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Nathal E, Degollado-García J, Rodríguez-Rubio HA, Bonilla-Suástegui A, Serrano-Rubio A. Fluorescein videoangiography (FL-VAG) as a predictor of cerebral bypass patency. World Neurosurg X 2024; 23:100287. [PMID: 38516026 PMCID: PMC10955417 DOI: 10.1016/j.wnsx.2024.100287] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2023] [Accepted: 02/20/2024] [Indexed: 03/23/2024] Open
Abstract
Background The fluorescein videoangiography (FL-VAG) has become a valuable adjunct tool in vascular neurosurgery. This work describes using the FL-VAG during bypass surgery and proposes a classification method for evaluating surgical results. Methods We analyzed 26 patients with 50 cerebral bypasses from September 2018 to September 2022. We used a three grades classification method based on the pass of intravenous fluorescein through the anastomosis. Grade 1 represents the synchronous and total filling of the "T" shape ("green T″) formed by the donor and recipient vessel, Grade 2, the asynchronous filling of the anastomosis (incomplete/asynchronous "green T″), and Grade 3, a non-patent anastomosis (absence of "green T″). Results Of the 26 patients, 8 underwent one bypass, 14 underwent double bypass, 2 underwent three bypasses, and 2 underwent four bypasses in two different interventions. The type of bypass was end-to-side anastomosis in 47 (94%) cases, internal maxillary artery to middle cerebral artery bypass with a radial artery graft (IMax-MCA anastomosis) in 2 (4%), and PICA-VA transposition in one (2%). We made 24 (48%) bypasses on the right side and 26 (52%) on the left side. After the initial surgery, thirty-nine (78%) bypasses were considered as Grade 1, 5 (10%) as Grade 2, and 6 (12%) as Grade 3. After intraoperative bypass patency assessment (IBPA), 45 (90%) of the bypasses were considered Grade 1 and remained patent on CTA. Conclusions Using FL-VAG and a three-tier classification method is a reliable tool to predict bypass patency. It is safe, low-risk, and available worldwide.
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Affiliation(s)
- Edgar Nathal
- Department of Vascular Neurosurgery, National Institute of Neurology and Neurosurgery “Manuel Velasco Suárez”, Mexico City USA
| | - Javier Degollado-García
- Department of Vascular Neurosurgery, National Institute of Neurology and Neurosurgery “Manuel Velasco Suárez”, Mexico City USA
| | - Héctor A. Rodríguez-Rubio
- Department of Vascular Neurosurgery, National Institute of Neurology and Neurosurgery “Manuel Velasco Suárez”, Mexico City USA
| | - Alfredo Bonilla-Suástegui
- Department of Vascular Neurosurgery, National Institute of Neurology and Neurosurgery “Manuel Velasco Suárez”, Mexico City USA
| | - Alejandro Serrano-Rubio
- Department of Vascular Neurosurgery, National Institute of Neurology and Neurosurgery “Manuel Velasco Suárez”, Mexico City USA
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Degollado-García J, Casas-Martínez MR, Mejia BRF, Balcázar-Padrón JC, Rodríguez-Rubio HA, Nathal E. Internal maxillary artery (IMax) - middle cerebral artery bypass in a patient with bilateral atherosclerotic carotid occlusion: A technical case report. J Cerebrovasc Endovasc Neurosurg 2024; 26:51-57. [PMID: 37997040 PMCID: PMC10995475 DOI: 10.7461/jcen.2023.e2022.11.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2022] [Revised: 02/21/2023] [Accepted: 05/12/2023] [Indexed: 12/06/2023] Open
Abstract
Since the first description of the possible utilization of the internal maxillary artery for bypass surgery, there are some reports of its use in aneurysm cases; however, there is no information about the possible advantages of this type of bypass for cerebral ischemic disease. We present a 77-year-old man with a history of diabetes, hypertension, systemic atherosclerosis, and two acute myocardial infarctions with left hemiparesis. Imaging studies reported total occlusion of the right internal carotid artery and 75% occlusion on the left side, with an old opercular infarction and repeated transient ischemic attacks in the right middle cerebral artery territory despite medical treatment. After a consensus, we decided to perform a bypass from the internal maxillary artery to the M2 segment of the middle cerebral artery using a radial artery graft. After performing the proximal anastomosis, the calculated graft's free flow was 216 ml/min. Subsequently, after completing the bypass, the patency was confirmed with fluorescein videoangiography and intraoperative Doppler. Postoperatively, imaging studies showed improvement in the perfusion values and the hemiparesis from 3/5 to 4+/5. The patient was discharged one week after the operation, with a modified Rankin scale of 1, without added deficits. The use of revascularization techniques in steno-occlusive disease indicates a select group of patients that may benefit from this procedure. In addition, internal maxillary artery bypass has provided a safe option for large areas of ischemia that cannot be supplied with a superficial temporal artery - middle cerebral artery bypass.
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Affiliation(s)
- Javier Degollado-García
- Vascular Neurosurgery Department, National Institute of Neurology and Neurosurgery “Manuel Velasco Suárez”, Mexico City, Mexico
| | - Martin R. Casas-Martínez
- Vascular Neurosurgery Department, National Institute of Neurology and Neurosurgery “Manuel Velasco Suárez”, Mexico City, Mexico
| | - Bill Roy Ferrufino Mejia
- Vascular Neurosurgery Department, National Institute of Neurology and Neurosurgery “Manuel Velasco Suárez”, Mexico City, Mexico
| | - Juan C. Balcázar-Padrón
- Vascular Neurosurgery Department, National Institute of Neurology and Neurosurgery “Manuel Velasco Suárez”, Mexico City, Mexico
| | - Héctor A. Rodríguez-Rubio
- Vascular Neurosurgery Department, National Institute of Neurology and Neurosurgery “Manuel Velasco Suárez”, Mexico City, Mexico
| | - Edgar Nathal
- Vascular Neurosurgery Department, National Institute of Neurology and Neurosurgery “Manuel Velasco Suárez”, Mexico City, Mexico
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Eguiluz-Melendez A, Sangrador-Deitos MV, Díaz-Bello S, Degollado-García J, Tena-Suck ML, Valencia-Ramos C, Marian-Magana R, Gómez-Amador JL. Microsurgical Resection of a Giant Trochlear Nerve Schwannoma: 2-Dimensional Operative Video. World Neurosurg 2023; 176:161. [PMID: 37169071 DOI: 10.1016/j.wneu.2023.05.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Revised: 04/29/2023] [Accepted: 05/01/2023] [Indexed: 05/13/2023]
Abstract
We present the case of a 17-year-old male, who complained of a 1-year onset of pulsatile headache, dysphagia, speech changes, and emotional lability. Neuroimaging revealed a large left-sided contrast-enhancing tumor located at the infratentorial space consistent with a large trochlear nerve schwannoma. The tumor was compressing the brainstem, obstructing the outflow of the third and lateral ventricles causing hydrocephalus, and disturbing the cortico-bulbar pathways bilaterally leading to the diagnosis of pseudobulbar palsy. After the patient consented the surgical procedure, he was operated through a subtemporal transtentorial approach placed in the lateral position. A lumbar drain was used for brain relaxation during the procedure and image guidance to define the limits of surgical exposure. A microsurgical technique was used, aiming to preserve the cranial nerves and the vascular structures running through the perimesencephalic cisterns. Gross total resection was achieved and clinical course remained uneventful aside from a transient third nerve palsy. Symptoms improved and the three-month follow-up revealed an almost complete function of the oculomotor nerve (Video 1). Trochlear nerve schwannomas are the rarest variety of the cranial nerve schwannomas. Depending on tumor size, clinical and neuroimaging signs of mass effect and brainstem compression, treatment can be observation, microsurgical resection through cranial base approaches or radiosurgery.1-5.
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Affiliation(s)
- Aldo Eguiluz-Melendez
- Neurosurgery Department, National Institute of Neurology and Neurosurgery "Manuel Velasco Suárez", Mexico City, Mexico
| | - Marcos V Sangrador-Deitos
- Neurosurgery Department, National Institute of Neurology and Neurosurgery "Manuel Velasco Suárez", Mexico City, Mexico.
| | - Sergio Díaz-Bello
- Neurosurgery Department, National Institute of Neurology and Neurosurgery "Manuel Velasco Suárez", Mexico City, Mexico
| | - Javier Degollado-García
- Neurosurgery Department, National Institute of Neurology and Neurosurgery "Manuel Velasco Suárez", Mexico City, Mexico
| | - Martha L Tena-Suck
- Neuropathology Department, National Institute of Neurology and Neurosurgery "Manuel Velasco Suárez", Mexico City, Mexico
| | - Cristopher Valencia-Ramos
- Neurosurgery Department, National Institute of Neurology and Neurosurgery "Manuel Velasco Suárez", Mexico City, Mexico
| | - Ricardo Marian-Magana
- Neurosurgery Department, National Institute of Neurology and Neurosurgery "Manuel Velasco Suárez", Mexico City, Mexico
| | - Juan L Gómez-Amador
- Neurosurgery Department, National Institute of Neurology and Neurosurgery "Manuel Velasco Suárez", Mexico City, Mexico
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Degollado-García J, Rodríguez-Rubio HA, Bonilla-Suastegui A, Serrano-Rubio A, Nicolas-Cruz CF, Nathal E. Limitation of fenestrated clips during clipping of middle cerebral artery aneurysm: Technical note. Surg Neurol Int 2023; 14:204. [PMID: 37404494 PMCID: PMC10316142 DOI: 10.25259/sni_374_2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2023] [Accepted: 05/27/2023] [Indexed: 07/06/2023] Open
Abstract
Background The middle cerebral artery (MCA) is a common site of cerebral aneurysms and 82.6% occur at the bifurcation. When surgery is selected as a therapeutic option, it intends to clip the neck completely because if some remnant occurs, there exists the possibility of regrowth and bleeding in the short- or long-term. Methods We analyzed one drawback of the fenestrated clips of Yasargil and Sugita types to occlude the neck totally at a specific point formed by the union of the fenestra with the blades, creating a triangular space where the aneurysm can protrude, giving place to a remnant that can lead to a future recurrence and rebleeding. We show two cases of ruptured MCA aneurysms in which a cross-clipping technique occluded a broad base and dysmorphic aneurysm using straight fenestrated clips. Results In both cases (one using a Yasargil clip and the other with a Sugita clip), a small remnant was visualized when fluorescein videoangiography (FL-VAG) was used. In both cases, the small remnant was clipped with a 3 mm straight miniclip. Conclusion We should be aware of this drawback when clipping aneurysms using fenestrated clips to ensure a complete obliteration of the aneurysm's neck.
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Affiliation(s)
| | | | | | | | | | - Edgar Nathal
- Corresponding author: Edgar Nathal, Department of Vascular Neurosurgery, National Institute of Neurology and Neurosurgery ‘Manuel Velasco Suárez’, Mexico City, Mexico.
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Muacevic A, Adler JR, Villanueva-Solórzano PL, Degollado-García J, Cano-Velázquez G, Tena-Suck ML, Ramos-Peek MA. Surgical Approach and Further Management of Intracranial Hemangioendothelioma With Double Location: A Case Report. Cureus 2022; 14:e32072. [PMID: 36600818 PMCID: PMC9803365 DOI: 10.7759/cureus.32072] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/29/2022] [Indexed: 12/02/2022] Open
Abstract
Hemangioendotheliomas are highly vascularized lesions, and their intracranial presentation is extremely rare. We present the case of a 65-year-old female patient who was evaluated for cranial deformity, headache, and left hemiplegia. Two bone lesions that were destroying and expanding the bone diploe with intracranial extension were identified in the fronto-temporal and parietal regions. Both lesions were multilobed and showed heterogeneous behavior. Mixed hemangioendotheliomas were identified after the successful resection of both tumors in two separate surgical procedures. The prognosis of this type of tumor with an intracranial location is not well-defined because there are too few reported cases.
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Degollado-García J, Medina-Pizarro M, Cano-Velazquez G, Balcázar-Padrón JC, Gutierrez-Avila O, Nathal E. Microsurgical treatment of carotid body tumors using periadventitial dissection: Analysis of outcomes and prognostic factors in a neurological referral center. Surg Neurol Int 2022; 13:487. [DOI: 10.25259/sni_572_2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2022] [Accepted: 09/24/2022] [Indexed: 11/04/2022] Open
Abstract
Background:
Surgical resection for carotid body tumors (CBTs) is the gold standard of treatment and continues to be a challenging procedure, commonly associated with high vascular injury rates and neurological complications.
Methods:
It is a retrospective case series study between January 2002 and November 2020, with a mean follow-up of 29 months in a single nationwide referral center. Thirty-one patients diagnosed with a carotid body tumor and treated with microsurgical periadventitial resection were included in the study. Patients’ demographics, comorbidities, clinical, radiological factors, and tumor grade, evaluated by the Shamblin scale, were obtained. Statistical analysis was performed on all collected data.
Results:
In this study, we included 31 patients (32 tumors), 80% of the patients were female, and 20% were male, with a mean age of 53 years. One patient presented with bilateral lesions, while 17 tumors were located on the left side. The most frequent symptom was a painless, slow-growing neck mass in 74% of patients. Using the Shamblin classification, 13% of tumors were Grade I, 53% Grade II, and 34% Grade III. In the postoperative period, 3% of patients presented with permanent cranial nerve deficit, while none had vascular injuries or postoperative stroke. A tumor >5 cm increased the risk for nerve lesion by 11 times (OR 12.6, CI 95% 7.4-11.4, P < 0.001).
Conclusion:
Preoperative embolization followed by periadventitial resection by means of a microsurgical technique is a safe and effective approach to remove CBT, with 3% cranial nerve injury rate and no need for vascular sacrifice or reconstruction.
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Affiliation(s)
- Javier Degollado-García
- Department of Vascular Neurosurgery, Instuto Nacional de Neurología y Neurocirugía “Manuel Velasco Suárez” - Mexico City, Mexico
| | - Mauricio Medina-Pizarro
- Department of Neurological Surgery, New York-Presbyterian Hospital, Weill Cornell Medical College, New York, United States,
| | - Gerardo Cano-Velazquez
- Department of Vascular Neurosurgery, Instuto Nacional de Neurología y Neurocirugía “Manuel Velasco Suárez” - Mexico City, Mexico
| | - Juan C. Balcázar-Padrón
- Department of Vascular Neurosurgery, Instuto Nacional de Neurología y Neurocirugía “Manuel Velasco Suárez” - Mexico City, Mexico
| | - Oscar Gutierrez-Avila
- Department of Neurological Surgery, Hospital Civil de Guadalajara. Guadalajara City, Mexico
| | - Edgar Nathal
- Department of Vascular Neurosurgery, Instuto Nacional de Neurología y Neurocirugía “Manuel Velasco Suárez” - Mexico City, Mexico
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Nathal E, Serrano-Rubio A, Monroy-Sosa A, Gutiérrez-Ávila O, Vázquez-Gregorio R, Degollado-García J, Lee Á. Operative considerations and surgical treatment of sylvian fissure arteriovenous malformations: a 20-year experience. Neurosurg Focus 2022; 53:E10. [DOI: 10.3171/2022.4.focus22109] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Accepted: 04/21/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE
Sylvian fissure (SF) arteriovenous malformations (AVMs) are among the most challenging vascular lesions amenable to neurosurgical treatment and account for 10% of all locations. As radiosurgery and endovascular techniques are increasingly involved in multimodal management protocols, the role of microsurgery needs to be reassessed as a stand-alone technique. The aim of this study was to show that total excision can be achieved with reasonable levels of morbidity and mortality in a real-world setting from a specialized high-volume center.
METHODS
Forty-three patients with SF AVMs were identified from a series of 577 AVM patients treated microsurgically over a 22-year period. The mean patient age was 33.07 years (range 15–60 years), and there were 22 male and 21 female patients. The mode of presentation was headache in 51.2%, hemorrhage in 34.9%, seizures in 30.2%, and steal phenomenon in 9.3%. The authors analyzed the anatomical basis and angiographic characteristics of such lesions.
RESULTS
In the preoperative period, 83.7% of the patients had a modified Rankin Scale (mRS) score of 0–2, and 16.3% had an mRS score of 3–5. After a 12-month follow-up, 95.3% of patients had an mRS score of 0–2, and 4.7% had a score of 3–6. The difference between pre- and postoperative scores was not statistically significant. SF AVMs have several particular features: 1) They produce angiographic steal of the anterior cerebral artery. 2) The nidus is fed by only one of the main trunks of the middle cerebral artery (MCA). 3) Participation of deep perforators is uncommon. 4) They have two or more early draining veins showing their fistulous nature. 5) Preoperative embolization and radiosurgery have a low rate of permanent cure.
CONCLUSIONS
These AVMs represent a surgical challenge due to their proximity to critical structures such as the MCA, insula, internal capsule, and speech and memory functions in the dominant hemisphere. Essential key points are the wide opening of the SF and proper differentiation between feeders and normal vessels. Although this location can seem daunting, SF AVMs carry no additional surgical risk if adequately managed.
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Affiliation(s)
- Edgar Nathal
- Department of Neurosurgery, National Institute of Neurology and Neurosurgery “Manuel Velasco Suárez,” Mexico City
| | - Alejandro Serrano-Rubio
- Department of Neurosurgery, National Institute of Neurology and Neurosurgery “Manuel Velasco Suárez,” Mexico City
| | - Alejandro Monroy-Sosa
- Department of Neurosurgery, National Institute of Neurology and Neurosurgery “Manuel Velasco Suárez,” Mexico City
- Department of Neurosurgery, Hospital General de Tláhuac, ISSSTE, Mexico City; and
| | - Oscar Gutiérrez-Ávila
- Department of Neurosurgery, National Institute of Neurology and Neurosurgery “Manuel Velasco Suárez,” Mexico City
| | - Rafael Vázquez-Gregorio
- Department of Neurosurgery, National Institute of Neurology and Neurosurgery “Manuel Velasco Suárez,” Mexico City
| | - Javier Degollado-García
- Department of Neurosurgery, National Institute of Neurology and Neurosurgery “Manuel Velasco Suárez,” Mexico City
| | - Ángel Lee
- Hospital Ángeles del Pedregal, Mexico City, Mexico
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