Fatih Keskin

Endovascular treatment of complex intracranial aneurysms by pipeline flow-diverter embolization device: a single-center experience

Abstract Objective: Endovascular coil embolization has become an effective treatment modality for most intracranial aneurysms. However, complex aneurysms including large and giant aneurysms, fusiform shaped aneurysms, wide necked aneurysm, or small aneurysm that are unsuitable for coil embolization are still deterrent to be treated. Flow diversion is a novel concept that is applied in the treatment of these complex intracranial aneurysms. Method: We review the results and important features of 25 aneurysms in 24 patients who underwent endovascular treatment by using the pipeline flow-diverter embolization device. Result: At 6 month follow-up, all aneurysms (100%) showed total occlusion in our series. Only one patient who had giant vertebrobasilar aneurysm experienced major complication related to endovascular treatment. Discussion: We suggest that parent artery reconstruction via flow diversion with the PED is a valid and safe treatment modality.

A case report of firearm bullet settling into the thoracic spinal canal without causing neurological deficit or vertebral bone destruction.

ObjectiveThe main objective of this study was to present a case of gunshot injury in which a bullet particle settled into the inferior-thoracic epidural canal, which was neurologically intact, without causing any vertebral bone destruction.Summary of background dataThere has been no previous report in the literature regarding a foreign body settling into the vertebral canal following gunshot injury without causing any bony destruction.Case reportA 40-year-old male patient was hospitalized in emergency service with the complaints of severe pain in his back and both legs secondary to a gunshot wound. The entrance wound of the traversing projectile was located at the level of the tenth costa at the inferior of the right scapula. Neurological examination revealed no motor deficit. His lung X-ray was normal at radiological examination. Direct radiograph determined a bullet nucleus on the medium line at thoracolumbar level T-12. Intracanalicular bullet nucleus was found at posterior epidural at the T-12 level on thoracic CT, myelography and CT myelography. No vertebral bone destruction was seen in the direct radiograph studies and serial CT. T12 total laminectomy was performed and epidural foreign body removed. The patient, whose pains ameliorated during the postoperative process, was discharged without any neurological deficit.ConclusionWe prefer removal of firearm particles settling into the spinal canal in view of possible later complications such as infection and the toxic effect of the metallic particles, unless there appears any risk of neurological detriment to the patient.

Telmisartan ameliorates oxidative stress and subarachnoid haemorrhage-induced cerebral vasospasm

Objectives: Growing evidence suggests that oxidative stress is one of the factors contributing to subarachnoid haemorrhage (SAH)-induced cerebral vasospasm. SAH-induced cerebral vasospam alters thioredoxin (Trx) cycle enzymes and thioredoxin-interacting protein (TXNIP) as an important endogenous antioxidant system. In this study, we have explored the effects of telmisartan on the vascular morphological changes, endothelial apoptosis, tissue oxidative stress status and the level of Trx cycle enzymes/ TXNIP in a rabbit SAH model. Methods: Forty male New Zealand rabbits were randomly divided into five groups of eight rabbits each: control group, sham group, SAH group, SAH + vehicle group and SAH + telmisartan group. SAH was created by a single cisterna magna blood injection. SAH + telmisartan group received telmisartan treatment (5 mg/kg intraperitoneal, once daily) for 72 h. The brainstem tissue Trx1, Trx2, Trx reductase (TrxR), TrxR1and TXNIP levels were investigated. Total oxidant status (TOS), total antioxidant status (TAS), malondialdehyde (MDA) levels and tumour necrosis factor alpha (TNF alpha) levels were investigated. Basilar artery segments were investigated for cross-sectional area, wall thickness measurements and endothelial apoptosis. Results: Telmisartan treatment restored the lowered level of Trx1, TrxR, TAS and the expression of TrxR1 seen in SAH. Telmisartan treatment also decreased TXNIP expression, TOS, MDA and TNF alpha levels. Morphological changes of cerebral vasospasm were attenuated after treatment. Endothelial apoptosis significantly reduced. Discussion: Treatment with telmisartan ameliorates oxidative stress and SAH-induced cerebral vasospasm in rabbits. These effects of telmisartan may be associated with downregulation of TXNIP and upregulation of Trx/TrxR.

Congenital carotid-jugular fistula in a child: a case report.

Congenital carotid–jugular (CJ) fistula of the neck is a very rare clinical entity that has various causes. The CJ fistulas are particularly prone to complications unlike other peripheral arteriovenous fistulas. The aim of this report is to present a case of a CJ fistula between the external carotid and the external jugular vein, which was successfully closed with detachable balloon by an endovascular approach. A 14-year-old child was admitted to our clinic with a pulsatile neck swelling. There was no previous history of trauma. A high-flow fistula between the external carotid and the external jugular vein was determined. The fistula was closed with detachable balloon by an endovascular approach. The postoperative angiogram demonstrated complete resolution of the fistula. Endovascular treatment of CJ fistulas with detachable balloons is a safe and less traumatic technique and may be an effective alternative to the open surgery in selected patients.

Radiological anatomy of the C7 vertebra: Clinical implications in spine surgery

Context: This study was designed to understand and define the special radio-anatomic morphometry of C7 vertebra by using multidetector computed tomography (MDCT). Aims: The major aim of the study was to detect the gender- and side-related morphometric differences of C7 vertebra among subjects. Setting and design: Our radiology unit database scanned for MDCT sections of the C7 vertebra. Materials and Methods: A total of 214 patients (134 men, 80 women) were selected. A detailed morphometric evaluation of C7 was done. Statistical analysis used: T test, ANOVA. Lamina length (P < 0.001), pedicle length (P < 0.001), outer cortical (P = 0.01) and inner cancellous pedicle (P < 0.001) width, pedicle angle to sagittal plane (P < 0.001) values were statistically significantly different on the right versus left side. When the results were stratified by gender, lamina length, inner cancellous lamina height, pedicle length, inner cancellous pedicle height, outer cortical pedicle width, lateral mass anteroposterior length, anteroposterior length of C7 corpus, height of C7 corpus (P < 0.001), C6-7 (P = 0.013) and C7-T1disc height (P = 0.04), transverse foramina perpendicular width at C7 (P = 0.046) values were found to be statistically significantly different. Vertebral artery most commonly enters into the transverse foramina at C6 level. Conclusions: Gender and side differences are important factors for preoperative planning and showed significant differences among subjects. MDCT is a practical option for investigating the exact anatomical features of osseous structures.

An Experimental Study: Does the Neuroprotective Effect Increase When Hypothermia Deepens After Traumatic Brain Injury?

Background: Experimental approaches have been promising with the use of therapeutic hypothermia after Traumatic Brain Injury (TBI) whereas clinical data have not supported its efficacy. Objectives: This study aimed to investigate whether using selective deeper brain cooling correlates with a more neuroprotective effect on Intracranial Pressure (ICP) increments following TBI in rats. Materials and Methods: Adult male Sprague-Dawley rats (mean weight = 300 g; n = 25) were subjected to brain injury using a modified Marmarou method. Immediately after the onset of TBI, rats were randomized into three groups. Selective brain cooling was applied around the head using ice packages. Intracranial Temperature (ICT) and ICP were continuously measured at 0, 30, 60, 120, and 180 minutes and recorded for all groups. Group 1 (n = 5) was normothermia and was assigned as the control group. Group 2 (n = 10) received moderate hypothermia with a target ICT of between 32°C - 33°C and Group 3 (n = 10) was given a deeper hypothermia with a target ICT of below 32°C. Results: All subjects reached the target ICT by the 30th minute of hypothermia induction. The ICT was significantly different in Group 2 compared to Group 1 only at the 120th minute (P = 0.017), while ICP was significantly lower starting from the 30th minute (P = 0.015). The ICT was significantly lower in Group 3 compared to Groups 1 and 2 starting from the 30th minute (P = 0.001 and P = 0.003, respectively). The ICP was significantly lower in Group 3 compared to Group 1 starting from 30th minute (P = 0.001); however, a significant difference in ICP between Group 3 and Group 2 was observed only at the 180th minute (P = 0.047). Conclusions: Results of this study indicate that selective brain cooling is an effective method of decreasing ICP in rats; however, the deeper hypothermia caused a greater decrease in ICP three hours after hypothermia induction.

Endovascular management of a collateral network aneurysm in a patient with spontaneous internal carotid artery occlusion

Spontaneous “non-moyamoya” arterial occlusion of the intracranial arteries is very unusual. Progressive occlusion of a major intracranial artery, independently from the etiology, can lead to the development of collateral arterial networks that supply blood flow to distal territories beyond the occlusion. These collateral arteries are typically small and conduct low flows, but the hemodynamic stress within them can lead to aneurysm formation within the collateral network. In this report we present a case of spontaneous internal carotid artery occlusion and collateral network aneurysm for the first time in the literature and discuss the main features of the etiology and endovascular treatment of this rare, challenging aneurysm.

The Role of Bone Subtraction Computed Tomographic Angiography in Determining Intracranial Aneurysms in Non-Traumatic Subarachnoid Hemorrhage

Background: The presence of blood in the subarachnoid space is an acute pathology with a serious risk of death and complications. The most common etiology (approximately 80%) is intracranial aneurysm. Objectives: The aim of this study was to assess the role of bone subtracted computed tomographic angiography (BSCTA), a novel and noninvasive method for determining and characterizing intracranial aneurysms. Patients and Methods: Sixty consecutive patients with clinically suspected non-traumatic subarachnoid hemorrhage (SAH) were considered to enter the study. The subtraction quality was inadequate in ten patients; thus, they were excluded, leaving 50 patients (84.4%) in the study. Bone subtracted and non-subtracted 3D images were obtained from the BSCTA raw data sets. All images obtained by digital subtraction angiography (DSA), BSCTA, and computed tomographic angiography (CTA) were evaluated for the presence or absence of an aneurysm and the location, minimal sac diameter, and neck size ratio of the aneurysm. DSA was considered as the gold standard during the evaluation of the data. Results: Of the 50 patients who participated in this study, 11 had no aneurysms as determined by both CTA and DSA. Examination of the remaining 39 patients revealed the presence of 51 aneurysms. While 3D-CTA could not detect six aneurysms that were located in the base of the skull, 3D-BSCTA easily detected them. Moreover, five aneurysms were only partially detected by 3D-CTA. According to this data, the sensitivity of 3D-BSCTA and 3D-CTA was calculated as 98% and 86.3%, respectively; the specificity was calculated as 100% and 90.9%, respectively, per aneurysm; and the sensitivity of 100% for 3D-BSCTA and 98% for 3D-CTA was achieved by using combined images with multi-planar reconstruction (MPR) and maximum intensity projection (MIP). BSCTA detected and characterized the aneurysms as well as DSA, and BSCTA and DSA gave concordant results in detecting aneurysms. Conclusions: BSCTA is easily accessible, less time consuming, and most importantly, a non-invasive technique for detecting intracranial aneurysms. It is also suitable for patients who have been referred to emergency services. Therefore, it can be used in emergency conditions and as a first-line diagnostic method in patients with non-traumatic SAH.

The Surgical Management of Traumatic C6-C7 Spondyloptosis

A case of traumatic spondyloptosis of the cervical spine at the C6-C7 level is reported. The patient was treated succesfully with a anterior-posterior combined approach and decompression. The patient had good neurological outcome after surgery. A-51-year-old female patient was transported to our hospitals emergency department after a vehicle accident. The patient was quadriparetic (Asia D, MRC power 4/5) with severe neck pain. Plain radiographs, computerize tomography and spinal magnetic resonance imaging (MRI) showed C6-7 spondyloptosis and C5, C6 posterior element fractures. Gardner-Wells skeleton traction was applied. Spinal alignment was reachived by traction and dislocation was decreased to a grade 1 spondylolisthesis. Then the patient was firstly operated by anterior approach. Anterior stabilization and fusion was firstly achieved. Seven days after first operation the patient was operated by a posterior approach. The posterior stabilization and fusion was achieved. Postoperative lateral X-rays and three-dimensional computed tomography showed the physiological realignment and the correct screw placements. The patients quadriparesis was improved significantly. Subaxial cervical spondyloptosis is a relatively rare clinical entity. In this report we present a summary of the clinical presentation, the surgical technique and outcome of this rarely seen spinal disorder.

Ruptured spinal artery aneurysm associated with coarctation of the aorta.

A 55-year-old woman presented with unconsciousness and tetraparesis. Routine blood tests were normal. Computed tomography (CT) of the brain showed ventricular hematoma and associated mild hydrocephalus (Fig. 1). Urgent external ventricular drainage was performed. Craniocervical magnetic resonance imaging showed an intradural paramedullary lesion primarily consistent with an aneurysm at the C6 level. Diffuse spinal hematoma and aneurysm was also seen on CT (Fig. 2). Computed tomography angiography showed coarctation of the aorta (Fig. 3). Spinal angiography showed coarctation of aorta with a ruptured, 10-mm, dissecting spinal artery aneurysm (SAA). The aneurysm was occluded successfully with endovascular coiling (Fig. 4). Spinal artery aneurysms are very rare pathologies. Coarctation of the aorta is a well-recognized risk factor for SAA aneurysm formation.