Since October 2016, HR-VW MRI has been used for aneurysmal wall assessment. Clinical characteristics, radiological data and surgical outcomes were analysed. RESULTS Nineteen proximal PICA aneurysms (vertebral artery (VA), P1, P2 and P3) were treated using the far-lateral approach. Ten distal PICA aneurysms (P4, P5) were treated using the suboccipital midline approach. Direct clipping or clip reconstruction was achieved in 19 aneurysms. Ten were trapped in conjunction with extracranial-intracranial or intracranial-intracranial bypass, including three occipital artery-PICA reimplantations, three PICA-VA reimplantations, two PICA-PICA side-to-side anastomoses, one PICA-PICA reimplantation and one PICA-PICA reanastomosis. All aneurysms were eventually completely obliterated and all bypasses remained patent. At the last follow-up, 26 patients (96.2%) achieved a good outcome (modified Rankin Scale score <3). Eight patients underwent HR-VW MRI. Among these, the six aneurysms with focal wall enhancement required bypass and the two with negative enhancement were successfully clipped. CONCLUSION PICA aneurysms have a higher frequency of complex features such as large or giant size and fusiform or dissecting morphology. Favourable outcomes were achieved with individualised microsurgical strategies based on angioarchitecture. HR-VW MRI may be used as a promising technique to predict aneurysmal atherosclerosis.
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Affiliation(s)
- Zixiao Yang
- Department of Neurosurgery, Huashan Hospital Fudan University, Shanghai, China.,National Center for Neurological Disorders, Shanghai, China.,Neurosurgical Institute of Fudan University, Shanghai, China.,Shanghai Clinical Medical Center of Neurosurgery, Shanghai, China
| | - Jianping Song
- Department of Neurosurgery, Huashan Hospital Fudan University, Shanghai, China.,National Center for Neurological Disorders, Shanghai, China.,Neurosurgical Institute of Fudan University, Shanghai, China.,Shanghai Clinical Medical Center of Neurosurgery, Shanghai, China
| | - Kai Quan
- Department of Neurosurgery, Huashan Hospital Fudan University, Shanghai, China.,National Center for Neurological Disorders, Shanghai, China.,Neurosurgical Institute of Fudan University, Shanghai, China.,Shanghai Clinical Medical Center of Neurosurgery, Shanghai, China
| | - Peiliang Li
- Department of Neurosurgery, Huashan Hospital Fudan University, Shanghai, China.,National Center for Neurological Disorders, Shanghai, China.,Neurosurgical Institute of Fudan University, Shanghai, China.,Shanghai Clinical Medical Center of Neurosurgery, Shanghai, China
| | - Qingzhu An
- Department of Neurosurgery, Huashan Hospital Fudan University, Shanghai, China.,National Center for Neurological Disorders, Shanghai, China.,Neurosurgical Institute of Fudan University, Shanghai, China.,Shanghai Clinical Medical Center of Neurosurgery, Shanghai, China
| | - Yuan Shi
- Department of Neurosurgery, Huashan Hospital Fudan University, Shanghai, China.,National Center for Neurological Disorders, Shanghai, China.,Neurosurgical Institute of Fudan University, Shanghai, China.,Shanghai Clinical Medical Center of Neurosurgery, Shanghai, China
| | - Peixi Liu
- Department of Neurosurgery, Huashan Hospital Fudan University, Shanghai, China.,National Center for Neurological Disorders, Shanghai, China.,Neurosurgical Institute of Fudan University, Shanghai, China.,Shanghai Clinical Medical Center of Neurosurgery, Shanghai, China
| | - Guo Yu
- Department of Neurosurgery, Huashan Hospital Fudan University, Shanghai, China.,National Center for Neurological Disorders, Shanghai, China.,Neurosurgical Institute of Fudan University, Shanghai, China.,Shanghai Clinical Medical Center of Neurosurgery, Shanghai, China
| | - Yanlong Tian
- Department of Neurosurgery, Huashan Hospital Fudan University, Shanghai, China.,National Center for Neurological Disorders, Shanghai, China.,Neurosurgical Institute of Fudan University, Shanghai, China.,Shanghai Clinical Medical Center of Neurosurgery, Shanghai, China
| | - Liangfu Zhou
- Department of Neurosurgery, Huashan Hospital Fudan University, Shanghai, China.,National Center for Neurological Disorders, Shanghai, China.,Neurosurgical Institute of Fudan University, Shanghai, China.,Shanghai Clinical Medical Center of Neurosurgery, Shanghai, China
| | - Wei Zhu
- Department of Neurosurgery, Huashan Hospital Fudan University, Shanghai, China .,National Center for Neurological Disorders, Shanghai, China.,Neurosurgical Institute of Fudan University, Shanghai, China.,Shanghai Clinical Medical Center of Neurosurgery, Shanghai, China
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Bypass Surgery Management of Complex Proximal and Distal Posterior Inferior Cerebellar Artery Aneurysms. J Craniofac Surg 2022; 33:2049-2054. [PMID: 35119411 DOI: 10.1097/scs.0000000000008507] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Accepted: 01/13/2022] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND For the complex posterior inferior cerebellar artery (PICA) aneurysms, standard microsurgical or endovascular technical options were not feasible. To determine the efficacy and outcomes of bypass surgery for complex PICA aneurysms, the authors herein review our recent surgical experience for complex PICA aneurysms. METHODS The authors retrospectively reviewed our experience of extracranial-intracranial bypass and intracranial-intracranial bypass surgery in treatment of proximal and distal complex PICA aneurysms at our institution from 2016 to 2020. RESULTS Twelve patients harboring 12 complex PICA aneurysms received bypass surgery at our institution. Seven (58.3%) patients with proximal PICA aneurysms underwent extracranial-intracranial bypass. Five (41.7%) patients with distal PICA aneurysms accepted intracranial-intracranial bypass. The postoperative symptom improvement: Of the 6 patients with preoperative hypoperfusion or ischemic of the cerebellar hemisphere, the symptom resolved in 5 patients, improved in 1 patient, of 5 patients with preoperative mass effect, the symptom resolved in 5 patients. During the follow-up period, ten patients had a modified Rankin scale (mRS) score of 0 to 1, and 1 patient had an mRS score of 2. One patient had an mRS score of 3. The long-term graft patency rate was 91.7%. All patients had no recurrence of intracranial aneurysm. CONCLUSIONS Base on the complexity of anatomy structure and the vascular architecture, an individualized strategy was proposed for each patient. The use of different types of bypass procedures (occipital artery-PICA end-to-end bypass, PICA-PICA end-to-end anastomosis, and/or occipital artery graft) can safely and effectively manage these complex PICA aneurysms.
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12
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A growing aneurysm of the posterior inferior cerebellar artery complicated with cerebellar infarction: A case report. Int J Surg Case Rep 2021; 88:106559. [PMID: 34763168 PMCID: PMC8590029 DOI: 10.1016/j.ijscr.2021.106559] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2021] [Revised: 10/30/2021] [Accepted: 10/30/2021] [Indexed: 11/28/2022] Open
Abstract
Introduction and importance Hereby we describe an instructive patient with cerebellar infarction and a growing aneurysm at the posterior inferior cerebellar artery (PICA), which was not a true cause of infarction. Case presentation A 50-year-old female presented with dizziness and posterior neck pain at our hospital (Mitaka city, Tokyo, Japan). Diffusion weighted magnetic resonance (MR) images showed cerebellar infarction in the left PICA territory and MR angiography study showed an aneurysm at the origin of the left PICA, which grew in 2 weeks. Since we considered cerebellar infarction was caused by thrombosis from the aneurysm, trapping of the PICA and occipital artery-PICA bypass was performed to prevent recurrent cerebellar infarction and rupture of the aneurysm by neurosurgeons. During the operation, dissection was observed at the distal PICA, which was diagnosed to be the true cause of cerebellar infarction. By the follow-up for 12 months at an outpatient, there was no recurrence of cerebral infarction. Clinical discussion A specimen of the artery showing the findings of dissection was not obtained, and the pathological diagnosis could not be made. It would be controversial whether a surgical procedure presented here was the most optimal. Conclusion This is a first reported case of growing aneurysms and cerebral infarction due to arterial dissection. Even if cerebral infarction is accompanied by growing aneurysms, arterial dissection should be included in the differential diagnoses of a cause of infarction. Posterior cervical pain can be a clue for early appropriate diagnosis in such a case. A patient with a growing aneurysm suffered from brain infarction with undiagnosed dissection. Even if an aneurysm grows, arterial dissection can be a true cause of infarction. Cervical pain can be a clue for diagnosing cause of infarction in such a case.
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13
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Lam J, Ravina K, Rennert RC, Russin JJ. Cerebrovascular bypass for ruptured aneurysms: A case series. J Clin Neurosci 2021; 85:106-114. [PMID: 33581780 DOI: 10.1016/j.jocn.2020.12.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2020] [Revised: 12/07/2020] [Accepted: 12/25/2020] [Indexed: 10/22/2022]
Abstract
In patients with aneurysmal subarachnoid hemorrhage (aSAH) unfavorable for endovascular or traditional open surgical techniques, surgical revascularization strategies comprise one of remaining limited options. There is nonetheless a paucity of data on the safety and efficacy of bypass in aSAH. In this study, we aimed to investigate complications and outcomes in a cohort of patients with aSAH treated with bypass. A prospective single-surgeon database of consecutive patients treated for aSAH between 2013 and 2018 was retrospectively analyzed. Complications and functional status at discharge were recorded and analyzed for the patients that underwent bypass surgery. Forty patients with aSAH were treated with bypass surgery (23 extracranial-intracranial; 17 intracranial-intracranial). All-cause perioperative mortality was 13% (6 patients). At discharge and at mean 14-month follow up, respectively, 16/40 (40%) and 16/25 (64%) of patients achieved a Glasgow Outcome Score of 4-5. All-cause, in-hospital complications occurred in 28 patients (70%), of which any ischemic complication occurred in 20 patients (50%), 7 (18%) being open surgical complications. This work represents the largest modern series of bypass for aSAH to date. In cases of aSAH unfavorable for endovascular intervention or traditional open surgical techniques, bypass remains a viable option in this complex group of patients.
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Affiliation(s)
- Jordan Lam
- Neurorestoration Centre, Department of Neurosurgery, Keck School of Medicine of the University of Southern California, 1333 San Pablo Street, Room B51 McKibben Hall, Los Angeles, CA 90033, USA
| | - Kristine Ravina
- Neurorestoration Centre, Department of Neurosurgery, Keck School of Medicine of the University of Southern California, 1333 San Pablo Street, Room B51 McKibben Hall, Los Angeles, CA 90033, USA
| | - Robert C Rennert
- Department of Neurological Surgery, University of California San Diego, San Diego, CA, USA
| | - Jonathan J Russin
- Neurorestoration Centre, Department of Neurosurgery, Keck School of Medicine of the University of Southern California, 1333 San Pablo Street, Room B51 McKibben Hall, Los Angeles, CA 90033, USA.
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14
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Larson AS, Mehta T, Grande AW. Neurosurgical management of aneurysms of the vertebrobasilar system: increasing indications for endovascular therapy with a continued role for open microneurosurgery. Neurosurg Rev 2021; 44:2469-2476. [PMID: 33409762 DOI: 10.1007/s10143-020-01460-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2020] [Revised: 11/16/2020] [Accepted: 12/09/2020] [Indexed: 11/26/2022]
Abstract
Aneurysms of the vertebrobasilar system remain among the most challenging subsets of aneurysms to treat with an open surgical approach. Since Charles Drake's pioneering work in the 1960s, several advances in microsurgical techniques have improved outcomes and feasibility in the open surgical management of these aneurysms. In parallel, the field of endovascular neurosurgery has provided several safe and effective treatment options. Multiple trials have suggested that endovascular therapy for aneurysms of the vertebrobasilar system is superior to open surgical management in most cases. In some instances, however, open surgical management likely represents a more effective and durable option relative to endovascular therapy. Therefore, continued training of future cerebrovascular specialists in open surgery of vertebrobasilar aneurysms remains crucial. With widespread utilization of endovascular techniques, however, proper exposure of trainees to such aneurysms is growing increasingly difficult. In this review, we discuss the recent advances in the endovascular management of vertebrobasilar aneurysms while also emphasizing the continued importance of open microneurosurgery in such cases.
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Affiliation(s)
- Anthony S Larson
- Department of Neurosurgery, University of Minnesota Medical School, 420 Delaware St SE., Minneapolis, MN, 55455, USA.
| | - Tapan Mehta
- Department of Neurosurgery, University of Minnesota Medical School, 420 Delaware St SE., Minneapolis, MN, 55455, USA
- Department of Interventional Neuroradiology and Neurology, Ayer Neuroscience Institute, Hartford Healthcare, West Hartford, CT, USA
| | - Andrew W Grande
- Department of Neurosurgery, University of Minnesota Medical School, 420 Delaware St SE., Minneapolis, MN, 55455, USA
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15
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Ravina K, Fredrickson VL, Donoho DA, Cavaleri JM, Strickland BA, Lam J, Russin JJ. An Expedited Transition to the Back Wall Suturing for Side-to-Side In Situ Microvascular Anastomosis: A Technique Update. Oper Neurosurg (Hagerstown) 2020; 19:E583-E588. [PMID: 32761245 DOI: 10.1093/ons/opaa231] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Accepted: 05/23/2020] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND The side-to-side in situ microvascular anastomosis is an important tool in the cerebrovascular neurosurgeon's armamentarium. The execution of the side-to-side anastomosis, however, can be limited by the inability to acquire sufficient visualization and approximation of the recipient and donor vessels. OBJECTIVE To expedite the transition to the back wall suturing of the donor and recipient vessels during side-to-side in situ microvascular anastomosis. METHODS Incorporation of the first suture throw from the outside to the inside of the vessel lumen with the initial stay suture at the proximal apex of the arteriotomy is described. The apical knot is tied between one limb of the resultant loop and the free end of the suture. The remainder of side-to-side anastomosis can then be completed in a standard fashion starting from the inside of the lumen. RESULTS This modification allows for an expedited transition to the back wall suturing of the 2 arterial segments and avoids difficulties associated with taking the first bite from behind the knot at the proximal apex of the arteriotomy or the transfer of the needle between the approximated vessels. This updated technique is illustrated with a case example, illustration, and video. CONCLUSION This technical modification for the side-to-side anastomosis helps optimize microsurgical efficiency by limiting needle, suture, and vessel handling after the initial suture placement, which has classically been a challenge of this bypass.
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Affiliation(s)
- Kristine Ravina
- Neurorestoration Center, Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Vance L Fredrickson
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Daniel A Donoho
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Jonathon M Cavaleri
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Ben A Strickland
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Jordan Lam
- Neurorestoration Center, Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Jonathan J Russin
- Neurorestoration Center, Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California.,Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California
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16
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Ravina K, Rennert RC, Brandel MG, Strickland BA, Chun A, Lee Y, Carey JN, Russin JJ. Comparative Assessment of Extracranial-to-Intracranial and Intracranial-to-Intracranial In Situ Bypass for Complex Intracranial Aneurysm Treatment Based on Rupture Status: A Case Series. World Neurosurg 2020; 146:e122-e138. [PMID: 33075570 DOI: 10.1016/j.wneu.2020.10.056] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2020] [Revised: 10/08/2020] [Accepted: 10/09/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Comparative outcomes of extracranial-to-intracranial (EC-IC) and intracranial-to-intracranial (IC-IC) bypass for complex aneurysm treatment based on rupture status are not well described in the literature. In this study, we compare outcomes of EC-IC and IC-IC bypass for complex intracranial aneurysm treatment based on rupture status. METHODS A prospective neurosurgical patient database was retrospectively reviewed. Sixty-three consecutive patients with aneurysm managed with revascularization were identified between July 2014 and December 2018. RESULTS During the study period, 41 patients with aneurysm underwent EC-IC bypass (65%; 24 [58.5%] ruptured, 17 [41.5%] unruptured) and 22 patients with aneurysm underwent IC-IC bypass (34.9%; 13 [59.1%] ruptured, 9 [40.9%] unruptured). Graft spasm occurred in 4 patients (9.8%) in the EC-IC group (all ruptured aneurysms) and all anastomoses were patent on immediate postoperative imaging. Perioperative mortality occurred in 5 patients who underwent EC-IC bypass (12.2%; 3 ruptured, 2 unruptured) EC-IC and 2 patients who underwent IC-IC bypass (9.1%; both ruptured); (P = 0.709). Bypass-related complications occurred only in patients with ruptured aneurysm (2 [8.3%] in the EC-IC group and 0 [0%] in the IC-IC group; P = 0.285). For unruptured aneurysms, the overall complication rate was lower in IC-IC compared with the EC-IC group (P = 0.006). Modified Rankin Scale scores on discharge were significantly lower in IC-IC compared with EC-IC bypass for unruptured aneurysms (P = 0.008). There was a trend for shorter temporary occlusion and hospitalization times and overall better outcomes with IC-IC compared with EC-IC bypass. CONCLUSIONS Although often considered riskier than EC-IC bypass, IC-IC in situ bypass showd a favorable technical and safety profile for the treatment of complex, unruptured aneurysms.
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Affiliation(s)
- Kristine Ravina
- Neurorestoration Center, Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Robert C Rennert
- Department of Neurosurgery, University of California San Diego, San Diego, CA, USA
| | - Michael G Brandel
- Department of Neurosurgery, University of California San Diego, San Diego, CA, USA
| | - Ben A Strickland
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Alice Chun
- Neurorestoration Center, Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Yelim Lee
- Neurorestoration Center, Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Joseph N Carey
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Jonathan J Russin
- Neurorestoration Center, Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA; Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA.
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17
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Rennert RC, Russin JJ. Commentary: Reimplantation Bypass Using One Limb of a Double-Origin Posterior Inferior Cerebellar Artery for Treatment of a Ruptured Fusiform Aneurysm: Case Report. Oper Neurosurg (Hagerstown) 2020; 19:E320-E321. [PMID: 32503035 DOI: 10.1093/ons/opaa171] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2020] [Accepted: 04/10/2020] [Indexed: 11/13/2022] Open
Affiliation(s)
- Robert C Rennert
- Department of Neurological Surgery, University of California San Diego, San Diego, California
| | - Jonathan J Russin
- Department of Neurological Surgery, Neurorestoration Center, Keck School of Medicine, University of Southern California, Los Angeles, California
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18
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Lam J, Rennert RC, Ravina K, Lamorie-Foote K, Rangwala SD, Russin JJ. Bypass and Deconstructive Technique for Hunt and Hess Grade 3-5 Aneurysmal Subarachnoid Hemorrhage Deemed Unfavorable for Endovascular Treatment: Case Series of Outcomes and Comparison with Clipping. World Neurosurg 2020; 138:e251-e259. [PMID: 32105867 DOI: 10.1016/j.wneu.2020.02.088] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2019] [Revised: 02/12/2020] [Accepted: 02/14/2020] [Indexed: 11/18/2022]
Abstract
BACKGROUND Intracranial bypass to treat ruptured aneurysms has been well described in the literature but is largely deferred in patients with higher Hunt and Hess (H & H) grades due to complexity and length of surgery, risk of inducing vasospasm, and poor prognosis. However, there is a paucity of data and no direct comparison with more traditional open surgical techniques. This study investigated outcomes in patients with H & H grade 3-5 aneurysmal subarachnoid hemorrhage (aSAH) unfavorable for stand-alone endovascular treatment managed with bypass compared with direct surgical clipping. METHODS A prospective database of patients treated for aSAH with H & H grade 3-5 between 2013 and 2018 was retrospectively analyzed. Complications and functional status at discharge and latest follow-up were compared between patients who underwent bypass surgery versus direct clipping. RESULTS Twenty-three patients underwent revascularization, and 60 underwent clipping alone. There were no significant differences in all-cause 30-day mortality (15% vs. 16%; P = 0.97) or Glasgow Outcome Scale and modified Rankin Scale at discharge or median 8-month follow-up (P > 0.67). There was a higher overall stroke rate with revascularization (P = 0.004), specifically endovascular treatment-related stroke (P = 0.049), with no difference in surgical (P = 0.47) or vasospasm-related stroke (P = 0.53). There were no differences in overall complications, medical complications, seizures, reruptures, hydrocephalus, or perioperative death (P > 0.05). CONCLUSIONS Bypass is a viable option for patients presenting with higher H & H grade aSAH deemed unfavorable for stand-alone endovascular therapy. Despite obvious differences in aneurysm complexity and a higher risk of stroke, functional outcomes with revascularization can be comparable with clipping in this high-risk patient cohort.
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Affiliation(s)
- Jordan Lam
- Neurorestoration Center, Department of Neurosurgery, Keck School of Medicine of the University of Southern California, Los Angeles, California, USA
| | - Robert C Rennert
- Department of Neurological Surgery, University of California, San Diego, California, USA
| | - Kristine Ravina
- Neurorestoration Center, Department of Neurosurgery, Keck School of Medicine of the University of Southern California, Los Angeles, California, USA
| | - Krista Lamorie-Foote
- Neurorestoration Center, Department of Neurosurgery, Keck School of Medicine of the University of Southern California, Los Angeles, California, USA
| | - Shivani D Rangwala
- Neurorestoration Center, Department of Neurosurgery, Keck School of Medicine of the University of Southern California, Los Angeles, California, USA
| | - Jonathan J Russin
- Neurorestoration Center, Department of Neurosurgery, Keck School of Medicine of the University of Southern California, Los Angeles, California, USA.
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19
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Miao HL, Zhang DY, Wang T, Jiao XT, Jiao LQ. Clinical Importance of the Posterior Inferior Cerebellar Artery: A Review of the Literature. Int J Med Sci 2020; 17:3005-3019. [PMID: 33173421 PMCID: PMC7646108 DOI: 10.7150/ijms.49137] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Accepted: 10/07/2020] [Indexed: 12/12/2022] Open
Abstract
The posterior inferior cerebellar artery (PICA), with its unique anatomical complexity, is of great clinical importance and involved in many diseases including aneurysm, ischemic stroke, neurovascular compression syndrome (NVCS), arteriovenous malformation (AVM), and brain tumor. However, a comprehensive systematic review of the importance of the PICA is currently lacking. In this study, we perform a literature review of PICA by searching all the associated papers in the PUBMED database hoping to provide a better understanding of the artery. The PICA has tortuous and variable course and territory, divided into 5 segments. Various aneurysms involving PICA were not uncommon, of which the treatment is challenging. The PICA infarct typically manifests lateral medullary syndrome (LMS) and is more likely to cause mass effects. The PICA frequently compresses the medulla and the cranial nerves resulting in various neurovascular compression syndromes (NVCS). Arteriovenous malformation (AVM) fed by PICA are associated with aneurysm and dissection which have high risk of rupture and worse outcome. PICA injured by head trauma can cause fatal SAH. VA terminating in PICA probably cause Bow hunter's syndrome (BHS). The PICA supplies many brain tumors and can be used in intracerebellar chemotherapy. The PICA can be exposed and injured during surgeries especially in telovelar approach, and it also plays an important role in bypass surgeries, hinting the surgical importance of PICA. In conclusion, PICA is very important in clinical practice.
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Affiliation(s)
- Hui-Lei Miao
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, No. 45, Changchun Street, Beijing 100032, China.,Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing 100730, China
| | - Deng-Yan Zhang
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, No. 45, Changchun Street, Beijing 100032, China.,School of General Practice and Continuing Education, Capital Medical University, Beijing 100069,China
| | - Tao Wang
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, No. 45, Changchun Street, Beijing 100032, China
| | - Xiao-Tian Jiao
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, No. 45, Changchun Street, Beijing 100032, China
| | - Li-Qun Jiao
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, No. 45, Changchun Street, Beijing 100032, China
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20
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Rennert RC, Strickland BA, Ravina K, Brandel MG, Bakhsheshian J, Fredrickson V, Carey J, Russin JJ. Assessment of ischemic risk following intracranial-to-intracranial and extracranial-to-intracranial bypass for complex aneurysms using intraoperative Indocyanine Green-based flow analysis. J Clin Neurosci 2019; 67:191-197. [PMID: 31266716 DOI: 10.1016/j.jocn.2019.06.036] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2019] [Revised: 05/13/2019] [Accepted: 06/21/2019] [Indexed: 11/28/2022]
Abstract
Cerebral bypass is often needed for complex aneurysms requiring vessel sacrifice, yet intraoperative predictors of ischemic risk in bypass-dependent territories are limited. Indocyanine Green (ICG)-based flow analyses (ICG-BFAs; Flow 800, Carl Zeiss, Oberkochen, Germany) semi-quantitatively assess cortical perfusion, and in this work we determine the efficacy of ICG-BFA for assessing post-operative ischemic risk during cerebral bypass surgery for complex aneurysms. Retrospective clinical and pre/post-bypass intra-operative ICG-BFA data (delay and blood flow index [BFI]) on ten patients undergoing cerebral bypass for complex cerebral aneurysms requiring vessel sacrifice were collected from a single-institution prospective database and analyzed via non-parametric testing and logistic regression. Mean age was 55.9 ± 14.8 years. Pre/post-bypass delay (median 35.6 [5.1-51.3] vs. 26.0 [17.1-59.9]; p = 0.2) and BFI (median 56.1 [8.1-120.4] vs. 32.2 [3.0-147.4]; p = 0.2) did not significantly differ. Two patients (20%) developed post-operative ischemia in bypass dependent territories. Delay ratio did not differ between patients with and without post-operative ischemia (median 1.15 [0.67-1.64] vs. 0.83 [0.36-3.56]; p = 0.6), nor predict stroke risk (odds ratio = 1.1, p = 0.9). Conversely, BFI ratio was significantly lower for patients experiencing post-operative ischemia than those without ischemia (median 0.11 [0.06-0.17] vs. 0.99 [0.28-1.42]; p = 0.03). A BFI ratio <0.21 predicted the occurrence of post-operative ischemia (odds ratio = 0.02, p = 0.05). These data suggest that intraoperative ICG-BFA may help assess post-operative ischemic risk during cerebral bypass surgery for complex aneurysms requiring vessel sacrifice.
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Affiliation(s)
- Robert C Rennert
- Department of Neurological Surgery, University of California San Diego, San Diego, CA, USA
| | - Ben A Strickland
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Kristine Ravina
- Neurorestoration Center, Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Michael G Brandel
- Department of Neurological Surgery, University of California San Diego, San Diego, CA, USA
| | - Joshua Bakhsheshian
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Vance Fredrickson
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Joseph Carey
- Department of Plastic Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Jonathan J Russin
- Neurorestoration Center, Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA.
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