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Castelli B, Scagnet M, Mussa F, Genitori L, Sardi I, Stagi S. Vascular complications in craniopharyngioma-resected paediatric patients: a single-center experience. Front Endocrinol (Lausanne) 2024; 15:1292025. [PMID: 38681768 PMCID: PMC11047119 DOI: 10.3389/fendo.2024.1292025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2023] [Accepted: 03/12/2024] [Indexed: 05/01/2024] Open
Abstract
Background Craniopharyngioma (CP), although slow growing and histologically benign, has high morbidity, mostly related to hypothalamus-pituitary dysfunction and electrolyte imbalance. Increased risk of vascular complications has been described. However, data are still poor, especially in the paediatric population. The aim of our study was to evaluate the occurrence, timing, and predisposing factors of deep venous thrombosis (DVT) and other vascular alterations in neurosurgical paediatric CP patients. Materials and Methods In a single-centre, retrospective study, we investigated 19 CP patients (11 males, 8 females, mean age 10.5 ± 4.3 years), who underwent neurosurgery between December 2016 and August 2022, referred to Meyer Children's Hospital IRCCS in Florence. Results Five patients (26.3%) presented vascular events, which all occurred in connection with sodium imbalances. Three DVT (two with associated pulmonary embolism, in one case leading to death) developed in the post-operative period, most frequently at 7-10 days. Elevated D-dimers, a reduced partial activated thrombin time and a prolonged C-reactive protein increase were highly related to thrombotic vascular events. One case of posterior cerebral artery pseudoaneurysm was described soon after neurosurgery, requiring vascular stenting. Superficial vein thrombophlebitis was a late complication in one patient with other predisposing factors. Conclusion CP patients undergoing neurosurgery are at risk of developing DVT and vascular alterations, thus careful follow-up is mandatory. In our study, we found that the phase of transition from central diabetes insipidus to a syndrome of inappropriate antidiuretic hormone secretion may be a period of significant risk for DVT occurrence. Careful vascular follow-up is mandatory in CP-operated patients.
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Affiliation(s)
- Barbara Castelli
- Department of Health Sciences, University of Florence, Florence, Italy
- Neuro-oncology Department, Meyer Children’s Hospital IRCCS, Florence, Italy
| | - Mirko Scagnet
- Neurosurgery Department, Meyer Children’s Hospital IRCCS, Florence, Italy
| | - Federico Mussa
- Neurosurgery Department, Meyer Children’s Hospital IRCCS, Florence, Italy
| | - Lorenzo Genitori
- Neurosurgery Department, Meyer Children’s Hospital IRCCS, Florence, Italy
| | - Iacopo Sardi
- Neuro-oncology Department, Meyer Children’s Hospital IRCCS, Florence, Italy
| | - Stefano Stagi
- Department of Health Sciences, University of Florence, Florence, Italy
- Struttura Organizzativa Complessa (SOC) Diabetology and Endocrinology, Meyer Children’s Hospital IRCCS, Florence, Italy
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Oliveira LDB, Cieslak PH, Marques GN, Batista S, Andreão FF, Palavani LB, Bocanegra-Becerra JE, Bertani R, Rabelo NN, Welling LC, Figueiredo EG. Maxillary artery utilization in subcranial-intracranial bypass procedures: a comprehensive systematic review and pooled analysis. Neurosurg Rev 2024; 47:41. [PMID: 38206429 DOI: 10.1007/s10143-023-02265-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2023] [Revised: 12/18/2023] [Accepted: 12/24/2023] [Indexed: 01/12/2024]
Abstract
The utilization of the internal maxillary artery (IMAX) in subcranial-intracranial bypass for revascularization in complex aneurysms, tumors, or refractory ischemia shows promise. However, robust evidence concerning its outcomes is lacking. Hence, the authors embarked on a systematic review with pooled analysis to elucidate the efficacy of this approach. We systematically searched PubMed, Embase, and Web of Science databases following PRISMA guidelines. Included articles used the IMAX as a donor vessel for revascularizing an intracranial area and reported at least one of the following outcomes: patency, complications, or clinical data. Favorable outcomes were defined as the absence of neurologic deficits or improvement in the baseline condition. Complications were considered any adverse event directly related to the procedure. Out of 418 retrieved articles, 26 were included, involving 183 patients. Among them, 119 had aneurysms, 41 experienced ischemic strokes (transient or not), 2 had arterial occlusions, and 3 had neoplasia. Furthermore, 91.8% of bypasses used radial artery grafts, and 87.9% revascularized the middle cerebral artery territory. The median average follow-up period was 12 months (0.3-53.1). The post-operation patency rate was 99% (95% CI: 97-100%; I2=0%), while the patency rate at follow-up was 82% (95% CI: 68-96%; I2=77%). Complications occurred in 21% of cases (95% CI: 9-32%; I2=58%), with no significant procedure-related mortality in 0% (95% CI: 0-2%; I2=0%). Favorable outcomes were observed in 88% of patients (95% CI: 81-96%; I2=0%), and only 3% experienced ischemia (95% CI: 0-6%; I2=0%). The subcranial-intracranial bypass with the IMAX shows excellent postoperative patency and considerable favorable clinical outcomes. While complications exist, the procedure carries a minimal risk of mortality. However, long-term patency presents heterogeneous findings, warranting additional research.
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Affiliation(s)
- Leonardo de Barros Oliveira
- Department of Neurosurgery, State University of Ponta Grossa, Uvaranas Campus - General Carlos Cavalcanti Avenue, 4748, Ponta Grossa, Paraná, Brazil.
| | - Pedro Henrique Cieslak
- Department of Neurosurgery, State University of Ponta Grossa, Uvaranas Campus - General Carlos Cavalcanti Avenue, 4748, Ponta Grossa, Paraná, Brazil
| | | | - Sávio Batista
- Federal University of Rio de Janeiro, Rio de Janeiro, Rio de Janeiro, Brazil
| | - Filipi Fim Andreão
- Federal University of Rio de Janeiro, Rio de Janeiro, Rio de Janeiro, Brazil
| | | | | | | | | | - Leonardo C Welling
- Department of Neurosurgery, State University of Ponta Grossa, Uvaranas Campus - General Carlos Cavalcanti Avenue, 4748, Ponta Grossa, Paraná, Brazil
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How I do it: internal maxillary artery to middle cerebral artery bypass to manage giant thrombosed internal carotid artery aneurysm. Acta Neurochir (Wien) 2023; 165:495-499. [PMID: 36547705 DOI: 10.1007/s00701-022-05463-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Accepted: 12/10/2022] [Indexed: 12/24/2022]
Abstract
BACKGROUND Internal maxillary artery (IMA) bypass has become popularized due to its medium-to-high blood flow, short graft length, and well-matched arterial caliber between donor and recipient vessels. METHOD We described an open surgery of a NEW "workhorse," the IMA bypass, to treat a giant, thrombosed cerebral aneurysm. The extracranial middle infratemporal fossa (EMITF) approach was used to unveil the pterygoid segment of the IMA for cerebral revascularization. CONCLUSION Although this technique is technically challenging, the variations in IMA can be effectively identified and sufficiently exposed in this technique to achieve favorable clinical outcomes with a high bypass patency rate.
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Nene A, Hong CS, McGuone D, Matouk CC, Omay SB. Staged endovascular treatment of a coexisting parasellar aneurysm and endoscopic resection of a pituitary macroadenoma: illustrative case. JOURNAL OF NEUROSURGERY: CASE LESSONS 2022; 3:CASE21699. [PMID: 36130536 PMCID: PMC9379633 DOI: 10.3171/case21699] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/12/2021] [Accepted: 01/20/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND
Intracranial aneurysms and pituitary adenomas are relatively common pathologies that, in rare instances, may concurrently present. Their management poses considerable clinical and technical challenges.
OBSERVATIONS
The authors present a case of a 66-year-old female patient with a fusiform aneurysm of the left internal carotid artery associated with a symptomatic pituitary macroadenoma that had been causing visual deficits for the past several years. She underwent successful placement of flow diverter stents across her aneurysm, followed by routine dual antiplatelet therapy to maintain stent patency. She underwent frequent serial radiographic, endocrine, and ophthalmological evaluations during this time to ensure stability of her pituitary adenoma. Following confirmation of aneurysm obliteration and subsequent de-escalation of antiplatelet medications to aspirin monotherapy, her tumor was subsequently resected via an endoscopic endonasal approach in a delayed fashion.
LESSONS
The authors review the literature regarding management of these concurrent pathologies and describe the aspects of the case that led them to their chosen treatment strategy. An algorithm is proposed regarding the management of parasellar aneurysms with a concurrent diagnosis of pituitary tumor pathology.
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Affiliation(s)
| | | | - Declan McGuone
- Pathology, Yale School of Medicine, New Haven, Connecticut
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5
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Jamshidi AM, Soldozy S, Elarjani T, Burks JD, Luther E, Starke RM. Fusiform Dilatation of the Internal Carotid Artery in Childhood-Onset Craniopharyngioma- A Systematic Review. World Neurosurg 2021; 162:77-84. [PMID: 34555575 DOI: 10.1016/j.wneu.2021.09.058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Revised: 09/12/2021] [Accepted: 09/13/2021] [Indexed: 11/17/2022]
Abstract
OBJECTIVE Patients with fusiform dilation of the internal carotid artery (FDCA) following pediatric craniopharyngioma resection typically have a benign clinical course. We sought to review the neurosurgical literature for FDCA outcomes after resection of these tumors. METHODS Using PubMed, Web of Science, and Cochrane databases we identified surgical series or case reports reporting incidences of FDCA following craniopharyngioma resection. Inclusion criteria included FDCA outcomes reported specifically after craniopharyngioma resection, with at least 6 months of follow-up data. RESULTS Our literature search yielded 12 full-text articles. This resulted in a total of 799 patients (376, 52.3% males). The weighted mean follow-up was 74.8 (9-140) months. The majority of tumors were found to be suprasellar (62.1%), with traditional microsurgery being more commonly employed than endoscopic endonasal surgery (80.9% versus 19.1%). Gross total resection was achieved in 42.6% of cases. A total of 55 aneurysms were reported, most commonly occurring at the terminal internal carotid artery (ICA) (66.7%) . Aneurysmal progression on follow-up occurred in 10 (18.5%) cases, with no reports of rupture. A total of 10 (18.2%) of aneurysms were treated with clipping, endovascular, or bypass techniques. CONCLUSIONS FDCA is a rare complication following pediatric craniopharyngioma resection. The exact cause is unclear, and factors related to tumor invasiveness, size, location, and differences in surgical approach all may contribute to FDCA development. The majority of patients who go on to develop FDCA follow an innocuous course on follow-up, with no reports of rupture in the present literature. For this reason, patients rarely require surgical or endovascular intervention for these lesions, and conservative management is favored.
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Affiliation(s)
- Aria M Jamshidi
- Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Sauson Soldozy
- Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA.
| | - Turki Elarjani
- Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Joshua D Burks
- Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Evan Luther
- Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Robert M Starke
- Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA
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Guo Y, Song Y, Hou K, Yu J. Intracranial Fusiform and Circumferential Aneurysms of the Main Trunk: Therapeutic Dilemmas and Prospects. Front Neurol 2021; 12:679134. [PMID: 34305790 PMCID: PMC8299836 DOI: 10.3389/fneur.2021.679134] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2021] [Accepted: 06/08/2021] [Indexed: 11/16/2022] Open
Abstract
Intracranial fusiform and circumferential aneurysms (IFCAs), especially those located on the main trunk, are uncommon and difficult to manage. Currently, literature focused on IFCAs on the main trunk of cerebral arteries is lacking. The treatment of IFCAs is still under debate. Therefore, in this review, we further explore the treatment of this complicated entity. In addition, we also present some interesting cases. Based on the literature review and our experience, we found that IFCAs are often located in the vertebrobasilar system and that ruptured or large symptomatic IFCAs are associated with increased mortality and higher rebleeding rates. The treatment strategies for IFCAs can be classified as deconstructive and reconstructive methods via open surgery and/or endovascular treatment (EVT). Currently, EVT is a popular method and the main therapeutic choice. In particular, flow diversion has revolutionized the treatment of IFCAs. Parent artery occlusion (PAO) with or without revascularization may still be considered a suitable choice. Complex IFCAs that cannot be resolved by EVT can also be treated via open surgery with or without extracranial–intracranial bypass. Targeted embolization for the weak points of IFCAs is a temporary or palliative choice that is rarely used. In summary, despite complications, both surgical treatment and EVT are effective options for appropriately selected cases. Due to the development of endovascular implants, EVT will have better prospects in the future.
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Affiliation(s)
- Yunbao Guo
- Department of Neurosurgery, The First Hospital of Jilin University, Changchun, China
| | - Ying Song
- Department of Neurosurgery, The First Hospital of Jilin University, Changchun, China
| | - Kun Hou
- Department of Neurosurgery, The First Hospital of Jilin University, Changchun, China
| | - Jinlu Yu
- Department of Neurosurgery, The First Hospital of Jilin University, Changchun, China
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Asha MJ, Oswari S, Takami H, Velasquez C, Almeida JP, Gentili F. Craniopharyngiomas: Challenges and Controversies. World Neurosurg 2021; 142:593-600. [PMID: 32987615 DOI: 10.1016/j.wneu.2020.05.172] [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: 04/11/2019] [Accepted: 04/05/2020] [Indexed: 12/24/2022]
Abstract
Despite its benign histopathology, the treatment of craniopharyngioma remains one of the most formidable challenges faced by skull base surgeons. The technical challenges of tackling these complex central skull base lesions are paralleled by clinical challenges related to their unique tumor biology and the often-complex decision making required. In this article, we critically appraise the most recent literature to explore the challenges and controversies surrounding the management of these lesions. The role of curative resections and the shift in the surgical paradigm toward the multidisciplinary goal-directed management approach are discussed.
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Affiliation(s)
- Mohammed J Asha
- Department of Neurosurgery, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada.
| | - Selfy Oswari
- Department of Neurosurgery, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
| | - Hirokazu Takami
- Department of Neurosurgery, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
| | - Carlos Velasquez
- Department of Neurosurgery, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
| | - Joao Paulo Almeida
- Department of Neurosurgery, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
| | - Fred Gentili
- Department of Neurosurgery, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
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Ryska P, Lojik M, Kocer N, Zelenak K, Cesak T, Cimflova P, Bhorkar AM, Vitkova E, Krajina A. Mechanical thrombectomy performed in thrombosed fusiform aneurysm after surgery for craniopharyngioma in adult: Case report. Biomed Pap Med Fac Univ Palacky Olomouc Czech Repub 2021; 165:336-341. [PMID: 33821846 DOI: 10.5507/bp.2021.018] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2021] [Accepted: 03/05/2021] [Indexed: 01/05/2023] Open
Abstract
INTRODUCTION Fusiform dilatation of the internal carotid artery (ICA) is reported as a possible complication of craniopharyngioma resection in childhood. Here, the authors describe such a complication in an adult patient who presented with acute symptomatic thrombosis 7 months after surgery. MATERIALS AND METHODS A 45-year-old woman presented with left hemispheric stroke due to a thrombotic supraclinoid occlusion of the terminal ICA (so called "T" occlusion). Successful revascularisation was achieved with mechanical thrombectomy. Beside recanalization of the M1 middle cerebral artery segment and ICA, an irregular filling of the fusiform aneurysm of the communicating segment of the left ICA was observed. The patient recovered after mechanical thrombectomy with no clinical sequelae. Due to the persistent filling of the aneurysm sac, a flow diverter stent was deployed across the diseased vessel segment two weeks later. The patient underwent resection of the craniopharyngioma from ipsilateral pterional craniotomy 7 months ago. Five years later the patient works full time as a nurse with no regrowth of the craniopharyngioma and no aneurysm reperfusion. RESULTS This case, together with four other previously reported cases, documents that fusiform aneurysm as a complication of the craniopharygioma resection is not restricted to the childhood population but may also rarely occur in adults. As the patient suffered from acute symptomatic thrombosis which required treatment under the protocol for acute large vessel occlusions, we decided to treat the aneurysm with the flow diverter stent.
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Affiliation(s)
- Pavel Ryska
- Department of Radiology, Faculty of Medicine in Hradec Kralove, Charles University and University Hospital Hradec Kralove, Czech Republic
| | - Miroslav Lojik
- Department of Radiology, Faculty of Medicine in Hradec Kralove, Charles University and University Hospital Hradec Kralove, Czech Republic
| | - Naci Kocer
- Department of Neuroradiology, Cerrahpasa Medical Faculty, Istanbul University-Cerrahpasa Istanbul, Turkey
| | - Kamil Zelenak
- Department of Radiology, Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava and University Hospital in Martin, Slovak Republic
| | - Tomas Cesak
- Department of Neurosurgery, Faculty of Medicine in Hradec Kralove, Charles University and University Hospital Hradec Kralove, Czech Republic
| | - Petra Cimflova
- Department of Medical Imaging, St. Anne's University Hospital Brno and Faculty of Medicine, Masaryk University Brno, Czech Republic
| | | | - Eva Vitkova
- Department of Neurology, Faculty of Medicine in Hradec Kralove, Charles University and University Hospital Hradec Kralove, Czech Republic
| | - Antonin Krajina
- Department of Radiology, Faculty of Medicine in Hradec Kralove, Charles University and University Hospital Hradec Kralove, Czech Republic
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Karsten MB, Scott RM. Long-term stability of fusiform dilatation of the internal carotid artery following surgery adjacent to the circle of Willis: report of 2 cases. J Neurosurg Pediatr 2021; 27:185-188. [PMID: 33276338 DOI: 10.3171/2020.7.peds20469] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Accepted: 07/15/2020] [Indexed: 11/06/2022]
Abstract
Fusiform dilatation of the internal carotid artery (FDCA) is a known postoperative imaging finding after craniopharyngioma resection. FDCA has also been reported following surgery for other lesions in the suprasellar region in pediatric patients and is thought to be due to trauma to the internal carotid artery (ICA) wall during tumor dissection. Here, the authors report 2 cases of pediatric patients with FDCA. Case 1 is a patient in whom FDCA was visualized on follow-up scans after total resection of a craniopharyngioma; this patient's subsequent scans and neurological status remained stable throughout a 20-year follow-up period. In case 2, FDCA appeared after resection and fenestration of a giant arachnoid cyst in a 3-year-old child, with 6 years of stable subsequent follow-up, an imaging finding that to the authors' knowledge has not previously been reported following surgery for arachnoid cyst fenestration. These cases demonstrate that surgery involving dissection adjacent to the carotid artery wall in pediatric patients may lead to the development of FDCA. On very long-term follow-up, this imaging finding rarely changes and virtually all patients remain asymptomatic. Neurointerventional treatment of FDCA in the absence of symptoms or significant late enlargement of the arterial ectasia does not appear to be indicated.
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Fusiform dilatation of internal carotid artery after pterional but not subfrontal craniotomy in 6 patients. Childs Nerv Syst 2021; 37:125-129. [PMID: 32564154 DOI: 10.1007/s00381-020-04753-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Accepted: 06/16/2020] [Indexed: 10/24/2022]
Abstract
PURPOSE Our study aimed to evaluate potential risk factors for the development of FDICA after suprasellar tumor resection. MATERIALS AND METHOD After reviewing all cases of pediatric patients who benefited from a suprasellar lesion resection in our two medical institutions, we found 6 patients with a FDICA. Surgical approach strategy (pterional or subfrontal approaches) was noted. Postoperative cranial MRI was performed in each patient 3 months after surgery and every year. When a FDICA occurred, MRI was performed 6 months after the diagnosis and 1 year later to detect any progression. RESULTS There were 6 males with a mean age at treatment of 11 years (6 to 15). Pterional approach was performed in these 6 patients. At the 2 institutions, we have done at least 50 pterional craniotomies for suprasellar lesion resection. No FDICA was reported after subfrontal approach in 27 consecutive pediatric patients operated on from a craniopharyngioma. The delay between the surgery and the diagnosis of the FDICA was 9 months (3 to 17 months). No symptoms related to the FDICA were recorded. The mean maximal diameter of the aneurysm was 14 mm (10 to 21). ICA bifurcation was involved in 2 cases. Asymptomatic FDICA progression was noted in 2 cases but no treatment was proposed. CONCLUSION The pathogenesis of FDICA is unclear, and might involve arterial wall necrosis caused by postoperative arachnoid fibrosis which might be worsened by the pterional approach.
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Xiao G, Yuan X, Yuan J, Li Y, Chen X. Intracranial fusiform aneurysm following microsurgery for adult craniopharyngioma: Clinical experience and review of literature. INTERDISCIPLINARY NEUROSURGERY 2020. [DOI: 10.1016/j.inat.2020.100710] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
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Wang L, Lu S, Cai L, Qian H, Tanikawa R, Shi X. Internal maxillary artery bypass for the treatment of complex middle cerebral artery aneurysms. Neurosurg Focus 2020; 46:E10. [PMID: 30717068 DOI: 10.3171/2018.11.focus18457] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2018] [Accepted: 11/14/2018] [Indexed: 12/27/2022]
Abstract
OBJECTIVEThe rapid innovation of the endovascular armamentarium results in a decreased number of indications for a classic surgical approach. However, a middle cerebral artery (MCA) aneurysm remains the best example of one for which results have favored microsurgery over endovascular intervention. In this study, the authors aimed to evaluate the experience and efficacy regarding surgical outcomes after applying internal maxillary artery (IMA) bypass for complex MCA aneurysms (CMCAAs).METHODSAll IMA bypasses performed between January 2010 and July 2018 in a single-center, single-surgeon practice were screened.RESULTSIn total, 12 patients (9 males, 3 females) with CMCAAs managed by high-flow IMA bypass were identified. The mean size of CMCAAs was 23.7 mm (range 10-37 mm), and the patients had a mean age of 31.7 years (range 14-56 years). The aneurysms were proximally occluded in 8 cases, completely trapped in 3 cases, and completely resected in 1 case. The radial artery was used as the graft vessel in all cases. At discharge, the graft patency rate was 83.3% (n = 10), and all aneurysms were completely eliminated (83.3%, n = 10) or greatly diminished (16.7%, n = 2) from the circulation. Postoperative ischemia was detected in 2 patients as a result of graft occlusion, and 1 patient presenting with subarachnoid hemorrhage achieved improved modified Rankin Scale scores compared to the preoperative status but retained some neurological deficits. Therefore, neurological assessment at discharge showed that 9 of the 12 patients experienced unremarkable outcomes. The mean interval time from bypass to angiographic and clinical follow-up was 28.7 months (range 2-74 months) and 53.1 months (range 19-82 months), respectively. Although 2 grafts remained occluded, all aneurysms were isolated from the circulation, and no patient had an unfavorable outcome.CONCLUSIONSThe satisfactory result in the present study demonstrated that IMA bypass is a promising method for the treatment of CMCAAs and should be maintained in the neurosurgical armamentarium. However, cases with intraoperative radical resection or inappropriate bypass recipient selection such as aneurysmal wall should be meticulously chosen with respect to the subtype of MCA aneurysm.
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Affiliation(s)
- Long Wang
- 1Department of Neurosurgery, SanBo Brain Hospital, Capital Medical University, Beijing, China.,2Department of Neurosurgery, Stroke Center, Teishinkai Hospital, Sapporo, Japan
| | - Shuaibin Lu
- 3Department of Neurosurgery, Beijing Shijingshan Hospital, Beijing, China
| | - Li Cai
- 4Department of Neurosurgery, The First Affiliated Hospital of University of South China, Hengyang, China.,5Arkansas Neuroscience Institute, St. Vincent Hospital, Little Rock, Arkansas; and
| | - Hai Qian
- 1Department of Neurosurgery, SanBo Brain Hospital, Capital Medical University, Beijing, China
| | - Rokuya Tanikawa
- 2Department of Neurosurgery, Stroke Center, Teishinkai Hospital, Sapporo, Japan
| | - Xiang'en Shi
- 1Department of Neurosurgery, SanBo Brain Hospital, Capital Medical University, Beijing, China.,6Department of Neurosurgery, Fuxing Hospital, Capital Medical University, Beijing, China
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Sandvik U, Ohlsson M, Edström E. Vascular complications in pediatric craniopharyngioma patients: a case-based update. Childs Nerv Syst 2019; 35:2273-2278. [PMID: 31667536 DOI: 10.1007/s00381-019-04394-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2019] [Accepted: 09/26/2019] [Indexed: 10/25/2022]
Abstract
PURPOSE Craniopharyngiomas remain a challenging entity for neurosurgeons because of their deep-seated, midline location, and intimate relationship with critical neurovascular structures. With high long-term survival rates, patients with craniopharyngioma are likely to experience significant late morbidity related to both disease and therapy. METHOD AND RESULTS In this paper, we present two cases of late vascular complications after multi-modal treatment of craniopharyngioma. CONCLUSION Available data suggests that pediatric patients with craniopharyngioma represent a particularly vulnerable group.
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Affiliation(s)
- Ulrika Sandvik
- Section for Neurosurgery, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden.
| | - Marcus Ohlsson
- Section for Neurosurgery, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Erik Edström
- Section for Neurosurgery, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
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Zaki Ghali MG, Srinivasan VM, Britz GW. Maxillary Artery to Intracranial Bypass. World Neurosurg 2019; 128:532-540. [DOI: 10.1016/j.wneu.2019.03.015] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2017] [Revised: 02/28/2019] [Accepted: 03/01/2019] [Indexed: 12/16/2022]
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Intracranial–Intracranial Bypass with a Graft Vessel: A Comprehensive Review of Technical Characteristics and Surgical Experience. World Neurosurg 2019; 125:285-298. [DOI: 10.1016/j.wneu.2019.01.259] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2018] [Accepted: 01/28/2019] [Indexed: 12/28/2022]
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16
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In Reply to “The Relevance of Surgical Anatomy for Harvesting the Internal Maxillary Artery and Nomenclature of a ‘New’ Bypass Technique”. World Neurosurg 2019. [DOI: 10.1016/j.wneu.2018.12.157] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Wang L, Qian H, Shi X. Direct Suturing Technique for Ruptured Blood-Blister Aneurysm: The Forgotten Way. World Neurosurg 2019; 123:471-472. [PMID: 30832183 DOI: 10.1016/j.wneu.2018.11.129] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2018] [Accepted: 11/12/2018] [Indexed: 11/28/2022]
Affiliation(s)
- Long Wang
- Department of Neurosurgery, SanBo Brain Hospital, Capital Medical University, Beijing, China.
| | - Hai Qian
- Department of Neurosurgery, SanBo Brain Hospital, Capital Medical University, Beijing, China
| | - Xiang'en Shi
- Department of Neurosurgery, SanBo Brain Hospital, Capital Medical University, Beijing, China; Department of Neurosurgery, Fuxing Hospital, Capital Medical University, Beijing, China
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18
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Wang L, Shi X. Letter: Minimally Invasive Exposure of the Maxillary Artery at the Anteromedial Infratemporal Fossa. Oper Neurosurg (Hagerstown) 2019; 16:E110. [PMID: 30535408 DOI: 10.1093/ons/opy365] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Long Wang
- Department of Neurosurgery SanBo Brain Hospital Capital Medical University Beijing, China
| | - Xiang'en Shi
- Department of Neurosurgery SanBo Brain Hospital Capital Medical University Beijing, China
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Wang L, Qian H, Shi X. Underestimation of Extracranial-to-Intracranial Bypass in Management of Vertebrobasilar Dolichoectatic Aneurysm. World Neurosurg 2018; 119:462. [PMID: 30347580 DOI: 10.1016/j.wneu.2018.08.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2018] [Accepted: 08/02/2018] [Indexed: 11/17/2022]
Affiliation(s)
- Long Wang
- Department of Neurosurgery, SanBo Brain Hospital, Capital Medical University, Beijing, China
| | - Hai Qian
- Department of Neurosurgery, SanBo Brain Hospital, Capital Medical University, Beijing, China
| | - Xiang'en Shi
- Department of Neurosurgery, SanBo Brain Hospital, Capital Medical University, Beijing, China.
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Wang L, Cai L, Qian H, Shi X. Overestimated Role of Extracranial-to-Intracranial Bypass in Management of Blood-Blister Aneurysm. World Neurosurg 2018; 118:391-392. [PMID: 30248817 DOI: 10.1016/j.wneu.2018.06.159] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2018] [Accepted: 06/19/2018] [Indexed: 12/15/2022]
Affiliation(s)
- Long Wang
- Department of Neurosurgery, SanBo Brain Hospital, Capital Medical University, Beijing, China
| | - Li Cai
- Department of Neurosurgery, The First Affiliated Hospital of University of South China, Hengyang, China; Arkansas Neuroscience Institute, CHI St. Vincent Infirmary, Little Rock, Arkansas, USA
| | - Hai Qian
- Department of Neurosurgery, SanBo Brain Hospital, Capital Medical University, Beijing, China
| | - Xiang'en Shi
- Department of Neurosurgery, SanBo Brain Hospital, Capital Medical University, Beijing, China.
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21
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Wang L, Cai L, Qian H, Tanikawa R, Lawton M, Shi X. The re-anastomosis end-to-end bypass technique: a comprehensive review of the technical characteristics and surgical experience. Neurosurg Rev 2018; 42:619-629. [PMID: 30255374 DOI: 10.1007/s10143-018-1036-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2018] [Revised: 09/04/2018] [Accepted: 09/18/2018] [Indexed: 11/24/2022]
Abstract
Re-anastomosis end-to-end bypass is a straightforward subtype of intracranial-intracranial reconstruction technique that has been utilized to treat complex aneurysms and skull base tumors. This simple technique involves connecting the cut ends of an afferent and efferent artery under added tension after excising the lesion. The current study aims to provide a detailed description of the technical pitfalls, ideal anatomical sites and indications, and clinical outcomes for intracranial complex disorders. A literature search was performed using the terms "intracranial-intracranial bypass," "re-anastomosis bypass," "reconstructive bypass," "end-to-end bypass," and "end-to-end anastomosis" to identify pertinent articles. Articles involving end-to-end re-anastomosis combined with other bypass methods were excluded. Computer-tablet-drawn illustrations of this technique are provided to enhance comprehension. Eighty-six patients who met our search and inclusion criteria were identified between 1978 and the present. However, comprehensive descriptions of medical records and neuroimaging were available in only 41 cases (40 complex aneurysms and a skull base tumor). Of 40 reported cases of complex cerebral aneurysms treated by this technique, the overall rate of full recovery without complication is 87.5% (35/40). Meanwhile, all aneurysms were completely eliminated from the circulation, with 92.5% of bypasses being patent. End-to-end re-anastomosis remains a simple modality in the microsurgical bypass armamentarium. Safe and effective surgical outcomes can be achieved in select cases that rarely involve perforators or branches.
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Affiliation(s)
- Long Wang
- Department of Neurosurgery, SanBo Brain Hospital, Capital Medical University, No. 50, Yikesong Rd, Haidian District, Beijing, 100093, China. .,Department of Neurosurgery, Stroke Center, Teishinkai Hospital, Sapporo, Japan. .,Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ, USA.
| | - Li Cai
- Department of Neurosurgery, The First Affiliated Hospital of University of South China, Hengyang, China.,Arkansas Neuroscience Institute, St. Vincent Hospital, Little Rock, AR, USA
| | - Hai Qian
- Department of Neurosurgery, SanBo Brain Hospital, Capital Medical University, No. 50, Yikesong Rd, Haidian District, Beijing, 100093, China
| | - Rokuya Tanikawa
- Department of Neurosurgery, Stroke Center, Teishinkai Hospital, Sapporo, Japan
| | - Michael Lawton
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ, USA
| | - Xiang'en Shi
- Department of Neurosurgery, SanBo Brain Hospital, Capital Medical University, No. 50, Yikesong Rd, Haidian District, Beijing, 100093, China.
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22
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Wang L, Qian H, Shi X. Reiteration of "Less Invasive" Way and Graft Selections for Internal Maxillary Bypass. World Neurosurg 2018; 122:705-706. [PMID: 30205227 DOI: 10.1016/j.wneu.2018.08.228] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2018] [Accepted: 08/31/2018] [Indexed: 11/19/2022]
Affiliation(s)
- Long Wang
- Department of Neurosurgery, SanBo Brain Hospital, Capital Medical University, Bejing, China
| | - Hai Qian
- Department of Neurosurgery, SanBo Brain Hospital, Capital Medical University, Bejing, China
| | - Xiang'en Shi
- Department of Neurosurgery, SanBo Brain Hospital, Capital Medical University, Bejing, China.
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23
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Wang L, Cai L, Qian H, Lawton MT, Shi X. The In Situ Side-To-Side Bypass Technique: A Comprehensive Review of the Technical Characteristics, Current Anastomosis Approaches, and Surgical Experience. World Neurosurg 2018; 115:357-372. [DOI: 10.1016/j.wneu.2018.04.173] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2018] [Revised: 04/21/2018] [Accepted: 04/23/2018] [Indexed: 12/18/2022]
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24
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Wang L, Shi X, Qian H. Feasibility of Using Internal Thoracic Artery as Donor Vessel in High-Flow Intracranial Bypass Surgery. World Neurosurg 2018; 113:396. [PMID: 29702962 DOI: 10.1016/j.wneu.2018.01.217] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2018] [Accepted: 01/31/2018] [Indexed: 11/26/2022]
Affiliation(s)
- Long Wang
- Department of Neurosurgery, SanBo Brain Hospital, Capital Medical University, Beijing, China; Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Xiang'en Shi
- Department of Neurosurgery, SanBo Brain Hospital, Capital Medical University, Beijing, China; Department of Neurosurgery, Fu Xing Hospital, Capital Medical University, Beijing, China.
| | - Hai Qian
- Department of Neurosurgery, SanBo Brain Hospital, Capital Medical University, Beijing, China
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Abstract
Internal maxillary artery (IMA) bypass has gained momentum in the last 5 years for the treatment of complex cerebrovascular disorders and skull base tumors. However, some issues regarding this treatment modality have been proposed. As one of the most experienced neurosurgical teams to perform internal maxillary artery bypass in the world (>100 clinical cases), we reviewed the literature in aspects of basic anatomy of maxillary artery with its variations to the lateral pterygoid muscle, initial anastomosis modalities, and subsequent exposure techniques in cadaver studies, preoperative arterial evaluation methods, optimal interposed graft selections, and surgical outcome in the management of complex aneurysms, skull base tumors, and steno-occlusive disorders.
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26
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Wang L, Shi X, Qian H. Letter: Graft Selection in High-Flow Internal Maxillary Artery Bypass. Oper Neurosurg (Hagerstown) 2018; 14:10-11. [PMID: 29088435 DOI: 10.1093/ons/opx222] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Affiliation(s)
- Long Wang
- Department of Neurosurgery SanBo Brain Hospital Capital Medical University Beijing, China
| | - Xiang'en Shi
- Department of Neurosurgery Fu Xing Hospital Capital Medical University Beijing, China.,Department of Neurosurgery SanBo Brain Hospital Capital Medical University Beijing, China
| | - Hai Qian
- Department of Neurosurgery SanBo Brain Hospital Capital Medical University Beijing, China
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Feasibility of Using a Superficial Temporal Artery Graft in Internal Maxillary Artery Bypass. World Neurosurg 2017; 108:971-972. [DOI: 10.1016/j.wneu.2017.08.072] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2017] [Accepted: 08/10/2017] [Indexed: 11/24/2022]
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Ghali MGZ, Srinivasan VM, Cherian J, Kim L, Siddiqui A, Aziz-Sultan MA, Froehler M, Wakhloo A, Sauvageau E, Rai A, Chen SR, Johnson J, Lam SK, Kan P. Pediatric Intracranial Aneurysms: Considerations and Recommendations for Follow-Up Imaging. World Neurosurg 2017; 109:418-431. [PMID: 28986225 DOI: 10.1016/j.wneu.2017.09.150] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2017] [Revised: 09/20/2017] [Accepted: 09/21/2017] [Indexed: 10/18/2022]
Abstract
BACKGROUND Pediatric intracranial aneurysms (IAs) are rare. Compared with adult IAs, they are more commonly giant, fusiform, or dissecting. Treatment often proves more complex, and recurrence rate and de novo aneurysmogenesis incidence are higher. A consensus regarding the most appropriate algorithm for following pediatric IAs is lacking. METHODS We sought to generate recommendations based on the reported experience in the literature with pediatric IAs through a thorough review of the PubMed database, discussion with experienced neurointerventionalists, and our own experience. RESULTS Digital subtraction angiography (DSA) was utilized immediately post-operatively for microsurgically-clipped and endovascularly-treated IAs, at 6-12 months postoperatively for endovascularly-treated IAs, and in cases of aneurysmal recurrence or de novo aneurysmogenesis discovered by non-invasive imaging modalities. Computed tomographic angiography was the preferred imaging modality for long-term follow-up of microsurgically clipped IAs. Magnetic resonance angiography (MRA) was the preferred modality for following IAs that were untreated, endovascularly-treated, or microsurgically-treated in a manner other than clipping. CONCLUSIONS We propose incidental untreated IAs to be followed by magnetic resonance angiography without contrast enhancement. Follow-up modality and interval for treated pediatric IAs is determined by initial aneurysmal complexity, treatment modality, and degree of posttreatment obliteration. Recurrence or de novo aneurysmogenesis requiring treatment should be followed by digital subtraction angiography and appropriate retreatment. Computed tomography angiography is preferred for clipped IAs, whereas contrast-enhanced magnetic resonance angiography is preferred for lesions treated endovascularly with coil embolization and lesions treated microsurgically in a manner other than clipping.
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Affiliation(s)
- Michael George Zaki Ghali
- Department of Neurosurgery, Drexel University College of Medicine, Philadelphia, Pennsylvania, USA; Department of Neurosurgery, Baylor College of Medicine, Houston, Texas, USA
| | | | - Jacob Cherian
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas, USA
| | - Louis Kim
- Department of Neurological Surgery, University of Washington, Seattle, Washington, USA
| | - Adnan Siddiqui
- Department of Neurosurgery, University at Buffalo, Buffalo, New York, USA
| | - M Ali Aziz-Sultan
- Vascular and Endovascular Neurosurgery, Department of Neurosurgery, Brigham & Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Michael Froehler
- Department of Neurology, Vanderbilt School of Medicine, Nashville, Tennessee, USA
| | - Ajay Wakhloo
- Department of Radiology, University of Massachusetts, Worcester, Massachusetts, USA
| | - Eric Sauvageau
- Baptist Neurological Institute, Lyerly Neurosurgery, Jacksonville, Florida, USA
| | - Ansaar Rai
- Department of Interventional Neuroradiology, West Virginia University, Morgantown, West Virginia, USA
| | - Stephen R Chen
- Department of Radiology, Baylor College of Medicine, Houston, Texas, USA
| | - Jeremiah Johnson
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas, USA
| | - Sandi K Lam
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas, USA
| | - Peter Kan
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas, USA.
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Wang L, Lu S, Qian H, Shi X. Internal Maxillary Artery Bypass with Radial Artery Graft Treatment of Giant Intracranial Aneurysms. World Neurosurg 2017; 105:568-584. [DOI: 10.1016/j.wneu.2017.06.014] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2017] [Revised: 06/01/2017] [Accepted: 06/02/2017] [Indexed: 11/24/2022]
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30
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Yağmurlu K, Spetzler RF. In Reply to “Is Internal Maxillary Artery Bypass Feasible without Zygomatic Osteotomy?”. World Neurosurg 2017; 104:1005. [DOI: 10.1016/j.wneu.2017.05.072] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2017] [Accepted: 05/11/2017] [Indexed: 10/19/2022]
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31
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Is Internal Maxillary Artery Bypass Feasible without Zygomatic Osteotomy? World Neurosurg 2017; 104:1004. [DOI: 10.1016/j.wneu.2017.01.134] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2017] [Accepted: 01/30/2017] [Indexed: 11/23/2022]
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32
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Internal Maxillary Bypass for Complex Pediatric Aneurysms. World Neurosurg 2017; 103:395-403. [PMID: 28433837 DOI: 10.1016/j.wneu.2017.04.055] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2017] [Revised: 04/06/2017] [Accepted: 04/07/2017] [Indexed: 11/20/2022]
Abstract
BACKGROUND Complex pediatric aneurysms (PAs) are an unusual clinicopathologic entity. Data regarding the use of a bypass procedure to treat complex PAs are limited. METHODS Internal maxillary artery-to-middle cerebral artery bypass with radial artery graft was used to isolate PAs. Bypass patency and aneurysm stability were evaluated using intraoperative Doppler ultrasound, indocyanine green videoangiography, and postoperative angiography. Modified Rankin Scale was used to assess neurologic function. RESULTS Over a 5-year period, 7 pediatric patients (≤18 years old) were included in our analysis. Mean age of patients was 14.4 years (range, 12-18 years), and mean size of PAs was 23.6 mm (range, 9-37 mm). All cases manifested with complex characteristics. Proximal artery occlusion was performed in 3 cases, complete excision following aneurysmal distal internal maxillary artery bypass was performed in 2 cases, and combined proximal artery occlusion and aneurysm excision was performed in the 2 remaining cases. Mean intraoperative blood flow was 61.6 mL/minute (range, 40.0-90.8 mL/minute). Graft patency rate was 100% during postoperative recovery and at the last follow-up examination (mean, 20 months; range, 7-45 months). All patients had excellent outcomes except for 1 patient who died of multiple-organ failure. CONCLUSIONS Internal maxillary artery bypass is an essential technique for treatment of selected cases of complex PAs.
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