Jakob Nemir

Treatment of giant and large fusiform middle cerebral artery aneurysms with excision and interposition radial artery graft in a 4-year-old child: case report.

BACKGROUND AND IMPORTANCE: We report an unusual case of complex giant and large fusiform aneurysms not amenable for clipping or coiling in a 4-year-old child managed with aneurysm resection and radial artery interposition graft. CLINICAL PRESENTATION: A 4-year-old child presented with repeated severe headache and vomiting. Computed tomography, magnetic resonance imaging, and magnetic resonance angiography and digital subtraction angiography showed a giant fusiform aneurysm on the right middle cerebral artery (MCA). Because of the complex shape, endovascular treatment or clip reconstruction was not possible, and a bypass procedure was planned. Right frontotemporal craniotomy and orbitotomy was performed. Two aneurysms involving the M1 segment of the MCA were found in line, 1 giant, and the other large in size. The aneurysms were resected and treated with short radial artery interposition graft, which was narrower than the proximal or distal MCA. The child recovered normally, and the bypass was patent after 1 year. CONCLUSION: Large fusiform MCA aneurysms may be difficult to treat, but there are treatment options that include a bypass procedure. Resection and short interposition radial artery graft is an excellent but rare treatment option in a very young child. This was a very successful treatment in this child. ABBREVIATIONS: ICA, internal carotid artery MCA, middle cerebral artery RA, radial artery RAG, radial artery graft STA, superficial temporal artery

Endovascular treatment of giant-dissecting posterior cerebral artery aneurysm in an infant

Intracranial aneurysms are extremely rare in the infant age group, with less than 200 cases described in the literature [1]. The pathogenesis most commonly includes connective tissue disorders, trauma, infection, or spontaneous arterial dissection [2, 3]. Clinical presentation is mainly due to ischemia, subarachnoid, or intracerebral hemorrhage, as well as mass effect of giant aneurysms, with their occurrence being more common in children than in adults. Asymptomatic, incidental aneurysms in children appear in up to 35% of the cases according to a report by Kakarla et al., while other authors report significantly lower percentages [4, 5]. We performed a literature review and discovered that there are no reports on incidentally found aneurysms in infants. Herein, we present a case of a 4-month-old male infant with an asymptomatic, posterior cerebral artery aneurysm. The patient was born in the 38th week of gestation, as a result of premature rupture of membranes. Due to immediate feeding difficulties and somnolence, later ascribed to an upper respiratory tract infection, a wide variety of diagnostic procedures was performed including cranial ultrasound. A choroid plexus cyst was found on ultrasound, requiring regular, monthly controls. At 2 months, a new anechogenic mass was found in the right temporal horn region. A computed tomography (CT) scan confirmed a hyperdense lesion, measuring 2 cm in its greatest diameter, with contrast opacification. Magnetic resonance angiogram (MRA) verified a vascular lesion (Figs. 1 and 2). Afterwards, digital subtraction angiography (DSA) was performed for definitive diagnosis before treatment. A 4F introducer sheath was placed for femoral access and 4F diagnostic catheter was used for selective catheterization. Large, dissecting, right posterior cerebral artery (PCA) aneurysmwas found, located between the P1 and P2 segments, measuring 15 mm in diameter. After verification of distal PCA filling via collateral vessels from the left PCA and left middle cerebral artery (MCA), the same catheter was then used as a Bguiding^ catheter, being placed in proximal cervical segment of the left vertebral artery. A 1.7F microcatheter was passed in coaxial fashion, and placed inside the aneurysmal neck and subsequently aneurysm and parent vessel occlusion were performed by placing four detachable coils. Control angiography showed obliteration of the parent vessel and aneurysm. The patient was discharged home on the fourth postoperative day. Follow-up magnetic resonance imaging (MRI) and MRA were performed 4 months after the procedure. Distal parts of the P3 segment have been revascularized via leptomeningeal collaterals. An ischemic lesion, 3 mm in diameter was found in the lower dorsal part of the thalamus, medially to the crus posterius of the internal capsule. At follow-up, there were no new infarcts on MRI, angiography showed parent vessel and aneurysm sac occlusion, and the patient was neurologically intact. This case of an incidentally found intracranial aneurysm in an infant provides a unique insight into the treatment of asymptomatic aneurysms in this age group. Although it is impossible to predict further dynamics of the clinical course had the aneurysm not been treated, the uneventful recovery of the patient demonstrates that endovascular coiling is an effective treatment method. Appropriate timing of the procedure, * Jakob Nemir jakob.nemir@kbc-zagreb.hr

Middle cerebral artery fusiform aneurysm presented with stroke and delayed subarachnoid hemorrhage trapping, thrombectomy, and bypass

Background: Ischemic stroke is a well-described but less frequent consequence of ruptured or unruptured intracranial aneurysms. To date, the optimal form of treatment for patients with a thrombosed cerebral aneurysm has not yet been well-defined. Case Description: Here, we report a case of a 68-year-old female patient presenting with cerebral stroke. Five days poststroke multislice computed tomography (MSCT) and MSCT angiography were performed for the evaluation of clinical deterioration, showing a left M2 middle cerebral artery (MCA) bifurcation aneurysm and subarachnoid hemorrhage. Having in mind the high mortality and morbidity rates after a re-rupture, as well as the digital subtraction angiography features of the aneurysm, urgent surgery was performed consisting of aneurysm trapping and superficial temporal artery (STA) to M3 MCA segment end-to-side anastomosis. The surgery and early postoperative period proceeded uneventfully and the patient gradually recovered from the previously diagnosed expressive dysphasia and cranial and extremity motor deficit. Conclusion: Our case describes a complex aneurysm treatment that consisted of aneurysm trapping, thrombus removal and an STA-M3 MCA branch bypass creation for the protection of the patent M3 insular MCA branch and prevention of further ischemia. This procedure rewarded us with an excellent clinical result.

Treatment of Giant and Large Fusiform MCA Aneurysms With Excision and Interposition Radial Artery Graft in a Four Year Old Child.

BACKGROUND AND IMPORTANCE: We report an unusual case of complex giant and large fusiform aneurysms not amenable for clipping or coiling in a 4-year-old child managed with aneurysm resection and RA interposition graft. CLINICAL PRESENTATION: A 4-year-old child presented with repeated severe headache and vomiting. Computed tomography, magnetic resonance imaging and magnetic resonance angiography and digital subtraction angiography showed a giant fusiform aneurysm on the right MCA. Because of the complex shape, endovascular treatment or clip reconstruction was not possible, and a bypass procedure was planned. Right frontotemporal craniotomy and orbitotomy was performed. Two aneurysms involving the M1 segment of the MCA were found in line, one giant, and the other large in size. The aneurysms were resected and treated with short radial artery interposition graft, which was narrower than the proximal or distal MCA. The child recovered normally, and the bypass was patent after 1 year. CONCLUSION: Large fusiform MCA aneurysms may be difficult to treat but there are treatment options that include a bypass procedure. Resection and short interposition radial artery graft is an excellent but rare treatment option in a very young child. This was very successful treatment in this child.

PbtO2monitoring in normobaric hyperoxia targeted therapy in acute subarachnoidal hemorrhage

Background: Low brain tissue oxygen tension (PbtO2), or brain hypoxia, is an independent predictor of poor outcome. Increasing inspirational fraction of oxygen could have a significant influence on treating lower PbtO2. Combined PbtO2 therapy, compared to the approach that focus only on regulation of cerebral perfusion pressure and intracranial pressure, shows better patient outcomes. Monitoring of PbtO2 could be helpful in individualizing treatment, preventing or limiting secondary brain injury, and maintaining better patient outcome. Case Description: We present a case of a patient with subarachnoidal hemorrhage to whom PbtO2 monitor was implanted, and normobaric hyperoxia treatment was adjusted according to PbtO2 measurement. The patient progressively recovered and was dismissed with Glasgow Coma Score 4/5/6. Conclusion: The use of PbtO2 monitoring may be useful for monitoring the local tissue values that are useful for induction of normobaric hyperoxia and optimizing the therapy toward more target-defined values. It is an important part of multimodal neuromonitoring, and is the gold standard for brain oxygenation monitoring that can lead to better patient outcome.

Predictors of functional outcome after spinal ependymoma resection

Aim: Spinal ependymomas are among the most common intramedullary neoplasms in both adults and children. While surgical resection is the golden treatment standard, the role chemotherapy and radiotherapy have in patients with spinal ependymomas remains unclear. The aim of this study is to determine the predictors of functional outcome following spinal ependymoma resection to single out patients that may require adjuvant therapy. Methods: We conducted a retrospective study on patients that underwent spinal ependymoma resection in our institution in a 10-year period. Magnetic resonance imaging of the spine was used to set the diagnosis of an intradural/intramedullary neoplasm. All patients underwent either gross tumor resection or tumor mass reduction. Histological diagnosis and histopathological grading of spinal ependymoma were done for all collected samples. Patients’ general and neurological examination were performed early after the surgery (within the 1st week) and in a 6-month follow-up. Results: A total of 51 intradural and intramedullary ependymoma resection surgeries on 43 patients were performed. There were slightly more male patients (57%) and the average patient age was 41 years. About 76.5% of patients presented with a tumor affecting one vertebrae level, while 23.5% presented with tumors expanding over two or more spinal regions. Gross tumor resection was achieved in 80% of cases, while 25% of procedures were performed on a recurring ependymomas. Most of the tumors (57%) were classified as G2 histological grade, while 8% were anaplastic ependymomas. In 80% of cases, early postoperative patient status was either better or equivalent to the preoperative one, while in a 6-month follow-up, up to 60% of cases showed a significant improvement over the preoperative status. Different demographic and clinical parameters were not proven to be predictors of postsurgical patient outcome including age, gender, and initial neurological presentation. Interestingly, most tumor characteristics were also not associated with postoperative functional outcome (histological grade, number of vertebrae levels affected, whether it is a primary or recurrent tumor). Even the scope of surgical procedure did not affect the functional outcome. The spinal region affected by the tumor was proven to be a predictor of early postoperative outcome (ρ= 0.346, P = 0.033), with lumbar spine being associated with the best outcomes. As expected, the scope of the surgery and whether gross tumor resection or tumor mass reduction was performed were the only significant predictors of tumor recurrence (ρ= 0.391, P = 0.005). Conclusions: Spinal ependymoma resection is an efficient procedure that improves the patient outcomes. Spinal region affected by the tumor is likely to be the most important predictor of functional outcome, while the procedure scope seems to be the most important predictor of tumor recurrence.

Validation of the Croatian version of the Oswestry Disability Index

PurposeTo translate, cross-culturally adapt, and validate the Croatian version of the Oswestry Disability Index (ODI).MethodsThe original English-language ODI was cross-culturally adapted into Croatian and then evaluated in a group of 114 patients with chronic low back pain (LBP) at the Department of Neurosurgery, Zagreb University School of Medicine. Confirmatory factor analysis (CFA) was conducted with three models: two were theory driven (unidimensional and two dimensional—static and dynamic factors); the other was based on our exploratory factor analysis (EFA). Internal consistency and test–retest reliability were evaluated using Cronbach’s α and the intraclass correlation coefficient (ICC), respectively. Construct validity was assessed by evaluating the correlation between the ODI and Visual Analogue Scale (VAS), and between the ODI and 36-item short form survey (SF-36) scores.ResultsThe EFA-derived two-dimensional structure explained 82.7% of the total variance and was significantly better than the other models (P < 0.001); however, none of the models had acceptable fit. Internal consistency (Cronbach α = 0.84) and test–retest reliability (ICC = 0.94) were satisfactory. The ODI was positively correlated with VAS (rs = 0.54, P < 0.001) and negatively correlated with all of the SF-36 sections (rs = − 0.35 to − 0.64, P < 0.001, all), apart from the role-physical (rs = − 0.02, P = 0.767).ConclusionsThe Croatian version of the ODI has acceptable psychometric properties. It appears to be suitable for assessment of LBP and treatment outcomes in Croatian-speaking patients. Overall, there was no evidence to reject the original unidimensional structure in favor of a two-factor solution. As such, the unidimensional structure should continue to be used in future studies.Graphical abstractThese slides can be retrieved under Electronic Supplementary Material.

Tentorial alignment and its relationship to cisternal dimensions of the pineal region: MRI anatomical study with surgical implications using the new clivotentorial method

OBJECTIVES Tentorial alignment and dimensions of posterior fossa cisterns are measurements whose variability can decrease surgical freedom if not taken into account when choosing the approach to the pineal region. The aim is to provide quantitative anatomical information regarding these dimensions, and to discuss their relevance in two most commonly used approaches to this region: the occipital transtentorial and supracerebellar-infratentorial approach. PATIENTS AND METHODS A retrospective study of midsagittal T1-weighted MRI images of 410 randomly selected healthy subjects was performed. The clivus-tentorium (C-T) angle was measured to assess tentorial alignment. The following distances were used as craniocaudal cisternal measurements: quadrigeminal cistern = superior colliculi - inferior part of the splenium of corpus callosum (SC-ISCC), and superior cerebellar cistern = vermis - inferior part of the splenium of corpus callosum (VER-ISCC). RESULTS Median C-T angle value was 19 ± 7°, the quadrigeminal cistern height 6.7 ± 1.6 cm, and the superior cerebellar cistern height 10.4 ± 2.6 cm. The C-T angle was negatively correlated with the SC-ISCC distance (r = -0.271; p <  0.001) and the VER-ISCC distance (r = -0.052, p >  0.001). The SC-ISCC distance was positively correlated with the VER-ISCC distance (r = 0.282; p < 0.001). CONCLUSION Our new method of measuring tentorial alignment provides a simple and effective aid in preoperative planning. For the first time, we present data on craniocaudal dimensions of posterior fossa cisterns, their relationship with tentorial alignment, and discuss their relevance in SCIT and OT approaches.

Intracranial Epidural Haematoma following Surgical Removal of a Giant Lumbosacral Schwannoma: A Case Report and Literature Review

Postoperative intracranial epidural haematoma (EDH) is an extremely rare complication following spinal surgery, with only a handful of cases described in the literature. We report the case of a 16-year-old girl who underwent a successful subtotal resection of a giant lumbosacral schwannoma (L2-S2 level). Recovery from general anaesthesia was uneventful; however, her neurological status deteriorated rapidly within 24 h after surgery. A head computed tomography scan revealed a large right frontoparietal EDH with midline shift. An immediate frontotemporoparietal osteoplastic craniotomy and evacuation of the EDH were performed. At 1 year postoperatively, the patient regained full neurological recovery with no radiological signs of growth of the residual tumour.

Hydrocephalus caused by H3N2 type A influenza virus or cerebellopontine angle schwannoma

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