Hilal Kanaan

In-stent thrombosis and stenosis after neck-remodeling device-assisted coil embolization of intracranial aneurysms.

BACKGROUND: Intrinsic thrombosis and stenosis are complications associated with the use of neck-remodeling devices in the treatment of intracranial aneurysms. OBJECTIVE: To examine the technical and anatomic factors that predict short- and long-term stent patency. METHODS: We undertook a retrospective review of 161 patients who underwent coil embolization of 168 ruptured and unruptured aneurysms assisted by the use of a neck-remodeling device. One hundred twenty-seven patients had catheter-based angiographic follow-up to evaluate 133 stent-coil constructs (mean, 15.4 months; median, 12.7 months). The technique of microcatheter jailing was used in a majority of patients; nonstandard stent configurations were also used. RESULTS: Clinical follow-up for all patients who had catheter-based angiograms demonstrated that among 133 stent constructs, a total of 9 (6.8%) had an in-stent event: 6 acute or subacute thrombosis (4.5%) and 3 delayed stenosis or occlusion (2.3%). Seven of these constructs were associated with a symptomatic event (5.3%). A significantly higher rate of in-stent events was seen with the use of constructs to treat anterior communicating artery aneurysms. When all patients are considered, including those who did not receive catheter-based follow-up imaging, 2 of 168 procedures (1.2%) resulted in the death of a patient, and procedural morbidity was 14.9%. CONCLUSION: From these results and those in the published literature, in-stent complication rates are low in carefully selected patients. The use of dual antiplatelet therapy, sensitivity assays, and glycoprotein IIb/IIIa inhibitors may decrease the rate of acute and chronic in-stent complications.

Expanded endoscopic endonasal resection of an olfactory schwannoma

Olfactory schwannomas are rare tumors of the anterior skull base that are possibly derived from ectopic Schwann cells, perivascular neural tissue, or sensory nerves of the meninges. The authors report the case of a 14-year-old boy with an olfactory schwannoma that extended inferiorly through the cranial base and superiorly into the frontal lobe. Because of the growth characteristics of the tumor and the significant overlying frontal lobe edema, the lesion was approached via an endonasal endoscopic route, as a strategy to minimize brain retraction. This tumor was characterized radiographically as contrast-enhancing with cystic areas and erosion into bone. The tumor showed immunoreactivity for S100 protein and leukocyte antigen 7 (CD57) but not epithelial membrane antigen, supporting the diagnosis of olfactory schwannoma. A gross-total resection was achieved. This approach represents a novel application of endoscopic endonasal surgery to the pediatric neurosurgical context, as well as a favorable outcome in an extremely unusual tumor type, that should be applicable to other appropriately selected pediatric brain tumors.

STEREOTACTIC RADIOSURGERY FOR RADIATION-INDUCED MENINGIOMAS

OBJECTIVERadiation-induced meningiomas of the brain are typically managed with surgical resection. Stereotactic radiosurgery (SRS) has become an important primary or adjuvant management for patients with intracranial meningiomas, but the value of this approach for radiation-induced tumors is unclear. METHODSThis series consisted of 19 patients (mean age, 40 years) with 24 tumors. The patients met criteria for a radiation-induced meningioma and underwent gamma knife radiosurgery. Seven patients had undergone a previous resection. The World Health Organization tumor grades for those with prior histology were Grade I (n = 5) and Grade II (n = 2). The median tumor volume was 4.4 cm3. Radiosurgery was performed using a median margin dose of 13 Gy. RESULTSSerial imaging was evaluated in all patients at a median follow-up of 44 months. The control rate was 75% after primary radiosurgery. Delayed resection after radiosurgery was performed in 5 patients (26%) at an average of 39 months. The median latency between radiation therapy for original disease and SRS for radiation-induced meningiomas was 29.7 years (range, 7.3–59.0 years). The overall survival after SRS was 94.1% and 80.7% at 3 and 5 years, respectively. No patient developed a subsequent radiation-induced tumor. The overall morbidity rate was 5.3% (1 optic neuropathy). Asymptomatic peritumoral imaging changes compatible with an adverse radiation effect developed in 1 patient. CONCLUSIONSRS provides satisfactory control rates either after resection or as an alternative to resection. Its role is most valuable for patients whose tumors affect critical neurological regions and who are poor candidates for resection.

Endovascular treatment of basilar artery occlusion by manual aspiration thrombectomy

Background and purpose Basilar artery occlusion remains one of the most devastating subtypes of stroke. Intravenous and intra-arterial therapy have altered the natural history of this disease; however, clinical results remain poor. Therefore, exploring more aggressive and innovative management is warranted. Methods Six consecutive patients presenting with a basilar artery occlusion were treated with the same general algorithm of intra-arterial tissue plasminogen activator and mechanical thrombectomy with the Merci retrieval system. If complete recanalization was not achieved after two passes, manual syringe aspiration through a 4.3F catheter was employed. Results All interventions utilizing aspiration thrombectomy resulted in recanalization, with five out of six cases displaying TIMI3/TICI3 flow and one patient resulting in complete recanalization of the basilar artery with persistent thrombus in one P2 segment (TIMI2/TICI2B). All patients survived, with five out of six independent in activities of daily living at 3 months (mRS 0–2). Conclusions Our small case series indicates that aspiration thrombectomy performed manually through a 4.3F catheter can facilitate recanalization of basilar artery occlusion with acceptable clinical outcomes.

Endovascular Revascularization of Chronic Symptomatic Vertebrobasilar Occlusion

Acute basilar artery occlusion is associated with a high risk of stroke, mortality, and poor outcome in survivors. Timely vessel revascularization is critical to improve the clinical outcome in this condition. A subset of patients survives acute occlusion with mild or no disability and some of these individuals develop recurrent ischemic events despite optimal medical therapy. The strategy for management of these patients is unknown.

Decompressive Hemicraniectomy, Strokectomy, or Both in the Treatment of Malignant Middle Cerebral Artery Syndrome

OBJECTIVE We sought to evaluate the impact of a craniotomy for strokectomy (CS) with bone replacement, decompressive hemicraniectomy (DHC), or DHC with a strokectomy (DHC+S) on outcome after malignant supratentorial infarction. METHODS We conducted a retrospective cohort study of cases of malignant supratentorial infarction treated by CS (n = 18), DHC (n = 17), or DHC+S (n = 33) at our institution from 2002 to 2008. End points included functional outcome measured by the modified Rankin Scale and incidence of mortality at 1 year. RESULTS Mean age, gender, side, vessel, and time from ictus to surgery were not statistically different between treatment groups. Stroke volume was significantly higher in the CS group. Operative time and blood loss were significantly higher in the DHC+S group. At 1 year, the median modified Rankin Scale score was 4 and overall survival was 71%. Functional outcomes and mortality for both the CS and DHC+S groups were not significantly different from the DHC group (P = 0.24). After adjusting for patient age, stroke volume, and time to surgery, there was no significant difference in outcome. CONCLUSION In patients with malignant supratentorial infarction, a strokectomy alone may be equivalent to a decompressive hemicraniectomy with or without brain resection.

Lower extremity monoparesis after aneurysmal subarachnoid hemorrhage

Two patients presented with acute subarachnoid hemorrhage from a ruptured intracranial aneurysm. Both patients were treated via endovascular coil embolization, and both developed delayed lower extremity monoparesis without associated symptoms that resolved over the ensuing months. An extensive work-up lead us to propose the following hypothesis: the painless peripheral neuropathy likely resulted from nerve root irritation from abundant subarachnoid blood in the lumbar cistern.

Sinus pericranii: A case report

A healthy 6-week-old white male presented with an intermittently enlarging reddish-blue plaque on the midline forehead and frontal scalp. Neuroimaging revealed an abnormal vascular communication between the extracranial and intracranial venous systems. This rare condition is termed sinus pericranii. The authors provide a review of sinus pericranii and describe its imaging findings, embryologic derivation, differential diagnosis, and clinical management.