Hekmat Zarzour

Trigeminocardiac reflex in a child during pre-Onyx DMSO injection for juvenile nasopharyngeal angiofibroma embolization. A case report.

We describe the occurrence of the trigeminocardiac reflex (TCR) during DMSO pre-flushing of the microcatheter in preparation for Onyx embolization via the internal maxillary artery. TCR has not been previously associated with embolization of extradural entities. Familiarity with this clinical reflex and its proper management may help in planning neurointerventional procedures involving DMSO injection in the trigeminal territory.

Cerebral vasospasm after transsphenoidal resection of pituitary macroadenomas: report of 3 cases and review of the literature.

BACKGROUND: Delayed ischemic events due to vasospasm are a well-known complication of aneurysmal subarachnoid hemorrhage (SAH). Severe vasospasm in other neurosurgical settings is not as well recognized. Delay in diagnosis and treatment of vasospasm in such settings may be associated with significant neurological morbidity. OBJECTIVE: To present three cases of symptomatic delayed cerebral vasospasm after transsphenoidal resection of pituitary macroadenomas. METHODS: Transsphenoidal resection in all cases was complicated by peritumoral hemorrhage with extension into the subarachnoid space. Two of the 3 patients required re-operation to evacuate the hematoma in the tumor bed because of progressive worsening neurological deficits. RESULTS: All 3 patients developed vasospasm of the intracranial vessels, starting as early as postoperative day 5 and appearing as late as postoperative day 10. Comparisons to the non-vascular pre-operative magnetic resonance imaging studies confirmed the “de-novo” nature of the vasospasm based on the caliber of the flow voids. CONCLUSION: Transsphenoidal surgery complicated by peritumoral hemorrhage is associated with a significant risk of neurological morbidity because of delayed cerebral vasospasm. Early recognition and management according to guidelines used for postaneurysmal SAH may help to improve outcomes in these patients. ABBREVIATIONS: ACA, anterior cerebral artery ICA, internal carotid artery SAH, subarachnoid hemorrhage

Off-label uses of the Pipeline embolization device: a review of the literature

The Pipeline embolization device (PED) is the most widely used flow diverter in endovascular neurosurgery. In 2011, the device received FDA approval for the treatment of large and giant aneurysms in the internal carotid artery extending from the petrous to the superior hypophyseal segments. However, as popularity of the device grew and neurosurgeons gained more experience, its use has extended to several other indications. Some of these off-label uses include previously treated aneurysms, acutely ruptured aneurysms, small aneurysms, distal circulation aneurysms, posterior circulation aneurysms, fusiform aneurysms, dissecting aneurysms, pseudoaneurysms, and even carotid-cavernous fistulas. The authors present a literature review of the safety and efficacy of the PED in these off-label uses.

Quantitative and qualitative analysis of the working area obtained by endoscope and microscope in various approaches to the anterior communicating artery complex using computed tomography-based frameless stereotaxy: a cadaver study.

OBJECTIVESurgical treatment of aneurysms of the anterior communicating artery complex is challenging, owing to its intricate vascular anatomy. Endoscopy is a recently rediscovered neurosurgical technique that could lend itself well to overcoming some of the vascular visualization challenges associated with this procedure. The purpose of this study was to quantify and compare the working area afforded by the microscope and the endoscope to the anterior communicating artery complex in different surgical approaches and using image guidance. METHODSWe performed a total of 9 dissections, including mini-supraorbital, pterional, and orbitozygomatic approaches bilaterally in 5 whole, fresh cadaver heads. We used computed tomography–based image guidance for intraoperative navigation as well as for quantitative measurements. We estimated the working area of the anterior communicating artery complex region, using both a rigid endoscope (4.0 mm in diameter and 18 cm long with 0- and 30-degree lenses) and an operating microscope. Operability was qualitatively assessed by the senior authors. RESULTSIn microscopic exposure, the orbitozygomatic approach provided the greatest working area (204.5 ± 33.9 mm2), as compared with the mini-supraorbital approach (114.8 ± 26.9 mm2) and pterional approach (170 ± 20.4 mm2; P < 0.05). Evaluation of the endoscopic working area showed that the supraorbital approach, using both 0- and 30-degree endoscopes, provided a working area greater than that of a conventional pterional approach (P < 0.05) and comparable to that of an orbitozygomatic approach (P > 0.05). CONCLUSIONIn our model, use of the endoscope, in an assistive manner to microscopic surgery, provided a working area advantage without loss of microneurosurgical techniques of dissection or of depth perception in the surgical field. This advantage was most prominent when smaller craniotomies were used.

Sinus thrombectomy for purulent cerebral venous sinus thrombosis utilizing a novel combination of the Trevo stent retriever and the Penumbra ACE aspiration catheter: the stent anchor with mobile aspiration technique

Intracranial complications of sinusitis are rare but life threatening. We present a case of a 17-year-old woman with sinusitis who deteriorated over the course of 12 days from subdural empyema and global purulent cerebral venous sinus thrombosis. The patient was managed with surgery and mechanical thrombectomy utilizing a novel ‘stent anchor with mobile aspiration technique’, in which a Trevo stent retriever (Stryker) was anchored in the superior sagittal sinus (SSS) while a 5 MAX ACE reperfusion catheter (Penumbra) was passed back and forth from the SSS to the sigmoid sinus with resultant dramatic improvement in venous outflow. The patient was extubated on postoperative day 3 and was discharged with minimal lower extremity weakness on postoperative day 11. This is the first report using the Trevo stent retriever for sinus thrombosis. It is important to keep these rare complications in mind when evaluating patients with oral and facial infections.

Perioperative outcomes in minimally invasive lumbar spine surgery: A systematic review

AIM To compare minimally invasive (MIS) and open techniques for MIS lumbar laminectomy, direct lateral and transforaminal lumbar interbody fusion (TLIF) surgeries with respect to length of surgery, estimated blood loss (EBL), neurologic complications, perioperative transfusion, postoperative pain, postoperative narcotic use, and length of stay (LOS). METHODS A systematic review of previously published studies accessible through PubMed was performed. Only articles in English journals or published with English language translations were included. Level of evidence of the selected articles was assessed. Statistical data was calculated with analysis of variance with P < 0.05 considered statistically significant. RESULTS A total of 11 pertinent laminectomy studies, 20 direct lateral studies, and 27 TLIF studies were found. For laminectomy, MIS techniques resulted in a significantly longer length of surgery (177.5 min vs 129.0 min, P = 0.04), shorter LOS (4.3 d vs 5.3 d, P = 0.01) and less perioperative pain (visual analog scale: 16 ± 17 vs 34 ± 31, P = 0.04). There is evidence of decreased narcotic use for MIS patients (postoperative intravenous morphine use: 9.3 mg vs 42.8 mg), however this difference is of unknown significance. Direct lateral approaches have insufficient comparative data to establish relative perioperative outcomes. MIS TLIF had superior EBL (352 mL vs 580 mL, P < 0.0001) and LOS (7.7 d vs 10.4 d, P < 0.0001) and limited data to suggest lower perioperative pain. CONCLUSION Based on perioperative outcomes data, MIS approach is superior to open approach for TLIF. For laminectomy, MIS and open approaches can be chosen based on surgeon preference. For lateral approaches, there is insufficient evidence to find non-inferior perioperative outcomes at this time.

Rotational angiography for diagnosis and surgical planning in the management of spinal vascular lesions

OBJECT The management of spinal vascular malformations has undergone significant evolution with the advent of advanced endovascular and angiographic technology. Three-dimensional rotational spinal angiography is an advanced tool that allows the surgeon to gain a better appreciation of the anatomy of these spinal vascular lesions and their relation to surrounding structures. This article describes the use of rotational angiography and 3D reconstructions in the diagnosis and management of spinal vascular malformations. METHODS The authors present representative cases involving surgical treatment planning for spinal vascular malformations with focus on the utility and technique of rotational spinal angiography. They report the use of rotational spinal angiography for a heterogeneous collection of vascular pathological conditions. RESULTS Eight patients underwent rotational spinal angiography in addition to digital subtraction angiography (DSA) for the diagnosis and characterization of various spinal vascular lesions. Postprocessed images were used to characterize the lesion in relation to surrounding bone and to enhance the surgeons ability to precisely localize and obliterate the abnormality. The reconstructions provided superior anatomical detail compared with traditional DSA. No associated complications from the rotational angiography were noted, and there was no statistically significant difference in the amount of radiation exposure to patients undergoing rotational angiography relative to traditional angiography. CONCLUSIONS The use of rotational spinal angiography provides a rapid and powerful diagnostic tool, superior to conventional DSA in the diagnosis and preoperative planning of a variety of spinal vascular pathology. A more detailed understanding of the anatomy of such lesions provided by this technique may improve the safety of the surgical approach.

Association of a Distal Intradural-Extracranial Posterior Inferior Cerebellar Artery Aneurysm With Chiari Type I Malformation: Case Report.

BACKGROUND AND IMPORTANCE Distal extracranial posterior inferior cerebellar artery (PICA) aneurysms are very rare lesions and have not been previously reported in association with a Chiari type I malformation (CMI). CLINICAL PRESENTATION A 56-year-old woman with a distal, low-lying, intradural-extracranial PICA aneurysm presented with a subarachnoid hemorrhage and was treated with coil embolization. The patient presented again 1 month later with symptoms of a CMI and was found to have tonsillar herniation and a large syrinx that appeared to be exacerbated by the coil mass. The patient was re-treated with a suboccipital craniectomy, C1-2 laminectomy, aneurysm trapping and excision, end-to-end PICA anastomosis, and expansile duraplasty. CONCLUSION Although just a single case, important teaching points regarding the angiographic appearance of a CMI and treatment options for distal PICA aneurysms that are situated below the foramen magnum can be learned. A low-lying caudal PICA loop should trigger a workup for a CMI. Caution should be taken when using coil embolization for aneurysms in the high cervical spinal canal. Bypass with aneurysm trapping and excision may be a superior treatment option in these cases because the posterior fossa and high cervical canal can be concomitantly decompressed. To our knowledge, this is the only case reported of a distal intradural-extracranial PICA aneurysm associated with a CMI.

Endovascular coiling of a ruptured basilar apex aneurysm with associated pseudoaneurysm

Acute intracranial pseudoaneurysms secondary to aneurysmal rupture are a rare entity with no clear evidence-based guidelines for treatment to our knowledge. There are numerous examples of successful treatment of pseudoaneurysms both surgically and endovascularly, the latter mainly within the anterior circulation. Risk of pseudoaneurysm rupture in the acute state during endovascular procedures with subsequent difficulty in controlling the bleeding without sacrificing the feeder artery has led to some reservation in using endovascular treatments more broadly. We report a rare case of a 52-year-old-woman who presented with acute subarachnoid hemorrhage and was found to have a ruptured 5 mm × 8 mm bi-lobulated basilar apex aneurysm on CT angiography. Digital subtraction angiography demonstrated an associated anterior pseudoaneurysm that was formed secondary to the aneurysm rupture. The true aneurysm was successfully coiled with careful avoidance of the pseudoaneurysmal sac. Pseudoaneurysms are frequently identified for the first time during digital subtraction angiography. Recognizing their presence is essential for treatment planning. Acute pseudoaneurysms associated with true aneurysmal rupture can be safely and successfully treated by endovascular coiling of the true aneurysm. Care must be taken to avoid manipulation of the pseudoaneurysmal sac during the embolization.

Acute Recanalization of a Partially Thrombosed Large Intracranial Aneurysm

BACKGROUND Thrombosed large intracranial aneurysms (TLIAs) are not continuously contemplated as stable lesions. Spontaneous recanalization of completely occluded large intracranial aneurysms has been described previously. CASE DESCRIPTION We report a middle-aged patient presenting with agitation, acute headache, visual field defects, and left hemiparesis. A large thrombosed posterior communicating (PCom) artery aneurysm was identified with an infarct at the same arterial territory on neuroimaging studies. Digital subtraction angiography (DSA) performed 1 week later demonstrated complete recanalization of the TLIA. It was treated endovascularly with coils. The patient returned several days later with augmenting headaches due to quadrigeminal system subarachnoid hemorrhage. Repeat DSA showed filling of the coiled aneurysm from the internal carotid artery injection. The PCom artery was catheterized and deconstructed. The patient was discharged to home with no additional neurologic deficits. CONCLUSIONS TLIAs are insidious vascular lesions. They can cause nerve or vessel damage by a mass effect or through ischemic stroke by emitting emboli into distal vasculature. We advise close periodic radiologic follow-up for TLIAs.