Ian R. Whittle

Giant intracranial aneurysms: diagnosis, management, and outcome

The diagnosis, management, and outcome of a consecutive series of 25 patients with giant intracranial aneurysms are presented. Symptoms and signs directly or indirectly attributable to the intracranial mass effect accounted for presentation in 16 (64%) patients of whom seven had no focal neurological deficits. Nine patients (36%) presented after subarachnoid hemorrhage. Subarachnoid hemorrhage was frequently associated with intraventricular or intracerebral hemorrhage, a poor clinical grading at admission, and a high mortality (67%). Computed tomographic features of the giant aneurysms were usually characteristic; however, angiography was particularly useful in those in close proximity to the skull base. Nineteen patients had a surgical procedure directly or indirectly aimed at obliteration, isolation, or reinforcement of the giant aneurysm. Successful surgical obliteration or occlusion was obtained in 12 (63%) patients, while seven (37%) had only reinforcement or exploration of the aneurysm. The mortality associated with definitive surgical treatment was 5.6%, and major morbidity occurred in 17%. The good long-term outcome in 75% of the patients after occlusion of the giant aneurysm contrasted with the continuing mortality (43%) and morbidity (43%) in those patients in whom surgical obliteration of the aneurysm was not attained. Although advances in microsurgical instrumentation, anesthetic techniques, and innovative revascularization procedures have facilitated the surgical management of giant aneurysms, significant improvement in the high overall mortality associated with these aneurysms (36% in this series) will probably only be attained by diagnosis of giant intracranial aneurysms before they bleed.

Focal seizures: An unusual presentation of giant intracranial aneurysms. A report of four cases with comments on the natural history and treatment

Four patients with partial epileptic seizures for several years, but without permanent neurological deficits, were found to have giant aneurysms of the middle cerebral artery. None had a history of subarachnoid hemorrhage. Operative findings included compression of the medial temporal and subfrontal cortex, infarction of the superior temporal gyrus, and evidence of previous hemorrhage from the aneurysms. In two patients, clipping of the aneurysm with decompression of the adjacent temporal lobe cured the seizure disorder. In the other two patients, the aneurysms could only be wrapped, and the seizures continued. It is postulated that focal compression of temporal lobe structures and local hemodynamic phenomena caused by the giant aneurysm predispose to epilepsy in these patients.

Experience with bucrylate (isobutyl-2-cyanoacrylate) embolization of cerebral arteriovenous malformations during surgery.

The clinical experience with five patients selected for embolization of cerebral arteriovenous malformations with bucrylate (isobutyl-2-cyanoacrylate) during surgery is described. Bucrylate embolization was used to obliterate one arteriovenous malformation with a dominant nutrient arterial network, and to facilitate surgical resection in two other cases. The extent of the embolization in one of these cases was limited because of segmental perfusion of the AVM nidus by different nutrient arteries. Histological examination of this arteriovenous malformation, resected 56 days after embolization, suggested bucrylate has minimal histotoxicity. Two arteriovenous malformations were found at operation to be unsuitable for embolization because of technical problems with access and exposure of nutrient arteries, and also because of vagaries in the angiographic data before surgery. In two cases, rapid polymerization of bucrylate resulted in gluing of the injection catheters into the arterial lumen. Two patients experienced transient postoperative neurological deficits after bucrylate embolization. Because of the potential hazards of the technique, direct bucrylate embolization of cerebral arteriovenous malformations should only be considered for those lesions felt unsuitable for direct microsurgical excision, and where facilities exist for recording angiographic data before surgery.

Otogenic pasteurella multocida brain abscess and glomus jugulare tumour.

We report the occurrence of a Pasteurella multocida temporal lobe abscess in an elderly woman who had a history of neglected chronic purulent otitis and in whom an extensive ipsilateral glomus tumour invading the petrous bone was found. We believe this is the first report in the literature of an otogenic cerebral abscess associated with a glomus jugulare tumour and the fifth report of a Pasteurella multocida brain abscess. The synergistic pathogenesis of the otitis and the glomus tumour in the evolution of the abscess is hypothesized.