Hugo Sterman Neto

The clip-wrap technique in the treatment of intracranial unclippable aneurysms

UNLABELLED Fusiform and dolichoectatic aneurysms are challenging lesions to treat with direct clipping. Treatment of these aneurysms often requires alternative surgical strategies, including extracranial-intracranial bypass, wrapping, or clip-wrap techniques. Nonetheless, these alternatives methods of treatment have been underused and frequently overlooked. OBJECTIVE To report a series of nine cases of otherwise untreatable aneurysms managed using the clip-wrap technique and discuss its surgical nuances. METHOD In the last four years, 9 cases of ruptured aneurysms treated by the clip-wrap techniques were identified in the Division of Neurological Surgery, University of São Paulo, School of Medicine. RESULTS The aneurysms were located at middle cerebral artery (2), anterior choroidal artery (1), anterior communicating artery (1), carotid ophthalmic (3), posterior cerebral artery (1) and posterior-inferior cerebellar artery (1). Three were dolichoectatic, 4 were unsuitable to complete surgical clipping because parent or efferent vessels arises from the aneurysm sac (1 MCA, 1 AcomA, 1 CO, 1 PICA aneurysms) and two, although ruptured aneurysms, were too small (<2mm) to be directly clipped. No early or late rebleeding was observed after 2 years mean follow-up. One patient deceased due to pulmonary tromboembolism. CONCLUSION Clip-wrap techniques for the treatment of fusiform and otherwise unclippable aneurysms seem to be safe and it can be associated with a low rate of acute or delayed postoperative complications. It can prevent rebleeding and represents an improvement when compared with the natural history.

Traumatic pseudoaneurysm of the superior cerebellar artery.

A 31-year-old man admitted to our hospital as the victim of aggression with an indeterminate object. At initial evaluation, he presented Glasgow Coma Scale score of 11, left anisocoria, without penetrating injury in head. Before performing computerized tomography scan, the patient’s level of consciousness worsened (Glasgow Coma Scale score 7). Skull computerized tomography scanning showed traumatic subarachnoid hemorrhage and hydrocephalus, with important ventricular blood, and a small cerebellar contusion (Fig. 1). External ventricular drainage with intracranial pressure monitoring was established. Because of the large amount of cisternal bleeding, we decided to perform a cerebral angiogram, that showed a pseudoaneurysm of the left superior cerebellar artery (SCA; Fig. 2). We performed an endovascular occlusion of the pseudoaneurysm (Fig. 3) without complications. In early follow-up, the patient developed shunt-dependent hydrocephalus. After final placement of a shunt, he was discharged for rehabilitation with Glasgow Outcome Scale score being 3. Traumatic intracranial aneurysms are rare, comprising less than 1% of all intracranial aneurysms. Less than 10% involve the posterior circulation. Aneurysms arising from the SCA are rarer and only six cases had been reported.1 Histologically, they are false aneurysms that contain none of the normal arterial layers but are lined by fibroconnective tissue surrounding a hole in the arterial wall.2 Penetrating wounds were responsible for 40% of the traumatic aneurysms located in posterior circulation.3 In the absence of a fracture or penetrating wound, like in our patient, some traumatic aneurysms have been observed on arteries in relation to the edge of rigid meningeal structures.1 We believe that in our case, the head trauma produced a rotary movement of the brain within the skull, tearing an arterial branch of the SCA that passes through the perimesencephalic cistern. DISCLOSURE The authors declare no conflicts of interest.

Does the use of DuraSeal in head and spinal surgeries reduce the risk of cerebrospinal fluid leaks and complications when compared to conventional methods of dura mater closure

INTRODUCTION Cerebrospinal fluid (CSF) fistula is a common neurosurgical complication, occurring in 1% to 27% of cases. The main clinical manifestations are postural headache, nausea, dizziness, photophobia, and tinnitus. This condition may be associated with inadequate wound healing and infection, meningitis, and pseudomeningocele, factors that increase patient morbidity and mortality. Despite the limitations, hermetic closure of the dura mater has been recommended for the prevention and treatment of CSF fistula. In recent years, techniques have been developed to reinforce the site of the dura mater closure, such as additional suture, autologous tissue grafts, fibrin sealants, and collagen sponges. DuraSeal is a dura mater sealant consisting of polyethylene glycol hydrogel (PEG hydrogel), to be applied at the site of suture, and has been indicated for head and spinal surgery with opening of the dura mater.

Endodermal cyst of the third cranial nerve.

Endodermal cysts are congenital lesions constituted by a ucus-secreting epithelium similar to that of the gastrointestinal ract/respiratory epithelium [1–3]. Intracranial endodermal cysts re rare [1–3] and, in these instances, they are found in the midline f the posterior fossa, anterior brainstem, and suprasellar region. hird cranial nerve cysts are an exquisitely rare occurrence with nly four cases described so far [4–7]. The authors describe a case f a third cranial nerve endodermal cyst, discuss its clinical picture, adiological nuances and clinical outcome.