Hamad Farhat

Eagle syndrome as a cause of transient ischemic attacks

Eagle syndrome is an uncommon entity but is well known in the otorhinolaryngology and oral surgery literature. This syndrome results from the compression of cranial nerves in the neck by an elongated styloid process causing unilateral cervical and facial pain. The styloid process can also cause compression of the cervical carotid arteries leading to the so-called carotid artery syndrome together with carotidynia or neurological symptoms due to flow reduction in these arteries. The authors discuss the case of a 70-year-old man who suffered from transient ischemic attacks on turning his head to the left, with immediate remission of symptoms when his head returned to the neutral position. The patient was studied with dynamic angiography, which clearly showed focal flow restriction. Once a diagnosis was made, the styloid process was removed surgically and the patient completely recovered from his symptoms. A postoperative angiogram demonstrated complete resolution of the pathology. Neurosurgeons might encounter patients with Eagle syndrome and should be aware of the symptoms and signs. Once the diagnosis is made, the treatment is clear and very effective.

Onyx embolization of carotid-cavernous fistulas

OBJECT The authors conducted a study to determine the safety and efficacy of embolization of carotid-cavernous fistulas (CCFs) with the ethylene vinyl alcohol copolymer, Onyx. METHODS They prospectively collected data in all patients with CCFs who underwent Onyx-based embolization at their institution over a 3-year period. The type of fistula, route of embolization, viscosity of Onyx, additional use of coils, extent of embolization, procedural complications, and clinical follow-up were recorded. RESULTS A total of 12 patients (5 men and 7 women who were age 24-88 years) underwent embolization in which Onyx was used. There were 1 Barrow Type A, 1 Type B, 3 Type C, and 7 Type D fistulas. Embolization was performed via a transvenous route in 8 cases and a transarterial route in 4 cases. Onyx 34 was used in all but 2 cases: a direct Type A fistula embolized with Onyx 500 and an indirect Type C fistula embolized with Onyx 18. Adjuvant embolization with framing coils was performed in 7 cases. All procedures were completed in a single session. Immediate fistula obliteration was achieved in all cases. Clinical resolution of presenting symptoms occurred in 100% of the patients by 2 months. Neurological complications occurred in 3 patients. One patient developed a complete cranial nerve (CN) VII palsy that has not resolved. Two patients developed transient neuropathies--1 a Horner syndrome and partial CN VI palsy, and 1 a complete CN III and partial CN V palsy. Radiographic follow-up (mean 16 months, range 4-35 months) was available in 6 patients with complete resolution of the lesion in all. CONCLUSIONS Onyx is a liquid embolic agent that is effective in the treatment of CCFs but not without hazards. Postembolization cavernous sinus thrombosis and swelling may result in transient compressive cranial neuropathies. The inherent gradual polymerization properties of Onyx allow for casting of the cavernous sinus but may potentially result in deep penetration within arterial collaterals that can cause CN ischemia/infarction. Although not proven, the angiotoxic effects of dimethyl sulfoxide may also play a role in postembolization CN deficits.

Carotid artery sacrifice for unclippable and uncoilable aneurysms: endovascular occlusion vs common carotid artery ligation.

BACKGROUND:Optimal treatment of intracranial aneurysms involves complete occlusion of the aneurysm with preservation of the parent artery and all of its branches. Attempts to occlude the aneurysm and preserve the parent artery may be associated with a higher level of risk than parent vessel occlusion or trapping. OBJECTIVE:To evaluate our series of patients with large and giant aneurysms who underwent treatment via endovascular coiling with parent artery sacrifice or surgical ligation of the common carotid artery (CCA) and gain insight into the advantages and risks of each of these alternatives. METHODS:We retrospectively reviewed all patients with aneurysms who underwent carotid sacrifice via endovascular occlusion or surgical CCA ligation during an 8-year period at our institution. RESULTS:Twenty-seven patients with large and giant aneurysms of the internal carotid artery underwent carotid artery sacrifice via endovascular occlusion (n = 15) or CCA ligation (n = 12). Of the patients who underwent endovascular occlusion, 3 developed groin complications, 1 developed a new sixth nerve palsy, 1 died from vasospasm related to subarachnoid hemorrhage, and 1 died secondary to rupture of an associated 3-mm anterior communicating artery aneurysm 5 days postoperatively. Of the patients undergoing CCA ligation, 1 patient developed a partial hypoglossal palsy. Clinical improvement of presenting symptoms was observed in all surviving patients regardless of the method of treatment. Complete aneurysm obliteration was documented in all patients during the initial hospital stay. The mean radiographic long-term follow-up was 14.2 months, which was available in 20 of the 25 surviving patients (80%). Complete obliteration was confirmed at follow-up in all but 2 patients with large cavernous aneurysms; 1 was initially treated with endovascular occlusion and the other with carotid ligation. CONCLUSION:Parent artery sacrifice is still a viable treatment for some complex aneurysms of the internal carotid artery. CCA ligation is a reasonable alternative to endovascular arterial sacrifice.

Direct percutaneous embolization of a carotid body tumor with Onyx

Carotid body tumors (CBTs) are rare highly vascular lesions that frequently require preoperative embolization to minimize surgical morbidity secondary to blood loss. Embolization has typically been performed via a transarterial route. However, this frequently results in incomplete devascularization of the tumor due to the complex angioarchitecture of the feeding arteries. Direct intralesional embolization has been used to gain easier accesses to the tumor vasculature and thus increase the likelihood of complete embolization. Cyanoacrylate glue has been the most commonly used embolic agent. The authors present a case of CBT that underwent direct intralesional embolization using Onyx (ev3; ethylene vinyl alcohol copolymer). To their knowledge, there have been no previous reports of direct percutaneous embolization of a CBT with this agent.

Isolated unilateral hypoglossal nerve palsy secondary to an atlantooccipital joint juxtafacet synovial cyst: Case report and review of the literature

Juxtafacet cysts of the atlantooccipital joint that present with isolated hypoglossal nerve palsy are rare and may mimic more common pathological entities. The authors report on the third such case in the literature and discuss the differential diagnosis, imaging hallmarks, preoperative recognition, and surgical management of this lesion, and provide a review of the literature. The authors discuss their experience with the treatment of a 67-year-old woman who presented with an isolated hypoglossal nerve palsy caused by a nonenhancing cystic septated lesion abutting the lateral medulla just medial to the left hypoglossal canal. The lesion was presumed to be a necrotic hypoglossal schwannoma or epidermoid tumor. Intradural surgical exploration failed to demonstrate an intradural lesion, but confirmed the presence of an extradural mass caudal to the hypoglossal nerve. Extradural exploration revealed a synovial cyst of the atlantooccipital joint, which was then resected. Postoperatively, the patient developed worsening dysphagia and hoarseness. Failure to recognize this rare entity preoperatively resulted in unnecessary intradural exploration and cranial nerve morbidity. In retrospect, the preoperative diagnosis of this lesion was suggested by lack of central enhancement, absence of dumbbell formation and the presence of erosive synovial changes. Regardless, the extreme rarity of this lesion at this location will always make its recognition challenging.

Transarterial embolization of a scalp hemangioma presenting with Kasabach-Merritt syndrome: Case report

A 2-month-old infant presented with an enlarging scalp hemangioma and consumptive coagulopathy. The patient became severely thrombocytopenic despite medical treatment. Transarterial embolization with Onyx was performed with significant reduction in the size of the tumor and complete resolution of the thrombocytopenia within 12 hours. Onyx embolization appears to be an excellent treatment option for hemangiomas presenting with Kasabach-Merritt syndrome that are unresponsive to standard medical therapy.

Cervical subarachnoid catheter placement for continuous cerebrospinal fluid drainage: a safe and efficacious alternative to the classic lumbar cistern drain.

BACKGROUND: Cerebrospinal fluid (CSF) drainage serves an important role in the management of patients with established or potential CSF fistulae. Classically, a lumbar CSF drain has been used for this purpose and has been shown to be safe and effective. In certain cases, such as extensive previous lumbar surgery, a lumbar drain cannot be used. In such instances, a cervical CSF drain can be inserted via a lateral C1-2 puncture and provides an excellent and safe alternative. OBJECTIVE: To describe the technique, safety, and effectiveness of placing a cervical drain for CSF drainage. Pitfalls and possible complications and their avoidance are also discussed. METHODS: Twenty-seven cervical drains were placed in 24 patients with a mean age of 56.1 years (range, 19-82 years). There were 13 women and 11 men. All cervical drains were placed via a lateral C1-2 puncture under direct fluoroscopic vision. A standard Hermetic closed-tip lumbar catheter was used in all cases. The drains were in place for an average of 5.96 days (range, 3-11 days). CSF surveillance was performed on the day of placement as well as every 48 hours that the drain was in place. RESULTS: Cervical drain placement was achieved in all cases, allowing for continuous CSF drainage. No permanent procedural complications occurred. There were no instances of meningitis. CONCLUSIONS: Placement of a cervical intrathecal catheter for CSF drainage is a safe and effective alternative when lumbar access is contraindicated or not achievable.

N-Butyl-2-cyanoacrylate Use in Intraoperative Ruptured Aneurysms as a Salvage Rescue: Case Report

OBJECTIVE AND IMPORTANCEThe use of N-butyl-2-cyanoacrylate (n-BCA) acrylic glue as a salvage rescue in procedural ruptured aneurysm should be part of the neurointerventionalists armamentarium. CLINICAL PRESENTATIONTwo patients, age 44 and 60 years, presented with Hunt and Hess grade 3 subarachnoid hemorrhage from aneurysmal rupture. INTERVENTIONWe report 2 cases in which n-BCA was used effectively as a salvage rescue in aneurysms that ruptured during coil embolization. CONCLUSIONThese 2 cases demonstrate a feasible technique for the salvage of iatrogenic aneurysm perforation during coil embolization, which, to our knowledge, has not been previously reported.

Balloon-assisted clipping of a large paraclinoidal aneurysm: a salvage procedure.

OBJECTIVESurgical clipping and parent vessel reconstruction of wide-neck paraclinoid aneurysms can be very challenging. We report a case of a ruptured paraclinoid aneurysm which failed standard clipping techniques. We were able to reconstruct this aneurysm while providing proximal and distal control using an adjuvant endovascular balloon. CLINICAL PRESENTATIONWe report the case of a 45-year-old woman presenting with a ruptured large paraclinoidal aneurysm, which involved a significant portion of the internal carotid artery wall. INTERVENTIONRepeated attempts at fenestrated clip placement resulted in slipping of the clip and occlusion of the parent artery. Ultimately, the aneurysm ruptured at the neck, and, despite trapping and direct aneurysmal suction decompression, significant bleeding was encountered. The bleeding point was packed, and, subsequently, endovascular access was obtained. A balloon was navigated and then inflated across the neck of the aneurysm using C-arm fluoroscopic guidance. The aneurysm was successfully clipped, and intraoperative angiography demonstrated no parent vessel stenosis. CONCLUSIONThis case demonstrates a salvage procedure in the event of intraoperative rupture and inadequate interruption of local blood flow. Balloon inflation resulted in adequate hemostasis and provided intraluminal support for optimal clip placement while preserving the parent artery.

A Tangential Gunshot Wound to the Head: Case Report and Review of the Literature

BACKGROUND Patients with tangential gunshot wounds (TGSWs) commonly present with a good Glasgow Coma Scale score and without a history of loss of consciousness. Typically, the bullet does not breach the skull, however, there is a considerable force directed into the brain, and these patients are best treated as sustaining a moderate-to-severe blunt head injury. These patients require observation and repeat imaging. Physicians should be aware of this entity as these patients can deteriorate in a delayed fashion. OBJECTIVES The authors present a case of a TGSW to the head in a neurologically intact patient. The initial post-injury computed tomography (CT) scan showed a very small subdural hematoma (SDH) with no overlying fracture of the skull. A delayed CT scan performed 4 h after arrival to the Emergency Department and 6 h after injury demonstrated an increase in size of the SDH, new traumatic subarachnoid hemorrhage, and bilateral cerebral contusions. Clinically, the patient showed worsening of her neurological examination. She underwent aggressive non-surgical treatment for increased intracranial pressure with almost complete recovery. CONCLUSION Although patients with TGSWs are typically in good condition upon presentation, these injuries are not always trivial, and these patients should have, at minimum, a non-contrast brain CT scan to evaluate underlying damage to the brain and skull. In addition, a delayed CT scan and close observation on a neurosurgical service are indicated.