Daniel L. Surdell

Revascularization for complex intracranial aneurysms.

The modern management of intracranial aneurysms includes both constructive and deconstructive strategies to eliminate the aneurysm from the circulation. Both microsurgical and endovascular techniques are used to achieve this goal. Although most aneurysms can be eliminated from the circulation with simple clip reconstruction and/or coil insertion, some require revascularization techniques to enhance tolerance of temporary arterial occlusion during clipping of the aneurysm neck or to enable proximal occlusion or trapping. In fact, the importance of revascularization techniques has grown because of the need for complex reconstructions when endovascular therapies fail. Moreover, the safety and feasibility of bypass have progressed due to advances in neuroanesthesia, technological innovations, and ~ 5 decades of accumulating wisdom by bypass practitioners. Cerebral revascularization strategies become necessary in select patients who possess challenging vascular aneurysms due to size, shape, location, intramural thrombus, atherosclerotic plaques, aneurysm type (for example, dissecting aneurysms), vessels arising from the dome, or poor collateral vascularization when parent artery or branch occlusion is required. These techniques are used to prevent cerebral ischemia and subsequent clinical sequelae. Bypass techniques should be considered in cases in which balloon test occlusion demonstrates inadequate cerebral blood flow and in which there is a need for Hunterian ligation, trapping, or prolonged temporary occlusion. This review article will focus on decision making in bypass surgery for complex aneurysms. Specifically, the authors will review graft options, the utility of balloon test occlusion in decision making, and bypass strategies for various aneurysm types.

Adenosine for temporary flow arrest during intracranial aneurysm surgery: a single-center retrospective review.

BACKGROUND:Clip application for temporary occlusion is not always practical or feasible. Adenosine is an alternative that provides brief periods of flow arrest that can be used to advantage in aneurysm surgery, but little has been published on its utility for this indication. OBJECTIVE:To report our 2-year consecutive experience with 40 aneurysms in 40 patients for whom we used adenosine to achieve temporary arterial occlusion during aneurysm surgery. METHODS:We retrospectively reviewed our clinical database between May 2007 and December 2009. All patients who underwent microsurgical clipping of intracranial aneurysms under adenosine-induced asystole were included. Aneurysm characteristics, reasons for adenosine use, postoperative angiographic and clinical outcome, cardiac complications, and long-term neurological follow-up with the modified Rankin Scale were noted. RESULTS:Adenosine was used for 40 aneurysms (10 ruptured, 30 unruptured). The most common indications for adenosine were aneurysm softening in 17 cases and paraclinoid location in 14 cases, followed by broad neck in 12 cases and intraoperative rupture in 6 cases. Troponins were elevated postoperatively in 2 patients. Echocardiography did not show acute changes in either. Clinically insignificant cardiac arrhythmias were noted in 5 patients. Thirty-six patients were available for follow-up. Mean follow-up was 12.8 months. The modified Rankin Scale score was 0 for 29 patients at the time of the last follow-up. Four patients had an modified Rankin Scale score of 1, and scores of 2 and 3 were found in 2 and 1 patients, respectively. CONCLUSION:Adenosine appears to allow safe flow arrest during intracranial aneurysm surgery. This can enhance the feasibility and safety of clipping in select circumstances.

Infectious intracranial aneurysms in the pediatric population: Endovascular treatment with Onyx

ObjectsInfectious intracranial aneurysms present a treatment challenge in the pediatric population. Current endovascular strategies and tools have been developed, which make treatment of infectious intracranial aneurysms with liquid embolics safe and effective. This study reviews the use of the liquid embolic Onyx in the treatment of infectious intracranial aneurysms in the pediatric population.Materials and methodsWe used an endovascular approach to treat ruptured infectious intracranial aneurysms. We embolized the aneurysms with either Onyx alone or in combination with platinum coils.ConclusionEndovascular therapy with liquid embolics (Onyx) has been shown to be a safe and effectual treatment option in the case of pediatric infectious intracranial aneurysms. The combination of endovascular modalities can also be used to tailor the therapeutic goal of exclusion of infectious aneurysms with good results. Further studies are needed to assess the long-term effectiveness of this approach to pediatric infectious intracranial aneurysms.

Preoperative Onyx Embolization of Aggressive Vertebral Hemangiomas

SUMMARY: We report the first use of Onyx in the embolization of spinal tumors in 2 cases of aggressive vertebral hemangioma. In both cases, Onyx embolization provided effective preoperative tumor devascularization after the initial prolonged particulate embolization with Embospheres made little overall impact. Onyx enables a more rapid and visible embolization than particles and is less technically demanding than traditional liquid embolic agents, such as n-butyl cyanoacrylate.

Type I spinal dural arteriovenous fistulas: historical review and illustrative case

Type I spinal dural arteriovenous fistulas are the most common vascular malformation of the spinal cord, and an important cause of reversible progressive myelopathy. This lesion remains underdiagnosed, with most patients presenting late in the course of the disease. In this article the authors provide a review of the literature with particular attention to historical aspects related to the pathophysiology, diagnosis, classification, clinical findings, natural history, and treatment of this lesion. An illustrative case is also provided.

Ruptured proximal lenticulostriate artery fusiform aneurysm presenting with subarachnoid hemorrhage : Case report

OBJECTIVELenticulostriate artery aneurysms are rare. When present, distal locations in and around the basal ganglia are more common and often present with intraparenchymal hemorrhage when ruptured. We present a very rare case of a ruptured proximal lenticulostriate fusiform aneurysm presenting with subarachnoid hemorrhage. CLINICAL PRESENTATIONWe report the case of a 31-year-old healthy man who presented after the sudden onset of headache, nausea, and lethargy without neurological deficits. Cranial computed tomographic scanning demonstrated diffuse subarachnoid hemorrhage, and a cranial computed tomographic angiogram demonstrated a vascular irregularity on the superior surface of the left distal M1 trunk of the middle cerebral artery. A cerebral angiogram demonstrated a left proximal lenticulostriate fusiform aneurysm without evidence of moyamoya-like vessels or vasculitis. No other pathology or infectious etiology was noted. INTERVENTIONEndovascular therapy was deemed unsafe, and microsurgical exploration and intervention was the more favorable and safe approach. A standard left pterional craniotomy was performed and the afferent lenticulostriate vessel into the fusiform aneurysm was visualized. Temporary clips were applied to the proximal and distal M1 trunk and miniclips were applied across the afferent portion and fundus of the aneurysm, thus sacrificing the parent lenticulostriate artery. A postoperative computed tomographic scan demonstrated an area of hypodensity in the left basal ganglia. The patients postoperative right facial and upper extremity weakness improved to normal several days after aneurysmal clipping. CONCLUSIONThis is the first report of a ruptured proximal lenticulostriate artery fusiform aneurysm, which presented as subarachnoid hemorrhage in a healthy patient without an underlying vascular disease.

Modern endovascular and aesthetic surgery techniques to treat arteriovenous malformations of the scalp: case illustration

BACKGROUND Arteriovenous malformations of the scalp consist of abnormally connecting arterial feeding vessels and draining veins, devoid of a normal capillary bed within the subcutaneous fatty layer of the scalp. We present a case of a left temporal scalp AVM treated for aesthetic and pain-related concerns. A multidisciplinary approach combining endovascular AVM embolization and AVM excision with local flap reconstruction was chosen. CASE DESCRIPTION The patient presented with a progressive painful pulsatile mass in the left temporal region. On examination, there was no evidence of any facial nerve compromise or any other neurologic deficits. Computed tomographic angiography revealed a 6-mm lesion located totally within the scalp and not associated with bone or periosteum. A recommendation was made to proceed with preoperative embolization to facilitate surgical resection. The AVM was occluded endovascularly using multiple detachable platinum coils, and the patient was neurologically intact. The following day, the patient was taken to the operating room. By that time, the mass was minimally pulsatile. The AVM was resected en bloc, and a 3-layered intermediate closure of the 5.5-cm defect was then performed. The procedure was well tolerated, and the patient had an uneventful postoperative course. CONCLUSIONS Scalp AVMs are interesting lesions with heterogeneous anatomical features. Treatment can be optimized in a multidisciplinary environment, using a prescribed treatment algorithm to minimize the size of soft/hard tissue defect and enhance cosmesis. Careful selection of therapeutic modalities based on AVM anatomy and aesthetic concerns can lead to safe and durable results with high patient satisfaction rates.

Spontaneous spinal epidural hematoma of unknown etiology: case report and literature review.

IntroductionOur objective is to emphasize the importance of recognizing and rapidly treating spontaneous spinal epidural hematoma (SSEH). SSEH is a pathologic entity traditionally thought to be exceptionally rare but which, in the era of MR imaging, is becoming increasingly prevalent, and which if treated with sufficient rapidity can be completely curable.Clinical PresentationOur particular case presented with clumsiness, neck pain with radiation to both arms, and bilateral arm weakness. According to the literature surveyed, most patients present with severe back and/or neck pain, often with a radicular component, followed by motor and/or sensory deficits.Intervention/TechniqueC5-6 decompressive hemilaminectomy with evacuation of hematoma.ConclusionAs evidenced in the literature, outcome depends on time to operation and prognosis is impacted by age and preoperative deficit. Because of the high risk of poor outcome without treatment, SSEH should always be a diagnostic consideration in patients whose presentation is even slightly suggestive. Rapid, appropriate treatment of these patients can often lead to complete recovery of function, whereas any delay in appropriate treatment can be catastrophic.

Symptomatic spontaneous intracranial carotid artery dissection treated with a self-expanding intracranial nitinol stent: a case report.

BACKGROUND Although extracranial carotid dissection with stroke is common, intracranial dissection with stroke is rare. Stenting has been used to treat extracranial carotid dissections. Intracranially, however, it is only recently that stents have become a feasible option for this disease. We present a case of a spontaneous intracranial CAD with progressive symptoms despite medical management treated with a self-expanding intracranial micronitinol stent. CASE DESCRIPTION A 47-year-old, right-handed woman presented to the emergency department after noticing left-sided face and arm weakness and numbness, along with slurred speech. The patient was started on aspirin 325 mg/d orally and lovenox 40 mg/d subcutaneously. On hospital day 2, the patient was noted to have repeated episodes of weakness and numbness on the left side and MRI evidence of a new stroke. A diagnostic cerebral angiogram from a selective right internal carotid injection revealed a flow-limiting stenosis secondary to a dissection of the supraclinoid internal carotid artery with severe flow limitation to the hemisphere. Endovascular management was decided on, and a Neuroform stent measuring 4.5 x 20 mm (Boston Scientific Corporation, Natick, Mass) was deployed across the dissection with significant improvement of flow to that hemisphere on the poststent angiogram. CONCLUSIONS This case illustrates the successful off-label use of a self-expanding intracranial nitinol stent to treat a symptomatic intracranial internal CAD in the setting of failure of traditional medical management. This is a promising application of novel endovascular technology.

Emergent Image-Guided Treatment of a Large CSF Leak to Reverse “In-Extremis” Signs of Intracranial Hypotension

SUMMARY: We report the use of an emergent, targeted fibrin spinal epidural blood patch with subarachnoid saline infusion to rapidly reverse “in-extremis” clinical and imaging signs of posterior-fossa coning brought about by acute-on-chronic intracranial hypotension, itself consequent to a cervicothoracic CSF leak. Treatment resulted in a dramatic recovery and eventual discharge with return to normal lifestyle and occupation. The clinical and imaging danger signs are reviewed; fibrin patch technique and potential pitfalls in postprocedure management are analyzed.