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Zakaria J, Gonzalez SM, Serrone JC. Destructive strategies in treating cerebrovascular pathology: Review and treatment algorithm. Rev Neurol (Paris) 2022; 178:1031-1040. [PMID: 36137828 DOI: 10.1016/j.neurol.2022.06.005] [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: 04/26/2022] [Revised: 05/27/2022] [Accepted: 06/08/2022] [Indexed: 12/14/2022]
Abstract
The goal of cerebrovascular pathology treatment is most often to angiographically eradicate a lesion with the lowest probability of morbidity. Destructive strategies using parent vessel occlusion are less commonly considered in the modern era. We review principles of parent vessel occlusion for treatment of cerebrovascular pathology and select cases to demonstrate these principles. Many common cerebrovascular conditions have been safely and effectively treated with destructive strategies including intracranial aneurysms, traumatic craniocervical vascular injuries, and oncologic indications such as carotid blowout. Avoiding procedural morbidity in these procedures involves assessment of collaterals distal to a planned parent vessel occlusion, determination of this arterial segment's eloquence, prevention of distal migration of endovascular devices or thrombus, and prevention of stump emboli. An algorithm for case selection and method of destructive technique versus a reconstructive approach can be used. Destructive strategies for treating cerebrovascular pathology are still relevant and can be applied safely in appropriately selected cases.
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Affiliation(s)
- J Zakaria
- Loyola University Health System, Department of Neurosurgery, Maywood, IL, United States
| | - S-M Gonzalez
- Loyola Stritch School of Medicine, Maywood, IL, United States
| | - J C Serrone
- Loyola University Health System, Department of Neurosurgery, Maywood, IL, United States; Loyola Stritch School of Medicine, Maywood, IL, United States; Edward Hines Jr., VA Hospital, Department of Neurosurgery, Hines, IL, United States.
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2
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The surgical management of intraoperative intracranial internal carotid artery injury in open skull base surgery-a systematic review. Neurosurg Rev 2021; 45:1263-1273. [PMID: 34802074 DOI: 10.1007/s10143-021-01692-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Revised: 11/03/2021] [Accepted: 11/06/2021] [Indexed: 01/25/2023]
Abstract
Intraoperative internal carotid artery (ICA) injury during open skull base surgery is a catastrophic complication. Multiple techniques and management strategies have been reported for endoscopic skull base surgery; however, the literature on managing this complication in open skull base surgery is limited. To perform a systematic review and give an overview of the different techniques described to manage this complication intraoperatively, a systematic review was conducted in PubMed, Ovid Medline, Ovid Embase and Scopus for literature published until July 2021. Titles and abstracts were screened. Studies meeting prespecified inclusion criteria were reviewed in full. PRISMA guidelines were strictly adhered to. Out of 4492 articles, only 12 articles could be included, reflecting an underreporting of open skull base ICA injuries. Multiple techniques can be used depending on the location and size of the injury as well as the surgeon's experience. Described techniques include the following: a primary repair via a micro-suture or nonpenetrating clips; wrapping or plugging; coating; occlusion of the parent artery with or without a bypass; packing with further endovascular management. A treatment algorithm is proposed.
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3
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Almefty RO, Al-Mefty O. Cervical to Petrous Carotid Artery High-Flow Bypass for Carotid Artery Pseudoaneurysm Through Zygomatic Approach: 2-Dimensional Operative Video. Oper Neurosurg (Hagerstown) 2021; 21:E334-E335. [PMID: 34192762 DOI: 10.1093/ons/opab235] [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: 02/22/2021] [Accepted: 05/03/2021] [Indexed: 11/14/2022] Open
Abstract
Pseudoaneurysms of the cervical internal carotid artery may generate grave risk from catastrophic rupture, thromboembolic stroke, or mass effect. They have many causes, including malignancy, infection, and iatrogenic and most commonly blunt or penetrating trauma.1 These aneurysms require treatment to eliminate their risk. Treatment options include trapping, with or without revascularization, or endovascular stenting. Trapping without revascularization requires evaluation of the cerebral collateral under a physiological challenge, which is usually done with a balloon occlusion test, which is not applicable in this lesion.2 Occluding the carotid without revascularization carries the risk of delayed ischemia and aneurysm formation.3,4 Carotid stenting has been applied in the treatment of these lesions5,6; however, the extent of the lesion in our patient from the carotid bifurcation to the petrous carotid makes endovascular treatment challenging. We present a patient with a delayed post-traumatic pseudoaneurysm of the carotid artery that extended from the bifurcation to the petrous carotid who was treated with trapping and high-flow saphenous vein bypass from the proximal cervical internal carotid to the petrous carotid. Adequate exposure of the petrous carotid to perform anastomosis requires a thorough knowledge of the anatomy and surgical nuances, which we demonstrate here through a zygomatic approach.7 The patient consented to the procedure and publication of imaging. Image at 2:28 from Al-Mefty O, Operative Atlas of Meningiomas, © LWW, 1997, with permission.
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Affiliation(s)
- Rami O Almefty
- Department of Neurosurgery, Lewis Katz School of Medicine, Temple University, Philadelphia, Pennsylvania, USA
| | - Ossama Al-Mefty
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
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4
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Nuñez M, Guillotte A, Faraji AH, Deng H, Goldschmidt E. Blood supply to the corticospinal tract: A pictorial review with application to cranial surgery and stroke. Clin Anat 2021; 34:1224-1232. [PMID: 34478213 DOI: 10.1002/ca.23782] [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: 07/05/2021] [Revised: 08/27/2021] [Accepted: 09/01/2021] [Indexed: 12/18/2022]
Abstract
The corticospinal tract (CST) is the main neural pathway responsible for conducting voluntary motor function in the central nervous system. The CST condenses into fiber bundles as it descends from the frontoparietal cortex, traveling down to terminate at the anterior horn of the spinal cord. The CST is at risk of injury from vascular insult from strokes and during neurosurgical procedures. The aim of this article is to identify and describe the vasculature associated with the CST from the cortex to the medulla. Dissection of cadaveric specimens was carried out in a manner, which exposed and preserved the fiber tracts of the CST, as well as the arterial systems that supply them. At the level of the motor cortex, the CST is supplied by terminal branches of the anterior cerebral artery and middle cerebral artery. The white matter tracts of the corona radiata and internal capsule are supplied by small perforators including the lenticulostriate arteries and branches of the anterior choroidal artery. In the brainstem, the CST is supplied by anterior perforating branches from the basilar and vertebral arteries. The caudal portions of the CST in the medulla are supplied by the anterior spinal artery, which branches from the vertebral arteries. The non-anastomotic nature of the vessel systems of the CST highlights the importance of their preservation during neurosurgical procedures. Anatomical knowledge of the CST is paramount to clinical diagnosis and treatment of heterogeneity of neurodegenerative, neuroinflammatory, cerebrovascular, and skull base tumors.
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Affiliation(s)
- Maximilano Nuñez
- Hospital El Cruce, Buenos Aires University Medical School, Florencio Varela, Argentina
| | - Andrew Guillotte
- University of Missouri School of Medicine, Columbia, Missouri, USA
| | - Amir H Faraji
- Department of Neurosurgery, Houston Methodist, Houston, Texas, USA
| | - Hansen Deng
- Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Ezequiel Goldschmidt
- Department of Neurosurgery, University of California San Francisco, San Francisco, California, USA
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Wang W, Liang X, Chen G, Yang P, Zhang J, Liu H, Zhao S, Li Y, Sun B, Kang J. Treatment of Intracranial Pseudoaneurysms With a Novel Covered Stent: A Series of 19 Patients With Midterm Follow-Up. Front Neurol 2020; 11:580877. [PMID: 33324325 PMCID: PMC7723868 DOI: 10.3389/fneur.2020.580877] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Accepted: 10/21/2020] [Indexed: 01/04/2023] Open
Abstract
Background: The optimal treatment for intracranial pseudoaneurysm is unclear. This study aims to analyze the outcome of treating intracranial pseudoaneurysm with a novel covered stent. Materials and Methods: The institutional imaging and clinical databases were retrospectively reviewed for patients with intracranial pseudoaneurysms treated with Willis covered stent from January 2017 to December 2019. The clinical presentations, etiology, intraoperative complications, and immediate and follow-up outcomes were analyzed. Results: A total of 19 patients with 20 pseudoaneurysms were enrolled for analysis. Seventeen patients presented with vision loss and two with epistaxis. Nineteen Willis covered stents were used with one for each patient without technical failure. Intraoperative thrombosis was encountered in one patient (5.3%), which was recanalized by tirofiban. During clinical follow-up, no further epistaxis occurred, and visual acuity improved in three (17.6%) patients. Endoleak occurred in seven (36.8%) patients after the initial balloon inflation and persisted in one (5.3%) patient after balloon re-inflation. This endoleak disappeared at 8 month follow-up. Finally, during angiographic follow-up (median 13 months), parent artery occlusion and in-stent stenosis occurred in one (5.3%) patient. No stent-related ischemic event was encountered. Conclusions: The Willis covered stent is feasible, safe, and efficient in treating intracranial pseudoaneurysms.
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Affiliation(s)
- Wei Wang
- Neurosurgery Department, Tongren Hospital of Capital Medical University, Beijing, China
| | - Xihong Liang
- Neurosurgery Department, Tongren Hospital of Capital Medical University, Beijing, China
| | - Guangli Chen
- Neurosurgery Department, Tongren Hospital of Capital Medical University, Beijing, China
| | - Peng Yang
- Neurosurgery Department, Tongren Hospital of Capital Medical University, Beijing, China
| | - Jialiang Zhang
- Neurosurgery Department, Tongren Hospital of Capital Medical University, Beijing, China
| | - Haocheng Liu
- Neurosurgery Department, Tongren Hospital of Capital Medical University, Beijing, China
| | - Shangfeng Zhao
- Neurosurgery Department, Tongren Hospital of Capital Medical University, Beijing, China
| | - Yong Li
- Neurosurgery Department, Tongren Hospital of Capital Medical University, Beijing, China
| | - Bowen Sun
- Neurosurgery Department, Tongren Hospital of Capital Medical University, Beijing, China
| | - Jun Kang
- Neurosurgery Department, Tongren Hospital of Capital Medical University, Beijing, China
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Kubo Y, Koji T, Murakami T, Yoshida K, Matsumoto Y, Ogasawara K. Long-Term Outcomes of Cerebral Blood Flow and Neurotransmitter Receptor Function on Iodine-123-Iomazenil Single-Photon Emission Computed Tomography and Cognitive Assessments After Parent Artery Occlusion Combined with Cerebral Revascularization for Internal Carotid Artery Aneurysms. World Neurosurg 2020; 143:e199-e205. [PMID: 32810631 DOI: 10.1016/j.wneu.2020.07.119] [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: 04/09/2020] [Revised: 07/13/2020] [Accepted: 07/15/2020] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Many studies of external-internal carotid artery (EC-IC) bypass as cerebral revascularization for unclippable internal carotid artery (ICA) aneurysms have reported surgical outcomes, including bypass patency and aneurysm resolution. However, no previous studies have assessed the long-term outcomes of cerebral blood flow (CBF), brain neural density, and cognition. The purpose of the present study was to evaluate the long-term outcomes of CBF and neurotransmitter receptor function using early and late images of iodine-123 (123I)-iomazenil (IMZ) single-photon emission computed tomography (SPECT) and the cognitive function of patients who had undergone EC-IC bypass for symptomatic aneurysms in the cavernous portion of the ICA. METHODS We performed a prospective observational study of 11 patients who had undergone superficial temporal artery-middle cerebral artery bypass or bypass using a saphenous vein graft for symptomatic aneurysms in the cavernous portion of the ICA. One patient experienced extensive infarction and, therefore, did not undergo postoperative testing. 123I-IMZ SPECT was performed with scanning at 23 minutes (early) and 180 minutes (late) after tracer administration before and after surgery. The preoperative and follow-up neuropsychological test scores from 6 patients were also analyzed. RESULTS None of 10 patients who had undergone EC-IC bypass showed reductions in CBF and brain neural density. In addition, the neuropsychological test scores had not changed significantly from preoperatively to postoperatively. CONCLUSION Using early and late 123I-IMZ SPECT, the present study has demonstrated that patients undergoing uncomplicated cerebral revascularization for unclippable ICA aneurysms will not experience reductions in CBF or neurotransmitter receptor function, and their cognitive function was not impaired.
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Affiliation(s)
- Yoshitaka Kubo
- Department of Neurosurgery, Iwate Medical University, Morioka, Japan.
| | - Takahiro Koji
- Department of Neurosurgery, Iwate Medical University, Morioka, Japan
| | | | - Kenji Yoshida
- Department of Neurosurgery, Iwate Medical University, Morioka, Japan
| | | | - Kuniaki Ogasawara
- Department of Neurosurgery, Iwate Medical University, Morioka, Japan
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Vaz-Guimaraes F, Fernandez-Miranda JC, Koutourousiou M, Hamilton RL, Wang EW, Snyderman CH, Gardner PA. Endoscopic Endonasal Surgery for Cranial Base Chondrosarcomas. Oper Neurosurg (Hagerstown) 2019; 13:421-434. [PMID: 28838112 DOI: 10.1093/ons/opx020] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2016] [Accepted: 01/24/2017] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Microsurgical resection via open approaches is considered the main treatment modality for cranial base chondrosarcomas (CBCs). The use of endoscopic endonasal approaches (EEAs) has been rarely reported. OBJECTIVE To present the endoscopic endonasal experience with CBCs at our institution. METHODS Retrospective review of the medical records of 35 consecutive patients who underwent EEA for CBC resection between January 2004 and April 2013. Surgical outcomes and variables that might affect extent of resection, complications, and recurrence were analyzed. RESULTS Forty-eight operations were performed (42 EEAs and 6 open approaches). Gross-total resection was achieved in 22 patients (62.9%), near total (≥90% tumor resection) in 11 (31.4%). Larger tumors were associated with incomplete resection in univariate and multivariate analysis ( P = .004, .015, respectively). In univariate analysis, tumors involving the lower clivus and cerebellopontine angle were associated with increased number of complications, especially postoperative cerebrospinal fluid leak ( P = .015) and new cranial neuropathy ( P = .037), respectively. Other major complications included 2 cases of meningitis and deep venous thrombosis, and 1 case of hydrocephalus and carotid injury. Involvement of the lower clivus, parapharyngeal space, and cervical spine required a combination of approaches to maximize tumor resection ( P = .017, .044, .017, respectively). No predictors were significantly associated with increased risk of recurrence. The average follow-up time was 44.6 ± 31 months. CONCLUSIONS EEAs may be considered a good option for managing CBCs without significant posterolateral extension beyond the basal foramina and can be used in conjunction with open approaches for maximal resection with acceptable morbidity.
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Affiliation(s)
| | - Juan C Fernandez-Miranda
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Maria Koutourousiou
- Department of Neurolog-ical Surgery, University of Louisville, Louisville, Kentucky
| | | | - Eric W Wang
- Department of Oto-laryngology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Carl H Snyderman
- Department of Oto-laryngology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Paul A Gardner
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
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8
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Briggs RG, Pryor DP, Conner AK, Nix CE, Milton CK, Kuiper JK, Palejwala AH, Sughrue ME. The Artery of Aphasia, A Uniquely Sensitive Posterior Temporal Middle Cerebral Artery Branch that Supplies Language Areas in the Brain: Anatomy and Report of Four Cases. World Neurosurg 2019; 126:e65-e76. [PMID: 30735868 DOI: 10.1016/j.wneu.2019.01.159] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2018] [Revised: 01/14/2019] [Accepted: 01/17/2019] [Indexed: 10/27/2022]
Abstract
BACKGROUND Arterial disruption during brain surgery can cause devastating injuries to wide expanses of white and gray matter beyond the tumor resection cavity. Such damage may occur as a result of disrupting blood flow through en passage arteries. Identification of these arteries is critical to prevent unforeseen neurologic sequelae during brain tumor resection. In this study, we discuss one such artery, termed the artery of aphasia (AoA), which when disrupted can lead to receptive and expressive language deficits. METHODS We performed a retrospective review of all patients undergoing an awake craniotomy for resection of a glioma by the senior author from 2012 to 2018. Patients were included if they experienced language deficits secondary to postoperative infarction in the left posterior temporal lobe in the distribution of the AoA. The gross anatomy of the AoA was then compared with activation likelihood estimations of the auditory and semantic language networks using coordinate-based meta-analytic techniques. RESULTS We identified 4 patients with left-sided posterior temporal artery infarctions in the distribution of the AoA on diffusion-weighted magnetic resonance imaging. All 4 patients developed substantial expressive and receptive language deficits after surgery. Functional language improvement occurred in only 2/4 patients. Activation likelihood estimations localized parts of the auditory and semantic language networks in the distribution of the AoA. CONCLUSIONS The AoA is prone to blood flow disruption despite benign manipulation. Patients seem to have limited capacity for speech recovery after intraoperative ischemia in the distribution of this artery, which supplies parts of the auditory and semantic language networks.
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Affiliation(s)
- Robert G Briggs
- Department of Neurosurgery, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA
| | - Dillon P Pryor
- Department of Neurosurgery, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA
| | - Andrew K Conner
- Department of Neurosurgery, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA
| | - Cameron E Nix
- Department of Neurosurgery, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA
| | - Camille K Milton
- Department of Neurosurgery, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA
| | - Joseph K Kuiper
- Department of Neurosurgery, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA
| | - Ali H Palejwala
- Department of Neurosurgery, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA
| | - Michael E Sughrue
- Department of Neurosurgery, Prince of Wales Private Hospital, Sydney, Australia.
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9
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Wolfswinkel EM, Landau MJ, Ravina K, Kokot NC, Russin JJ, Carey JN. EC-IC bypass for cerebral revascularization following skull base tumor resection: Current practices and innovations. J Surg Oncol 2018; 118:815-825. [PMID: 30196557 DOI: 10.1002/jso.25178] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2018] [Accepted: 07/05/2018] [Indexed: 11/09/2022]
Abstract
Complex skull base tumors can involve critical vessels of the head and neck. To achieve a gross total resection, vessel sacrifice may be necessary. In cases where vessel sacrifice will cause symptomatic cerebral ischemia, surgical revascularization is required. The purpose of this paper is to review cerebral revascularization for skull base tumors, the indications for these procedures, outcomes, advances, and future directions.
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Affiliation(s)
- Erik M Wolfswinkel
- Division of Plastic and Reconstructive Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Mark J Landau
- Division of Plastic and Reconstructive Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Kristine Ravina
- Neurorestoration Center, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Niels C Kokot
- Department of Otolaryngology- Head and Neck Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Jonathan J Russin
- Neurorestoration Center, 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
| | - Joseph N Carey
- Division of Plastic and Reconstructive Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California
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10
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Xin C, Zhang J, Li Z, Xiong Z, Yang B, Wu X, Wang H, Zou Y, Wu R, Zhao W, Chen J. Treatment of giant cavernous aneurysm in an elderly patient via extracranial-intracranial saphenous vein bypass graft in a hybrid operating room: A case report. Medicine (Baltimore) 2018; 97:e0295. [PMID: 29620651 PMCID: PMC5902283 DOI: 10.1097/md.0000000000010295] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
RATIONALE Extracranial-intracranial saphenous vein bypass (EC-IC SVB) remains indispensable for treating giant cavernous aneurysms. We report an unusual case of a giant cavernous aneurysm in an elderly patient treated with EC-IC SVB in a hybrid operating room. Immediately following proximal ligation of the internal carotid artery (ICA), she suffered an acute intraoperative encephalocele. PATIENT CONCERNS A 71-year-old woman had suffered from severe headache and double vision for 4 months. DIAGNOSES The woman was diagnosed with a right giant cavernous aneurysm. INTERVENTIONS She was treated with an EC-IC SVB with therapeutic ICA occlusion in the first biplane hybrid operating room in China. Just after proximal ligation of the ICA, she developed an acute encephalocele, and immediately underwent decompressive craniectomy. During the surgery she underwent 3 angiographic explorations. OUTCOMES After surgery, the aneurysm disappeared, and the graft was patent. Postoperative computed tomography and computed tomography angiography indicated a cranial defect and graft patency. LESSONS Although a hybrid operating room could improve the patency of grafts, the timing of ICA ligation for giant cavernous aneurysm via EC-IC bypass deserves further discussion. Second-stage ICA occlusion could offer an alternative for elderly patients requiring such treatment. In addition, cranial flap removal could prevent further neurologic deficits in a case of acute intraoperative encephalocele.
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Raheja A, Couldwell WT. Management of Cavernous Sinus Involvement in Sinonasal and Ventral Skull Base Malignancies. Otolaryngol Clin North Am 2017; 50:365-383. [PMID: 28314403 DOI: 10.1016/j.otc.2016.12.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Cavernous sinus (CS) involvement by sinonasal and ventral skull base malignancies is infrequently encountered in neurosurgical practice. Despite advancements in skull base microneurosurgery and endoscopic techniques, detailed knowledge and experience of the surgical management of these lesions are limited. This article elaborates on surgical strategies and approaches for CS involvement of malignant ventral skull base tumors. The article discusses the indications, techniques, nuances, advantages, limitations, and complications of minimally invasive CS biopsy, transcranial microscopic, and transfacial endoscopic approaches to the CS using illustrative diagrams and operative videos. The principles and nuances of a high-flow cerebral revascularization procedure are mentioned.
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Affiliation(s)
- Amol Raheja
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, 175 North Medical Drive East, Salt Lake City, UT 84132, USA
| | - William T Couldwell
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, 175 North Medical Drive East, Salt Lake City, UT 84132, USA.
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12
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Matsukawa H, Miyata S, Tsuboi T, Noda K, Ota N, Takahashi O, Takeda R, Tokuda S, Kamiyama H, Tanikawa R. Rationale for graft selection in patients with complex internal carotid artery aneurysms treated with extracranial to intracranial high-flow bypass and therapeutic internal carotid artery occlusion. J Neurosurg 2017; 128:1753-1761. [PMID: 28574313 DOI: 10.3171/2016.11.jns161986] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE After internal carotid artery (ICA) sacrifice without revascularization for complex aneurysms, ischemic complications can occur. In addition, hemodynamic alterations in the circle of Willis create conditions conducive to the formation of de novo aneurysms or the enlargement of existing untreated aneurysms. Therefore, the revascularization technique remains indispensable. Because vessel sizes and the development of collateral circulation are different in each patient, the ideal graft size to prevent low flow-related ischemic complications (LRICs) in external carotid artery (ECA)-middle cerebral artery (MCA) bypass with therapeutic ICA occlusion (ICAO) has not been well established. Authors of this study hypothesized that the adequate graft size could be calculated from the size of the sacrificed ICA and the values of MCA pressure (MCAP) and undertook an investigation in patients with complex ICA aneurysms treated with ECA-graft-MCA bypass and therapeutic ICAO. METHODS In the period between July 2006 and January 2016, 80 patients with complex ICA aneurysms were treated with ECA-MCA bypass and therapeutic ICAO. Preoperative balloon test occlusion (BTO) was performed, and the BTO pressure ratio was defined as the mean stump pressure/mean preocclusion pressure. Low flow-related ischemic complications were defined as new postoperative neurological deficits and ipsilateral cerebral blood flow reduction. Initial MCAP (iMCAP), MCAP after clamping the ICA (cMCAP), and MCAP after releasing the graft (gMCAP) were intraoperatively monitored. The MCAP ratio was defined as gMCAP/iMCAP. Based on the Hagen-Poiseuille law, the expected MCAP ratio ([expected gMCAP]/iMCAP) was hypothesized as follows: (1 - cMCAP/iMCAP)(graft radius/ICA radius)2 + (cMCAP/iMCAP). Correlations between the BTO pressure ratio and cMCAP/iMCAP, and between the actual and expected MCAP ratios, were evaluated. Risk factors for LRICs were also evaluated. RESULTS The mean BTO pressure ratio was significantly correlated with the mean cMCAP/iMCAP (r = 0.68, p < 0.0001). The actual MCAP ratio correlated with the expected MCAP ratio (r = 0.43, p < 0.0001). If the expected MCAP ratio was set up using the BTO pressure ratio instead of cMCAP/iMCAP (BTO-expected MCAP ratio), the mean BTO-expected MCAP ratio significantly correlated with the expected MCAP ratio (r = 0.95, p < 0.0001). During a median follow-up period of 26.1 months, LRICs were observed in 9 patients (11%). An actual MCAP ratio < 0.80 (p = 0.003), expected MCAP ratio < 0.80 (p = 0.001), and (M2 radius/graft radius)2 < 0.49 (p = 0.002) were related to LRICs according to the Cox proportional-hazards model. CONCLUSIONS Data in the present study indicated that it was important to use an adequate graft to achieve a sufficient MCAP ratio in order to avoid LRICs and that the adequate graft size could be evaluated based on a formula in patients with complex ICA aneurysms treated with ICAO.
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Affiliation(s)
- Hidetoshi Matsukawa
- 1Department of Neurosurgery, Stroke Center, Teishinkai Hospital, Sapporo; and
| | - Shiro Miyata
- 1Department of Neurosurgery, Stroke Center, Teishinkai Hospital, Sapporo; and
| | - Toshiyuki Tsuboi
- 1Department of Neurosurgery, Stroke Center, Teishinkai Hospital, Sapporo; and
| | - Kosumo Noda
- 1Department of Neurosurgery, Stroke Center, Teishinkai Hospital, Sapporo; and
| | - Nakao Ota
- 1Department of Neurosurgery, Stroke Center, Teishinkai Hospital, Sapporo; and
| | - Osamu Takahashi
- 2Center for Clinical Epidemiology, Internal Medicine, St. Luke's International Hospital, Tokyo, Japan
| | - Rihee Takeda
- 1Department of Neurosurgery, Stroke Center, Teishinkai Hospital, Sapporo; and
| | - Sadahisa Tokuda
- 1Department of Neurosurgery, Stroke Center, Teishinkai Hospital, Sapporo; and
| | - Hiroyasu Kamiyama
- 1Department of Neurosurgery, Stroke Center, Teishinkai Hospital, Sapporo; and
| | - Rokuya Tanikawa
- 1Department of Neurosurgery, Stroke Center, Teishinkai Hospital, Sapporo; and
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13
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Chen C, Hou B, Li WS, Guo Y. Combining Internal Carotid Ligation with Low-Flow Bypass for Treating Large-Giant Cavernous Sinus Segment Aneurysms: A Report of Four Cases. World Neurosurg 2017; 100:280-287. [DOI: 10.1016/j.wneu.2017.01.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2016] [Revised: 01/03/2017] [Accepted: 01/04/2017] [Indexed: 11/17/2022]
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Almefty R, Dunn IF, Aziz-Sultan MA, Al-Mefty O. Delayed Carotid Pseudoaneurysms from Iatrogenic Clival Meningeal Branches Avulsion: Recognition and Proposed Management. World Neurosurg 2017; 104:736-744. [PMID: 28300709 DOI: 10.1016/j.wneu.2017.03.016] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2017] [Revised: 03/03/2017] [Accepted: 03/04/2017] [Indexed: 11/18/2022]
Abstract
BACKGROUND Carotid injury during anterior skull base approaches is promptly recognizable and mandates immediate treatment; likewise, development of pseudoaneurysms after such injuries is anticipated and managed. METHODS We report here on the delayed development of a pseudoaneurysm as the result of avulsion of clival meningeal arteries that manifests as unalarming intraoperative bleeding. RESULTS AND CONCLUSIONS The bleeding is brisk and arterial but easily controlled. Immediate postoperative angiography is negative, necessitating repeated angiography to depict the delayed formation. It is best treated by endovascular means that maintains patency of the carotid artery, calling for the development of a suitable device that obliterates the opening of the pseudoaneurysm while maintaining carotid flow that is deployable in the tortuous carotid artery.
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Affiliation(s)
- Rami Almefty
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA; Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona, USA.
| | - Ian F Dunn
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Muhammad Ali Aziz-Sultan
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Ossama Al-Mefty
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
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15
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Sriamornrattanakul K, Sakarunchai I, Yamashiro K, Yamada Y, Suyama D, Kawase T, Kato Y. Surgical treatment of large and giant cavernous carotid aneurysms. Asian J Neurosurg 2017; 12:382-388. [PMID: 28761512 PMCID: PMC5532919 DOI: 10.4103/1793-5482.180930] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Cavernous carotid aneurysms (CCAs) are uncommon pathologic entities. Extradural place and the skull base location make this type of an aneurysm different in clinical features and treatment techniques. Direct aneurysm clipping is technically difficult and results in a significant postoperative neurological deficit. Therefore, several techniques of indirect surgical treatment were developed with different surgical outcomes, such as proximal occlusion of internal carotid artery (ICA) or trapping with or without bypass (superficial temporal artery-middle cerebral artery bypass or high-flow bypass). High-flow bypass with proximal ICA occlusion seems to be the most appropriate surgical treatment for CCA because of the high rate of symptom improvement, aneurysm thrombosis, and minimal postoperative complications. However, in cases of CCA presented with direct carotid-cavernous fistula, the appropriate surgical treatment is high-flow bypass with aneurysm trapping, which the fistula can be obliterated immediately after surgery.
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Affiliation(s)
- Kitiporn Sriamornrattanakul
- Department of Surgery, Division of Neurosurgery, Faculty of Medicine, Vajira Hospital, Navamindradhiraj University, Bangkok, Thailand
| | - Ittichai Sakarunchai
- Department of Surgery, Division of Neurosurgery, Prince of Songkla University, Songkhla, Thailand
| | - Kei Yamashiro
- Department of Neurosurgery, Banbuntane Hotokukai Hospital, Fujita Health University, Nagoya, Japan
| | - Yasuhiro Yamada
- Department of Neurosurgery, Banbuntane Hotokukai Hospital, Fujita Health University, Nagoya, Japan
| | - Daisuke Suyama
- Department of Neurosurgery, Banbuntane Hotokukai Hospital, Fujita Health University, Nagoya, Japan
| | - Tsukasa Kawase
- Department of Neurosurgery, Banbuntane Hotokukai Hospital, Fujita Health University, Nagoya, Japan
| | - Yoko Kato
- Department of Neurosurgery, Banbuntane Hotokukai Hospital, Fujita Health University, Nagoya, Japan
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16
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Bhogal P, Paraskevopoulos D, Makalanda HL. The use of a stent-retriever to cause mechanical dilatation of a vasospasm secondary to iatrogenic subarachnoid haemorrhage. Interv Neuroradiol 2017; 23:330-335. [PMID: 28604190 DOI: 10.1177/1591019917694838] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Objective To report the use of a stent-retriever in the management of vasospasm secondary to craniopharyngioma resection. Postoperative improvement was seen both clinically and on perfusion imaging. Methods A patient was admitted for resection of a large craniopharygioma. On day 6 postoperatively the patient had an acute hemiparesis. A computed tomography angiogram and perfusion scan demonstrated acute right-sided cerebral vasospasm and a perfusion defect in the territory of the middle cerebral artery (MCA). Results A pREset 4 × 20 mm stent-retriever was used to dilate the M1 and proximal M2 segments of the right MCA mechanically. This resulted in immediate dilatation of the spastic segment and improvement in the transit time on the angiogram. There was an improvement in the clinical status post-procedure and a computed tomography perfusion performed 24 hours after the procedure showed symmetrical perfusion. A computed tomography angiogram and magnetic resonance imaging performed 1 week later showed a symmetrical appearance to the MCA and no evidence of restricted diffusion. Conclusion The use of commercially available stent-retrievers can cause mechanical dilatation of vasospastic vessels. The stents do not need to be deployed for a prolonged period nor do they need to be implanted to have a prolonged dilatory effect on the spastic vessels.
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Affiliation(s)
| | - Dimitris Paraskevopoulos
- 2 Department of Neurosurgery, Barts Health NHS Trust, St. Bartholomew's and The Royal London Hospital, London, UK.,3 Centre for Neuroscience and Trauma at the Blizard Institute, Barts & The London School of Medicine & Dentistry, Queen Mary University of London, London, UK
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17
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Goehre F, Jahromi BR, Lehecka M, Lehto H, Kivisaari R, Andrade-Barazarte H, Ibrahim TF, Párraga RG, Ludtka C, Meisel HJ, Koivisto T, von und zu Fraunberg M, Niemelä M, Jääskeläinen JE, Hernesniemi JA. Posterior Cerebral Artery Aneurysms: Treatment and Outcome Analysis in 121 Patients. World Neurosurg 2016; 92:521-532. [DOI: 10.1016/j.wneu.2016.03.063] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2016] [Revised: 03/20/2016] [Accepted: 03/21/2016] [Indexed: 10/22/2022]
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18
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Katsevman GA, Braca JA, Welch KC, Ashley WW. Delayed Presentation of an Extracranial Internal Carotid Artery Pseudoaneurysm and Massive Epistaxis Secondary to a Nasal Foreign Body: Case Report and Review of the Literature. World Neurosurg 2016; 92:585.e13-585.e19. [DOI: 10.1016/j.wneu.2016.05.018] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2016] [Revised: 05/08/2016] [Accepted: 05/09/2016] [Indexed: 01/04/2023]
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19
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Raper DMS, Ding D, Peterson EC, Crowley RW, Liu KC, Chalouhi N, Hasan DM, Dumont AS, Jabbour P, Starke RM. Cavernous carotid aneurysms: a new treatment paradigm in the era of flow diversion. Expert Rev Neurother 2016; 17:155-163. [DOI: 10.1080/14737175.2016.1212661] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Affiliation(s)
- Daniel M. S. Raper
- Department of Neurological Surgery, University of Virginia, Charlottesville, VA, USA
| | - Dale Ding
- Department of Neurological Surgery, University of Virginia, Charlottesville, VA, USA
| | - Eric C. Peterson
- Department of Neurosurgery, University of Miami Miller School of Medicine, University of Miami Hospital, Jackson Memorial Hospital, Miami Children’s Hospital, Miami, FL, USA
| | | | - Kenneth C. Liu
- Department of Neurological Surgery, University of Virginia, Charlottesville, VA, USA
| | - Nohra Chalouhi
- Department of Neurosurgery, Thomas Jefferson University, Philadelphia, PA, USA
| | - David M. Hasan
- Department of Neurological Surgery, University of Iowa, Iowa City, IA, USA
| | - Aaron S. Dumont
- Department of Neurological Surgery, Tulane University, New Orleans, LA, USA
| | - Pascal Jabbour
- Department of Neurosurgery, Thomas Jefferson University, Philadelphia, PA, USA
| | - Robert M. Starke
- Department of Neurosurgery, University of Miami Miller School of Medicine, University of Miami Hospital, Jackson Memorial Hospital, Miami Children’s Hospital, Miami, FL, USA
- Department of Radiology, University of Miami Miller School of Medicine, University of Miami Hospital and Jackson Memorial Hospital, Miami, FL, USA
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20
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Ibrahim TF, Jahromi BR, Miettinen J, Raj R, Andrade-Barazarte H, Goehre F, Kivisaari R, Lehto H, Hernesniemi J. Long-Term Causes of Death and Excess Mortality After Carotid Artery Ligation. World Neurosurg 2016; 90:116-122. [DOI: 10.1016/j.wneu.2016.01.023] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2015] [Revised: 01/03/2016] [Accepted: 01/04/2016] [Indexed: 01/22/2023]
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21
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Han Z, Qi H, Yin W, Du Y. Letter to the Editor: Low-flow bypass and wrap-clipping for ruptured blister aneurysms of the ICA. J Neurosurg 2016; 124:1143-4. [PMID: 26894461 DOI: 10.3171/2015.10.jns152277] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Zongli Han
- Peking University Shenzhen Hospital, Futian District, Shenzhen, Guangdong, P. R. China; and ,School of Medical Technology and Nursing, Shenzhen Polytechnic, Xili Lake, Nanshan District, Shenzhen, Guangdong, P. R. China
| | - Hui Qi
- Peking University Shenzhen Hospital, Futian District, Shenzhen, Guangdong, P. R. China; and ,School of Medical Technology and Nursing, Shenzhen Polytechnic, Xili Lake, Nanshan District, Shenzhen, Guangdong, P. R. China
| | - Wei Yin
- Peking University Shenzhen Hospital, Futian District, Shenzhen, Guangdong, P. R. China; and ,School of Medical Technology and Nursing, Shenzhen Polytechnic, Xili Lake, Nanshan District, Shenzhen, Guangdong, P. R. China
| | - Yanli Du
- Peking University Shenzhen Hospital, Futian District, Shenzhen, Guangdong, P. R. China; and ,School of Medical Technology and Nursing, Shenzhen Polytechnic, Xili Lake, Nanshan District, Shenzhen, Guangdong, P. R. China
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22
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Chan JYW, Wong STS, Chan RCL, Wei WI. Extracranial/intracranial vascular bypass and craniofacial resection: New hope for patients with locally advanced recurrent nasopharyngeal carcinoma. Head Neck 2015; 38 Suppl 1:E1404-12. [PMID: 26566179 DOI: 10.1002/hed.24234] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/31/2015] [Indexed: 01/22/2023] Open
Affiliation(s)
- Jimmy Yu Wai Chan
- Department of Surgery, Division of Head and Neck Surgery; University of Hong Kong Medical Centre Queen Mary Hospital; Hong Kong SAR China
| | - Stanley Thian Sze Wong
- Department of Surgery, Division of Head and Neck Surgery; University of Hong Kong Medical Centre Queen Mary Hospital; Hong Kong SAR China
| | - Richie Chiu Lung Chan
- Department of Surgery, Division of Head and Neck Surgery; University of Hong Kong Medical Centre Queen Mary Hospital; Hong Kong SAR China
| | - William Ignace Wei
- Department of Surgery, Division of Head and Neck Surgery; University of Hong Kong Medical Centre Queen Mary Hospital; Hong Kong SAR China
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23
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Rustemi O, Amin-Hanjani S, Shakur SF, Du X, Charbel FT. Donor Selection in Flow Replacement Bypass Surgery for Cerebral Aneurysms: Quantitative Analysis of Long-term Native Donor Flow Sufficiency. Neurosurgery 2015; 78:332-41; discussion 341-2. [DOI: 10.1227/neu.0000000000001074] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Abstract
BACKGROUND:
Graft selection in extracranial-intracranial bypass surgery for cerebral aneurysms has traditionally been based on clinical impression and operator preference. However, decision making can be optimized with a donor selection algorithm based on intraoperative flow data.
OBJECTIVE:
To present long-term follow-up and quantitative assessment of flow sufficiency for native donors selected in this manner.
METHODS:
Patients with bypass for anterior circulation intracranial aneurysms using only a native donor (superficial temporal artery) selected on the basis of an intraoperative flow algorithm over a 10-year period were retrospectively studied. Intracranial hemispheric and bypass flows were assessed preoperatively and postoperatively when available with quantitative magnetic resonance angiography.
RESULTS:
Twenty-two patients with flow data were included (median aneurysm size, 22 mm). The intraoperative flow offer (cut flow) of the superficial temporal artery was sufficient in these cases relative to the flow demand in the sacrificed vessel (59 vs 28 mL/min) to warrant its use. Bypass flow averaged 81 mL/min postoperatively (n = 19). Bypass flows were highest in the immediate postoperative period but remained stable between the intermediate and final follow-up (40 vs 52 mL/min; P = .39; n = 8). Mean ipsilateral hemisphere flows were maintained after bypass (299 vs 335 mL/min; P = .42; n = 7), and remained stable over intermediate and long-term follow-up. Ipsilateral hemispheric flows remained similar to contralateral flows at all time points.
CONCLUSION:
Despite a relative reduction in bypass flow over time, hemispheric flows were maintained, indicating that simple native donors can carry sufficient flow for territory demand long term when an intraoperative flow-based algorithm is used for donor selection.
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Affiliation(s)
- Oriela Rustemi
- Department of Neurosurgery, University of Illinois at Chicago, Chicago, Illinois
| | - Sepideh Amin-Hanjani
- Department of Neurosurgery, University of Illinois at Chicago, Chicago, Illinois
| | - Sophia F. Shakur
- Department of Neurosurgery, University of Illinois at Chicago, Chicago, Illinois
| | - Xinjian Du
- Department of Neurosurgery, University of Illinois at Chicago, Chicago, Illinois
| | - Fady T. Charbel
- Department of Neurosurgery, University of Illinois at Chicago, Chicago, Illinois
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24
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Ogungbemi A, Elwell V, Choi D, Robertson F. Permanent endovascular balloon occlusion of the vertebral artery as an adjunct to the surgical resection of selected cervical spine tumors: A single center experience. Interv Neuroradiol 2015; 21:532-7. [PMID: 26092437 DOI: 10.1177/1591019915590072] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND AND PURPOSE Complete surgical resection of cervical spine tumors is often challenging when there is tumor encasement of major neck vessels. Pre-operative endovascular sacrifice of the major vessels can facilitate safe tumor resection. The use of transarterial detachable coils has been described in this setting, but it can be time-consuming and costly to occlude a patent parent vessel using this method. Our aim was to evaluate the safety and effectiveness of our endovascular detachable balloon occlusion technique, performed without prior balloon test occlusion in the pre-operative management of these tumors. METHODS We retrospectively reviewed 18 consecutive patients undergoing pre-operative unilateral permanent endovascular balloon occlusion of tumor-encased vertebral arteries in our institution. Procedure-related ischemic or thromboembolic complication was defined as focal neurologic deficit attributable to the endovascular occlusion which occurs before subsequent surgical resection. RESULTS Successful pre-operative endovascular vertebral artery sacrifice using detachable balloons was achieved in 100% (n = 18) of cases without prior balloon test occlusion. Procedural complication rate was 5.6% as one patient developed transient focal neurology secondary to a delayed cerebellar infarct at home on day 11 and subsequently made a full recovery. There were no cases of distal balloon migration. Complete macroscopic resection of tumor as reported by the operating surgeon was achieved in 89% of cases. CONCLUSION Pre-operative endovascular sacrifice of the vertebral artery using detachable balloons and without prior balloon test occlusion is a safe procedure with low complication rates and good surgeon reported rates of total resection.
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Affiliation(s)
| | - Vivien Elwell
- National Hospital for Neurology and Neurosurgery, London, UK
| | - David Choi
- National Hospital for Neurology and Neurosurgery, London, UK
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25
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Pancucci G, Potts MB, Rodríguez-Hernández A, Andrade H, Guo L, Lawton MT. Rescue Bypass for Revascularization After Ischemic Complications in the Treatment of Giant or Complex Intracranial Aneurysms. World Neurosurg 2015; 83:912-20. [PMID: 25700972 DOI: 10.1016/j.wneu.2015.02.001] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2014] [Revised: 01/29/2015] [Accepted: 02/02/2015] [Indexed: 11/26/2022]
Abstract
BACKGROUND Surgical trapping or endovascular deconstruction commonly is used for the treatment of giant or complex intracranial aneurysms. Preoperative balloon test occlusion and cerebral blood flow studies and intraoperative neurophysiologic monitoring can indicate whether sufficient collateralization exists or whether revascularization is needed. Hemodynamic insufficiency can occur, however, despite passing these tests, necessitating posttreatment revascularization. METHODS We conducted a retrospective review of patients who underwent surgical or endovascular parent vessel occlusion for the management of giant or complex intracranial aneurysms and subsequently required rescue bypass for symptoms of hemodynamic insufficiency. Pre- and postrevascularization functional status was measured with the modified Rankin Scale. RESULTS During a 15-year period from 1997 to 2012, a rescue bypass was performed in 5 patients each harboring a giant or complex intracranial internal carotid artery (ICA) aneurysm that was treated with surgical trapping or endovascular deconstruction in a previous procedure. All bypasses were extracranial-to-intracranial and included cervical ICA to middle cerebral artery, subclavian to middle cerebral artery, and cervical ICA to supraclinoid ICA anastomoses via either a saphenous vein or radial artery graft. Functional outcome at time of last follow-up was improved in each patient (improvement in modified Rankin Scale of 1-3 points). CONCLUSIONS Ischemic complications must always be anticipated in the treatment of giant or complex intracranial aneurysms, even if pre- and intraoperative blood flow studies indicate sufficient collateralization. Here we show that extracranial-to-intracranial bypass is an effective option to rescue unanticipated hemodynamic insufficiency after parent vessel occlusion. This study emphasizes the need for cerebrovascular surgeons to maintain proficiency in complex bypass techniques.
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Affiliation(s)
- Giovanni Pancucci
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California, USA
| | - Matthew B Potts
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California, USA
| | - Ana Rodríguez-Hernández
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California, USA
| | - Hugo Andrade
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California, USA
| | - LanJun Guo
- Neurophysiological Monitoring Service, University of California, San Francisco, San Francisco, California, USA
| | - Michael T Lawton
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California, USA.
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26
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Yang T, Tariq F, Chabot J, Madhok R, Sekhar LN. Cerebral Revascularization for Difficult Skull Base Tumors: A Contemporary Series of 18 Patients. World Neurosurg 2014; 82:660-71. [DOI: 10.1016/j.wneu.2013.02.028] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2012] [Accepted: 02/05/2013] [Indexed: 10/27/2022]
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Ambekar S, Madhugiri V, Sharma M, Cuellar H, Nanda A. Evolution of management strategies for cavernous carotid aneurysms: a review. World Neurosurg 2014; 82:1077-85. [PMID: 24690538 DOI: 10.1016/j.wneu.2014.03.042] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2013] [Accepted: 03/13/2014] [Indexed: 10/25/2022]
Abstract
OBJECTIVE Cavernous carotid aneurysms are considered benign lesions with indolent natural history. Apart from idiopathic aneurysms, traumatic, iatrogenic, and mycotic aneurysms are common in the cavernous segment of the carotid artery. With rapid advances in endovascular therapy, management of cavernous carotid aneurysms has evolved. Our aim was to review the management options available for cavernous carotid aneurysms. METHODS The English literature was searched for various studies describing the management of cavernous carotid aneurysms and the evolution of various treatments was studied. RESULTS Numerous treatment options are available such as conservative management, Hunterian ligation, surgical clipping, and endovascular therapy. The introduction of flow-diverting stents has revolutionized the management of these lesions. The evolution of various treatment strategies are described. CONCLUSIONS A thorough knowledge of all the options is paramount to individualize therapy. We discuss the indications of treatment, various management options for cavernous carotid aneurysms and their outcomes.
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Affiliation(s)
- Sudheer Ambekar
- Department of Neurosurgery, Louisiana State University Health Sciences Center, Shreveport, Louisiana, USA
| | - Venkatesh Madhugiri
- Department of Neurosurgery, Jawaharlal Institute of Postgraduate Medical Education and Research, Puduchery, India
| | - Mayur Sharma
- Center of Neuromodulation, Wexner Medical center, The Ohio State University, Columbus, Ohio, USA
| | - Hugo Cuellar
- Department of Neurosurgery, Louisiana State University Health Sciences Center, Shreveport, Louisiana, USA
| | - Anil Nanda
- Department of Neurosurgery, Louisiana State University Health Sciences Center, Shreveport, Louisiana, USA.
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Abstract
It is increasingly recognized that one can identify a higher risk patient for perioperative stroke. The risk of stroke around the time of operative procedures is fairly substantial and it is recognized that patients initially at risk for vascular events are those most likely to have this risk heightened by invasive procedures. Higher risk patients include those of advanced age and there is a cumulative risk, over time, of coexistent hypertension, atherosclerosis, diabetes mellitus, cardiac disease and clotting disorders. There are a number of possible mechanisms associated with the procedure (e.g., preoperative hypercoagulability, holding of antithrombic therapy at the time of the procedure and cardiac arrhythmia) that can promote a thrombo-embolic event. Examples of these include: direct mechanical trauma to extracranial vessels related to operations on the head and neck; and vascular injury as a consequence of vascular and innovative endovascular procedures affecting the cerebral circulation (e.g., carotid endarterectomy, extracranial or intracranial angioplasty with stenting, and use of the MERCI clot retrieval device), as well as various endovascular methods that have been developed to obliterate cerebral aneurysms and arteriovenous malformations as an alternative to surgical clipping and surgical resection, respectively.
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Affiliation(s)
- Uma Menon
- Department of Neurology, LSU Health Sciences Center, Shreveport, LA 71103, USA.
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29
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Requejo F, Sierre S, Lipsich J, Zuccaro G. Endovascular treatment of post-pharyngitis internal carotid artery pseudoaneurysm with a covered stent in a child: a case report. Childs Nerv Syst 2013; 29:1369-73. [PMID: 23532343 DOI: 10.1007/s00381-013-2083-y] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2013] [Accepted: 03/15/2013] [Indexed: 12/17/2022]
Abstract
CASE REPORT We report a case of 4-year-old boy patient, who developed after a streptococcal pharyngitis a painful, pulsatile, and growing right-sided mass in the neck. Imaging studies revealed an extracranial right internal carotid artery pseudoaneurysm. The patient was successfully treated with stent-graft deployment. After 18 months of follow-up, the pseudoaneurysm is excluded from the circulation, the carotid artery is patent, and the patient is free from any neurological deficit. DISCUSSION Covered stents might be considered as a valid therapeutic option to treat carotid artery pseudoaneurysms.
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Affiliation(s)
- Flavio Requejo
- Department of Interventional Radiology, Hospital Nacional de Pediatría Prof. J.P. Garrahan, Combate de Pozos 1881 (1254), Buenos Aires, Argentina.
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30
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Kim LJ, Tariq F, Sekhar LN. Pediatric bypasses for aneurysms and skull base tumors: short- and long-term outcomes. J Neurosurg Pediatr 2013; 11:533-42. [PMID: 23452030 DOI: 10.3171/2013.1.peds12444] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Cerebral bypass is a useful microsurgical technique for the treatment of unclippable aneurysms and invasive skull base tumors. The authors present the largest reported series of cerebrovascular bypasses in the pediatric population. They describe the short- and long-term clinical and radiographic outcomes of extracranial-intracranial and local bypasses performed for complex cerebral aneurysms and recurrent, invasive, and malignant skull base tumors in pediatric patients. METHODS A consecutive series of 17 pediatric patients who underwent revascularization were analyzed retrospectively for indications, graft patency, and neurological outcomes. RESULTS The mean age was 12 years (median 11 years, range 4-17 years), and there were 7 boys (41%) and 10 girls (59%). A total of 18 bypasses were performed in 17 patients and included 10 aneurysm cases (55.5%) and 8 tumor cases (45%). Of these 18 bypasses, there were 11 (61.1%) extracranial-intracranial bypasses (10 saphenous vein grafts [90%] and 1 radial artery graft [10%]), 1 side-to-side anastomosis (5.5%), 2 intracranial reimplants (11.1%), and 4 interposition bypass grafts (22.2%; 2 radial artery grafts, 1 saphenous vein graft, and 1 lingual artery graft). The mean clinical follow-up was 40.5 months (median 24 months, range 3-197 months). The mean radiographic follow-up was 40 months (median 15 months, range 9-197 months). Eighty-two percent of patients (14 of 17) achieved a modified Rankin Scale score between 0 and 2; however, 2 patients died of disease progression during long-term follow-up. The short-term (0- to 3-month) graft patency rate was 100%. Two patients had graft stenosis (11.7%) and underwent graft revisions. Two patients (11.1%) with giant middle cerebral artery aneurysms (> 25 mm) had strokes postoperatively but recovered without a persistent neurological deficit. One patient observed for 197 months showed a stable dysplastic change at the end of the graft. The long-term graft patency was 100% with a mean follow-up of 40 months. There were 2 deaths in the cohort during follow-up; both patients died of malignant tumors (osteogenic sarcoma and chondrosarcoma). CONCLUSIONS The authors conclude that in properly selected cases, bypasses can be safely performed in patients with aneurysms and skull base tumors. The bypasses remained patent over long periods of time despite the growth of the patients.
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Affiliation(s)
- Louis J Kim
- Department of Neurological Surgery, University of Washington, Seattle, Washington 98104, USA.
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31
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Almefty K, Spetzler RF. Management of giant internal carotid artery aneurysms. World Neurosurg 2013; 82:40-2. [PMID: 23542390 DOI: 10.1016/j.wneu.2013.03.064] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2013] [Accepted: 03/21/2013] [Indexed: 10/27/2022]
Affiliation(s)
- Kaith Almefty
- Division of Neurological Surgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Robert F Spetzler
- Division of Neurological Surgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA.
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32
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Kalani MYS, Kalb S, Martirosyan NL, Lettieri SC, Spetzler RF, Porter RW, Feiz-Erfan I. Cerebral revascularization and carotid artery resection at the skull base for treatment of advanced head and neck malignancies. J Neurosurg 2013; 118:637-42. [DOI: 10.3171/2012.9.jns12332] [Citation(s) in RCA: 50] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Object
Resection of cancer and the involved artery in the neck has been applied with some success, but the indications for such an aggressive approach at the skull base are less well defined. The authors therefore evaluated the outcomes of advanced skull base malignancies in patients who were treated with bypass and resection of the internal carotid artery (ICA).
Methods
The authors retrospectively reviewed the charts of all patients with advanced head and neck cancers who underwent ICA sacrifice with revascularization in which an extracranial-intracranial bypass was used between 1995 and 2010 at the Barrow Neurological Institute.
Results
Eighteen patients (11 male and 7 female patients; mean age 46 years, range 7–69 years) were identified. There were 4 sarcomas and 14 carcinomas that involved the ICA at the skull base. All patients underwent ICA sacrifice with revascularization. One patient died of a stroke after revascularization. A second patient died of the effects of a fistula between the oral and cranial cavities (surgery-related mortality rate 11.1%). Eight months after the operation, 1 patient developed occlusion of the bypass and died. Complications associated with the bypass surgery included 1 case of subdural hematoma (SDH) with blindness, 1 case of status epilepticus, and 1 case of asymptomatic bypass occlusion (bypass-related morbidity 16.7%). Complications associated with tumor resection included 3 cases of CSF leakage requiring repair and shunting, 1 case of hydrocephalus requiring shunting, 1 case of SDH, and 1 case of contralateral ICA injury requiring a bypass (tumor resection morbidity rate 33.3%). In 1 patient treated with adjuvant therapy before surgery, the authors identified only a radiation effect and no tumor on resection. In a second patient the bypass was occluded, and her tumor was not resected. The other 16 patients underwent gross-total resection of their tumor. Excluding the surgery-related deaths, the mean and median lengths of survival in this series were 13.2 and 8.3 months, respectively (range 1.5–48 months). Including the surgery-related deaths, the mean and median lengths of survival were 11.8 and 8 months, respectively (range 17 days–48 months). At last follow-up all patients had died of cancer or cancer-related causes.
Conclusions
Despite maximal surgical intervention, including ICA sacrifice at the skull base with revascularization, patient survival was dismal, and the complication rate was significant. The authors no longer advocate such an aggressive approach in this patient population. On rare occasions, however, such an approach may be considered for low-grade malignancies.
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Affiliation(s)
- M. Yashar S. Kalani
- 1Division of Neurological Surgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center
| | - Samuel Kalb
- 1Division of Neurological Surgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center
| | - Nikolay L. Martirosyan
- 1Division of Neurological Surgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center
| | - Salvatore C. Lettieri
- 2Divisions of Plastic Surgery and
- 4Division of Plastic Surgery, Mayo Clinic, Rochester, Minnesota
| | - Robert F. Spetzler
- 1Division of Neurological Surgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center
| | - Randall W. Porter
- 1Division of Neurological Surgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center
| | - Iman Feiz-Erfan
- 3Neurosurgery, Maricopa Medical Center, Phoenix, Arizona; and
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Couldwell WT, Taussky P, Sivakumar W. Submandibular High-Flow Bypass in the Treatment of Skull Base Lesions. Neurosurgery 2012; 71:645-50; discussion 650-1. [DOI: 10.1227/neu.0b013e318260fedd] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Abstract
BACKGROUND:
Cerebral bypass surgery remains an integral part of the treatment of complex skull base tumors and unclippable aneurysms.
OBJECTIVE:
The authors retrospectively analyzed a single-surgeon experience using a high-flow submandibular–infratemporal saphenous vein graft bypass technique after carotid artery sacrifice in the resection of complex skull base tumors and carotid isolation in unclippable aneurysms.
METHODS:
Data on indications, surgical technique, bypass patency, complications, and outcome were collected for patients treated with adjunctive submandibular high-flow bypass for skull base lesions.
RESULTS:
Eleven patients (age range, 13-77 years) were treated for various skull base lesions: 4 patients were treated for skull base tumors with resection of the internal carotid artery (ICA), 6 were treated for aneurysms not amenable to clipping, and one was treated for invasive Mucor infection. With the use of a saphenous vein graft, a high-flow bypass was created from the high cervical ICA or external carotid artery to ICA or middle cerebral artery by means of a submandibular–infratemporal route. Postoperative angiography indicated bypass patency in 10 of 11 patients. There was no operative mortality. Follow-up of up to 12 years (mean, 56 months) was achieved.
CONCLUSION:
Direct high-flow submandibular–infratemporal interpositional saphenous vein bypass graft is an effective and durable technique for the treatment of complex skull base lesions where ICA revascularization is indicated.
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Affiliation(s)
| | - Philipp Taussky
- Department of Neurosurgery, University of Utah, Salt Lake City, Utah
| | - Walavan Sivakumar
- Department of Neurosurgery, University of Utah, Salt Lake City, Utah
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Chen L, Lang L, Zhou L, Song D, Mao Y. Bypass or not? Adjustment of surgical strategies according to motor evoked potential changes in large middle cerebral artery aneurysm surgery. World Neurosurg 2011; 77:398.E1-6. [PMID: 22501021 DOI: 10.1016/j.wneu.2011.11.036] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2010] [Revised: 10/22/2011] [Accepted: 11/23/2011] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To report the use of neuroelectrophysiologic monitoring to alter the course in aneurysm surgery to minimize postoperative infarction and bypass-related adverse events. METHODS Two patients with large middle cerebral artery (MCA) aneurysms were admitted to the authors' hospital. Direct clipping seemed to be difficult, and postoperative paralysis was not rare in the authors' experience owing to prolonged temporal occlusion of the parent artery. Balloon test occlusion (BTO) was positive in one patient, who developed paralysis and aphasia 3 minutes after balloon occlusion of the feeding M1 artery. A bypass procedure seemed to be inevitable in both patients. Motor evoked potentials (MEPs) and sensory evoked potentials (SEPs) were used for monitoring during the operation. RESULTS For the patient with a positive BTO result, MEP waves did not change until 17 minutes after temporary clip placement. The aneurysm was clipped, and the occlusion time was 24 minutes. MEP waves recovered quickly after reperfusion. In the other patient, there were early changes in MEP waves after temporary clipping. After bypass construction from the temporal artery to the inferior M2 trunk, the time window of safe occlusion was prolonged to 7-8 minutes. Both the aneurysm and the bypassed branch were obliterated, and the clip reconstruction was done to preserve the flow from M1 to the superior M2 trunk. Permanent postoperative disability did not occur in either patient. CONCLUSIONS Intraoperative physiologic monitoring is a complementary method to preoperative BTO to evaluate the window of safe occlusion with high reliability.
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Affiliation(s)
- Liang Chen
- Department of Neurosurgery, Huashan Hospital, Fudan University, Shanghai, China
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Abstract
BACKGROUND AND PURPOSE Complex cerebral aneurysms may require indirect treatment with revascularization. This manuscript describes various surgical revascularization techniques together with clinical outcomes. METHODS Thirty-two consecutive patients with complex cerebral aneurysm were managed from November 2005 to October 2008. Techniques used for revascularization were high-flow bypass, low-flow bypass, branch artery reimplantion, and primary reanastomosis. Physiologic and anatomic monitoring technologies, including electroencephalography, somatosensory evoked potential monitoring, microvascular doppler ultrasonography, and/or indocyanine green videoangiography were used intraoperatively to assess both brain physiology and vascular anatomy. Patient outcome was determined using the Glasgow Outcome Scale at discharge and at a mean of 12 months post operation (range 6-25 months). RESULTS Two cervical carotid aneurysms (6%) were resected followed by primary reanastomosis, 21 aneurysms (66%) were trapped following saphenous vein high-flow bypasses, five (16%) were clipped after superficial temporal or occipital artery low-flow bypasses, and four (12%) middle cerebral branch arteries were reimplanted. Of the 32 patients at discharge, 29 (91%) had a Glasgow Outcome Scale of four or five, two (6%) had severe disability, and one (3%) died. CONCLUSION Cerebral revascularization remains an effective and reliable procedure for treatment of complex cerebral aneurysms. Low morbidity and mortality rates reflect the maturity of patient selection and surgical technique in the management of these lesions.
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Hassan T, Sultan A, Elwany M. Evaluation of Balloon Occlusion Test for Giant Brain Aneurysms under Local Anaesthesia. Neuroradiol J 2011; 24:735-42. [DOI: 10.1177/197140091102400511] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2010] [Accepted: 01/03/2011] [Indexed: 11/15/2022] Open
Abstract
We describe our experience in balloon test occlusion for giant carotid or basilar aneurysms under hypotension. Twenty-four patients underwent balloon test occlusion (BTO) during the year 2008. Only patients showed absence of any neurological deficits after 20 minutes under normal tension then another 20 minutes under hypotension were considered tolerable for occlusion of the parent artery. Of the 24 patients, four (16.67%) had deficits at normal tension and two (8.33%) had deficits at hypotensive phase. None of the 18 (75%) patients who clinically tolerated test occlusion and had parent artery sacrifice show any complication at follow-up period of two years. Two patients with clinical intolerability underwent carotid artery sacrifice after STA-MCA bypass without sequelae. Balloon test occlusion with hypotension is a useful, competent and simple technique in the evaluation of tolerance to parent artery occlusion in case of giant and complex intracranial aneurysms.
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Affiliation(s)
- T. Hassan
- Department of Neurosurgery, Alexandria University; Alexandria, Egypt
| | - A.E. Sultan
- Department of Neurosurgery, Alexandria University; Alexandria, Egypt
| | - M.N. Elwany
- Department of Neurosurgery, Alexandria University; Alexandria, Egypt
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Roh SW, Ahn JS, Sung HY, Jung YJ, Kwun BD, Kim CJ. Extracranial-intracranial bypass surgery using a radial artery interposition graft for cerebrovascular diseases. J Korean Neurosurg Soc 2011; 50:185-90. [PMID: 22102946 DOI: 10.3340/jkns.2011.50.3.185] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2011] [Revised: 06/24/2011] [Accepted: 09/08/2011] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE To investigate the efficacy of extracranial-intracranial (EC-IC) bypass surgery using a radial artery interposition graft (RAIG) for surgical management of cerebrovascular diseases. METHODS The study involved a retrospective analysis of 13 patients who underwent EC-IC bypass surgery using RAIG at a single neurosurgical institute between 2003 and 2009. The diseases comprised intracranial aneurysm (n=10), carotid artery occlusive disease (n=2), and delayed stenosis in the donor superficial temporal artery (STA) following previous STA-middle cerebral artery bypass surgery (n=1). Patients were followed clinically and radiographically. RESULTS Bypass surgery was successful in all patients. At a mean follow-up of 53.4 months, the short-term patency rate was 100%, and the long-term rate was 92.3%. Twelve patients had an excellent clinical outcome of Glasgow Outcome Scale (GOS) 5, and one case had GOS 3. Procedure-related complications were a temporary dysthesia on the graft harvest hand (n=1) and a hematoma at the graft harvest site (n=1), and these were treated successfully with no permanent sequelae. In one case, spasm occurred which was relieved with the introduction of mechanical dilators. CONCLUSION EC-IC bypass using a RAIG appears to be an effective treatment for a variety of cerebrovascular diseases requiring proximal occlusion or trapping of the parent artery.
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Affiliation(s)
- Sung Woo Roh
- Department of Neurological Surgery, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
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Fusco MR, Harrigan MR. Cerebrovascular dissections: a review. Part II: blunt cerebrovascular injury. Neurosurgery 2011; 68:517-30; discussion 530. [PMID: 21135751 DOI: 10.1227/neu.0b013e3181fe2fda] [Citation(s) in RCA: 76] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
Traumatic cerebrovascular injury (TCVI) is present in approximately 1% of all blunt force trauma patients and is associated with injuries such as head and cervical spine injuries and thoracic trauma. Increased recognition of patients with TCVI in the past quarter century has been because of aggressive screening protocols and noninvasive imaging with computed tomography angiography. Extracranial carotid and vertebral artery injuries demonstrate a spectrum of severity, from intimal disruption to traumatic aneurysm formation or vessel occlusion. The most common intracranial arterial injuries are carotid-cavernous fistulae and traumatic aneurysms. Data on the long-term natural history of TCVI are limited, and management of patients with TCVI is controversial. Although antithrombotic medical therapy is associated with improved neurological outcomes, the optimal medication regimen is not yet established. Endovascular techniques have become more popular than surgery for the treatment of TCVI; endovascular options include stenting of dissections, intra-arterial thrombolysis for acute ischemic stroke caused by trauma, and embolization of traumatic aneurysms.
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Affiliation(s)
- Matthew R Fusco
- Department of Surgery, Division of Neurosurgery, University of Alabama at Birmingham, Birmingham, Alabama, USA
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Ko JK, Lee TH, Lee JI, Choi CH. Endovascular treatment using graft-stent for pseudoaneurysm of the cavernous internal carotid artery. J Korean Neurosurg Soc 2011; 50:48-50. [PMID: 21892405 DOI: 10.3340/jkns.2011.50.1.48] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2010] [Revised: 01/06/2011] [Accepted: 07/01/2011] [Indexed: 11/27/2022] Open
Abstract
A 57-year-old man presented with a 2-day history of left oculomotor palsy. Digital subtraction angiography revealed a pseudoaneurysm of the left cavernous internal carotid artery (ICA) measuring 37×32 mm. The pseudoaneurysm was treated with a balloon expandable graft-stent to occlude the aneurysmal neck and preserve the parent artery. A post-procedure angiogram confirmed normal patency of the ICA and complete sealing of the aneurysmal neck with no opacification of the sac. After the procedure, the oculomotor palsy improved gradually, and had completely resolved 3 months after the procedure. A graft-stent can be an effective treatment for a pseudoaneurysm of the cavernous ICA with preservation of the parent artery.
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Affiliation(s)
- Jun Kyeung Ko
- Department of Neurosurgery, School of Medicine, Pusan National University, Busan, Korea
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Lawton MT, Spetzler RF. Internal carotid artery sacrifice for radical resection of skull base tumors. Skull Base 2011; 6:119-23. [PMID: 17170986 PMCID: PMC1656574 DOI: 10.1055/s-2008-1058903] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
When dealing with skull base tumors that encase the internal carotid artery (ICA), the surgeon must decide between ICA preservation and incomplete tumor resection, or radical resection with ICA sacrifice. In our experience with more than 300 anterior skull base tumors, the ICA was sacrificed in only 10 patients. These tumors were malignant, except for one meningioma that occluded the ICA and produced translent ischemic symptoms. All patients had the ICA resected with the tumor, and all patients underwent revascularization (cervical ICA-MCA saphenous bypass, n = 4; cervical-to-supraclinoid bypass, n = 1; petrous-to-supraclinoid bypass, n = 3; bonnet bypass, n = 2). This small patient series reflects our practice of preserving the ICA whenever possible. We recommend preserving the ICA with benign tumors because they do not invade the artery, or do so only to a limited extent. In addition, similar rates of tumor recurrence are seen after aggressive resection with or without ICA sacrifice. In contrast, we recommend radical tumor resection and sacrifice of the ICA with malignant tumors because they directly threaten the integrity of the ICA and the patient's survival. The ICA should not be considered a limitation to radical tumor resection because the ICA can be reconstructed safely with an appropriate bypass procedure.
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Segal DH, Sen C, Bederson JB, Catalano P, Sacher M, Stollman AL, Lorberboym M. Predictive value of balloon test occlusion of the internal carotid artery. Skull Base Surg 2011; 5:97-107. [PMID: 17171183 PMCID: PMC1661829 DOI: 10.1055/s-2008-1058940] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Balloon test occlusion (BTO) of the internal carotid artery (ICA) is used in conjunction with single-photon emission computed tomography (SPECT) imaging to assess the cerebrovascular collateral reserve prior to surgical manipulation of the artery. The present report reviews 56 consecutive patients with tumors or vascular lesions at the base of the skull who underwent BTO and subsequent treatment on that basis within a 3-year period. Four patients underwent carotid sacrifice, since they tolerated the BTO and had normal SPECT imaging. Postoperatively, one patient had patchy infarcts in the frontal lobe, another a middle cerebral artery territory infarction, a third had a lacunar infarct, and the fourth had an impending stroke and was treated with an emergent revascularization procedure. There were 15 patients who underwent saphenous vein bypass grafting, of these there were three graft occlusions, one of which resulted in an infarction. There were two other infarctions due to technical difficulties, one being related to the revascularization procedure. Based on these results, we suggest that passing BTO with a normal SPECT study does not necessarily indicate that the patient is immune to stroke following carotid sacrifice. Revascularization should be considered, when ICA sacrifice is deemed necessary to treat the pathologic condition adequately, to minimize the likelihood of a stroke.
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Abstract
Asterion meningiomas arise from the posterior petrous ridge at the junction of the transverse and sigmoid sinuses (sinodural angle). The authors retrospectively reviewed the charts of seven patients with asterion meningiomas who underwent a Simpson I tumor resection by either the petrosal or suboccipital approach. Patients presented with headaches, dizziness, ataxia, or seizures. Preoperative angiograms and intraoperative observations confirmed occlusion of the transverse and sigmoid sinuses by tumor, thrombus, or both in four of the patients. In all cases, tumor infiltrated the sinuses and the sinuses were ligated without adverse sequelae. Temporal bone invasion was seen in one patient who had the only tumor recurrence. Postoperatively, there were two transient CSF leaks. Asterion meningiomas can be completely resected with a low incidence of major morbidity. In this small series, a patent transverse/sigmoid sinus was resected in three patients without sequelae. We believe that in young patients with asterion meningiomas a nondominant transverse/sigmoid sinus should be resected if the torcula is patent. More research is needed to determine the safety of resecting a patent dominant transverse/sigmoid sinus.
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Darsaut TE, Darsaut NM, Chang SD, Silverberg GD, Shuer LM, Tian L, Dodd RL, Do HM, Marks MP, Steinberg GK. Predictors of Clinical and Angiographic Outcome After Surgical or Endovascular Therapy of Very Large and Giant Intracranial Aneurysms. Neurosurgery 2011; 68:903-15; discussion 915. [DOI: 10.1227/neu.0b013e3182098ad0] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Abstract
BACKGROUND:
Risk factors for poor outcome in the treatment of very large (≥20-24 mm) and giant (≥25 mm) intracranial aneurysms remain incompletely defined.
OBJECTIVE:
To present an aggregate clinical series detailing a 24-year experience with very large and giant aneurysms to identify and assess the relative importance of various patient, aneurysm, and treatment-specific characteristics associated with clinical and angiographic outcomes.
METHODS:
The authors retrospectively identified 184 aneurysms measuring 20 mm or larger (85 very large, 99 giant) treated at Stanford University Medical Center between 1984 and 2008. Clinical data including age, presentation, and modified Rankin Scale (mRS) score were recorded, along with aneurysm size, location, and morphology. Type of treatment was noted and clinical outcome measured using the mRS score at final follow-up. Angiographic outcomes were completely occluded, occluded with residual neck, partly obliterated, or patent with modified flow.
RESULTS:
After multivariate analysis, risk factors for poor clinical outcome included a baseline mRS score of 2 or higher (odds ratio [OR], 0.23; 95% confidence interval [CI]: 0.08-0.66; P = .01), aneurysm size of 25 mm or larger (OR, 3.32; 95% CI: 1.51-7.28; P < .01), and posterior circulation location (OR, 0.18; 95% CI: 0.07-0.43; P < .01). Risk factors for incomplete angiographic obliteration included fusiform morphology (OR, 0.25; 95% CI: 0.10-0.66; P #x003C; .01), posterior circulation location (OR, 0.33; 95% CI: 0.13-0.83; P = .02), and endovascular treatment (OR, 0.14; 95% CI: 0.06-0.32; P < .01). Patients with incompletely occluded aneurysms experienced higher rates of posttreatment subarachnoid hemorrhage and had increased mortality compared with those with completely obliterated aneurysms.
CONCLUSION:
Our results suggest that patients with poor baseline functional status, giant aneurysms, and aneurysms in the posterior circulation had a significantly higher proportion of poor outcomes at final follow-up. Fusiform morphology, posterior circulation location, and endovascular treatment were risk factors for incompletely obliterated aneurysms.
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Affiliation(s)
- Tim E. Darsaut
- Department of Neurosurgery, Stanford Stroke Center and Stanford Institute for Neuro-Innovation and Translational Neurosciences, Stanford University School of Medicine, Stanford, California
| | - Nicole M. Darsaut
- Department of Neurosurgery, Stanford Stroke Center and Stanford Institute for Neuro-Innovation and Translational Neurosciences, Stanford University School of Medicine, Stanford, California
| | - Steven D. Chang
- Department of Neurosurgery, Stanford Stroke Center and Stanford Institute for Neuro-Innovation and Translational Neurosciences, Stanford University School of Medicine, Stanford, California
| | - Gerald D. Silverberg
- Department of Neurosurgery, Stanford Stroke Center and Stanford Institute for Neuro-Innovation and Translational Neurosciences, Stanford University School of Medicine, Stanford, California
- Current address: Department of Neurosurgery, Warren Alpert Medical School, Brown University, Providence, Rhode Island
| | - Lawrence M. Shuer
- Department of Neurosurgery, Stanford Stroke Center and Stanford Institute for Neuro-Innovation and Translational Neurosciences, Stanford University School of Medicine, Stanford, California
| | - Lu Tian
- Department of Health Research and Policy, Stanford Stroke Center and Stanford Institute for Neuro-Innovation and Translational Neurosciences, Stanford University School of Medicine, Stanford, California
| | - Robert L. Dodd
- Department of Neurosurgery, Stanford Stroke Center and Stanford Institute for Neuro-Innovation and Translational Neurosciences, Stanford University School of Medicine, Stanford, California
- Department of Radiology, and Stanford Stroke Center and Stanford Institute for Neuro-Innovation and Translational Neurosciences, Stanford University School of Medicine, Stanford, California
| | - Huy M. Do
- Department of Radiology, and Stanford Stroke Center and Stanford Institute for Neuro-Innovation and Translational Neurosciences, Stanford University School of Medicine, Stanford, California
| | - Michael P. Marks
- Department of Radiology, and Stanford Stroke Center and Stanford Institute for Neuro-Innovation and Translational Neurosciences, Stanford University School of Medicine, Stanford, California
| | - Gary K. Steinberg
- Department of Neurosurgery, Stanford Stroke Center and Stanford Institute for Neuro-Innovation and Translational Neurosciences, Stanford University School of Medicine, Stanford, California
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Zhu YQ, Gu BX, Li MH, Wang W, Cheng YS, Tan HQ, Wang JB, Zhang PL, Ma LT. Safety, feasibility, and mid-term follow-up of Willis stent graft placement in the treatment of symptomatic complicated intra- or extra-cranial aneurysms: A multicenter experience. MINIM INVASIV THER 2010; 19:320-8. [DOI: 10.3109/13645706.2010.527770] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Computed Tomographic Angiography in Evaluation of Superficial Temporal to Middle Cerebral Artery Bypass. J Comput Assist Tomogr 2010; 34:437-9. [DOI: 10.1097/rct.0b013e3181cfbca2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Temporary balloon occlusion during the surgical treatment of giant paraclinoid and vertebrobasilar aneurysms. Acta Neurochir (Wien) 2010; 152:435-42. [PMID: 20186525 DOI: 10.1007/s00701-009-0566-0] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2009] [Accepted: 11/06/2009] [Indexed: 12/11/2022]
Abstract
PURPOSE We propose the combined neurosurgical-endovascular treatment with the balloon occlusion of parent artery during surgery of giant paraclinoid and vertebrobasilar aneurysms, which are unsuitable for a pure endovascular or surgical approach. METHODS Between January 2003 and December 2007, we treated surgically 15 giant aneurysms (11 paraclinoid and four vertebrobasilar) with the combined approach of surgery and endovascular intraoperative technique. FINDINGS Complete aneurysm occlusion was achieved in all 15 aneurysms, as confirmed by intraoperative angiographic control. In one paraclinoid aneurysm, a small recurrence became evident 1 year after surgery and needed coil embolisation. CONCLUSIONS The temporary balloon occlusion technique is useful and improves the safety of the unavoidable exposure of the parent artery in the surgical treatment of giant paraclinoid and vertebrobasilar aneurysms.
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Li MH, Li YD, Tan HQ, Luo QY, Cheng YS. Treatment of Distal Internal Carotid Artery Aneurysm with the Willis Covered Stent: A Prospective Pilot Study. Radiology 2009; 253:470-7. [PMID: 19789235 DOI: 10.1148/radiol.2532090037] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Ming-Hua Li
- Institute of Diagnostic and Interventional Neuroradiology, the Sixth Affiliated People's Hospital, Shanghai Jiao Tong University, No. 600 Yi Shan Road, Shanghai 200233, China
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Carlson A, Yonas H. Xenon Techniques in Predicting Patients at Risk for Stroke after Balloon Test Occlusion. Neurosurgery 2009; 64:E1206. [DOI: 10.1227/01.neu.0000346235.44093.02] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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