James L. Budny

Extracranial-intracranial arterial bypass and basilar artery ligation in the treatment of giant basilar artery aneurysms.

Two patients with giant aneurysms of the basilar artery treated with prophylactic extracranial-intracranial arterial bypass (EIAB) to the rostral brain stem before basilar artery ligation are presented. In both cases, the bypass provided considerable collateral flow to the upper basilar, posterior cerebral, and superior cerebellar arteries. Basilar artery ligation has been shown to be an effective, albeit dangerous, means of treating giant aneurysms of the basilar artery. The risk of significant brain stem ischemia after ligation is at least 30%. EIAB to the rostral brain stem should be considered whenever basilar artery ligation is performed, especially in cases where angiography demonstrates poor collateral circulation to the distal basilar artery.

Revascularization of the Rostral Brain Stem

The clinical and angiographic diagnosis of rostral brain stem vascular insufficiency is reviewed. The various possibilities for surgical revascularization of this area include anastomosis of the superficial temporal or occipital artery to the main stem of the posterior cerebral or superior cerebellar artery of their branches. A new technique for anastomosing the superficial temporal artery to the posterior cerebral artery in the tentorial incisura is presented, and other methods of rostral brain stem revascularization are considered. Indications for revascularization of the rostral brain stem are not clearly defined, but should include clinical and angiographic evidence of upper brain stem ischemia.

Thrombolysis of the cervical internal carotid artery before balloon angioplasty and stent placement: report of two cases.

The application of endovascular techniques to the treatment of cervical carotid artery bifurcation atherosclerosis has been delayed because of the fear of causing embolic events while traversing the diseased portion of the artery with an angioplasty balloon catheter. Symptomatic carotid arteries often contain fresh or partially digested intraluminal thrombus. Before we cross certain carotid bifurcation lesions with angioplasty catheters, we deliver 100,000 to 200,000 units of urokinase in an attempt to digest loose thrombus. We have witnessed changes in the angiographic appearance of the diseased portion of the vessel after urokinase treatment, such as widening of the lumen, that suggest clot lysis. We present two patients who had symptomatic internal carotid artery stenosis. Angiography showed irregular narrowing of the internal carotid artery origin. One patient was selected for angioplasty instead of carotid endarterectomy because of severe cardiac risk factors. The other patient had major angiographic risk factors manifested by poor collateral circulation. The angiographic findings and history of transient ischemic attacks led us to suspect the presence of soft, loose plaque debris or thrombus in both cases. Therefore, we performed thrombolysis with urokinase before angioplasty. Repeat angiography showed widening of the arterial lumen and smoothing of the plaque profile. Subsequent angioplasty and stent placement were uneventful. Intraarterial thrombolysis can produce a change in the angiographic appearance of symptomatic atherosclerotic lesions of the cervical carotid artery bifurcation. Digestion of intralesional thrombus may provide a safer environment for deployment of endovascular remodeling devices by decreasing the likelihood of embolic phenomena. We believe thrombolysis should be done before angioplasty in select patients.

Microvascular surgical anatomy of the vertebrobasilar junction

OBJECTIVE We examined the pertinent microvascular anatomy of 28 formalin-fixed brains to develop anatomic guidelines for aneurysm surgery in the region of the vertebrobasilar junction. METHODS Using a surgical microscope, the outer diameters were observed for the following main arteries: vertebral, basilar, posteroinferior cerebellar, and anteroinferior cerebellar. The number of lower brain stem perforating arteries was examined in relation to their course. The distance between the arteries and their perforators was measured with respect to anatomic landmarks. RESULTS The anatomy of the main arteries was characteristically variable, whereas the anatomy of the perforators was constant, particularly in terms of their numbers and points of penetration into the brain substance. The four major points of entry were the lateral medullary area just caudal to the posterior olivary sulcus, the posterior olivary sulcus, the small lateral fossa at the superior olivary groove, and the foramen cecum. Each of these areas coincides with the origin of common vertebrobasilar aneurysms. CONCLUSION The anatomy of the main arteries was variable. In contrast, the perforators penetrated the adjoining brain stem at specific locations, regardless of the caliber of the main artery. Despite a small vertebral artery or its major branches, perforators penetrating the brain are significant and may effect the outcome of aneurysm surgery or endovascular procedures.

Lumbar discectomy: use of an epidural morphine sponge for postoperative pain control.

A technique for extended ambulatory epidural pain control after lumbar discectomy is described; preliminary results with 45 patients are reported; and alternative methods of narcotic analgesia are reviewed. In this technique, an absorbable gelatin sponge (Gelfoam, Upjohn Co., Kalamazoo, MI) is contoured to the laminotomy defect, placed in methylprednisolone acetate (40-80 mg), and then injected with 2 to 4 mg of preservative-free morphine (a small needle was used to fill the sponge). The sponge is placed over the defect before closure. A review of office and hospital records was conducted. The series consisted of 33 men and 12 women (mean age, 39 yr; range, 24-57 yr); records showed narcotic use in 34 patients (parenteral in 3) and work-related injuries in 14 patients. Thirty-three patients were ambulatory postoperatively on the day of surgery; all were ambulatory by postoperative day (POD) 1. On the day of surgery, 18 patients did not require any postoperative analgesics; on POD 1, 22 patients did not require analgesics. Six patients received parenteral narcotics; four received one dose only, and two had two or more doses. Thirty-one patients were discharged from the hospital on POD 1, and 10 were discharged POD 2. The other patients were discharged from the hospital on POD 3 (three patients) or POD 4 (one patient). When they were discharged, all patients received a limited supply of acetaminophen with codeine for pain control at home. After discharge, phone follow-up (at 1 week) and office follow-ups (at 3-5 weeks) revealed only one patient with more than mild discomfort. Three patients required one-time bladder catheterization, and one patient had presumed discitis 1 month postoperatively. In a control group who had undergone surgery 3 months previously, the average day of discharge had been POD 3.07; no control patient had been discharged on POD 1, and only 20% had been discharged on POD 2. This method provides effective, safe, and extended analgesia after lumbar discectomy.

High-Risk Factors in Symptomatic Patients Undergoing Carotid Artery Stenting With Distal Protection: Buffalo Risk Assessment Scale (BRASS).

BACKGROUND Demographics and vascular anatomy may play an important role in predicting periprocedural complications in symptomatic patients undergoing carotid artery stenting (CAS). OBJECTIVE To predict factors associated with increased risk of complications in symptomatic patients undergoing CAS and to devise a CAS scoring system that predicts such complications in this patient population. METHODS A retrospective study was conducted that included patients who underwent CAS for symptomatic carotid stenosis during a 3-year period. Demographics and anatomic characteristics were subsequently correlated with 30-day outcome measures. RESULTS A total of 221 patients were included in the study. The cumulative rate of periprocedural complications was 7.2%, including stroke (3.2%), myocardial infarction (3.2%), and death (1.4%). Renal disease increased the risk of all complications. National Institutes of Health Stroke Scale score ≥10 at presentation, difficult femoral access, and diseased calcified aortic arch increased the risk of stroke and all complications. Type III aortic arch correlated with increased risk of stroke. Pseudo-occlusion and concentric calcification of the carotid artery increased the risk of myocardial infarction, death, and all complications. Carotid tortuosity and anatomy hostile to the deployment of distal protection devices increased the risk of stroke, myocardial infarction, death, and all complications. CONCLUSION Our results suggest that CAS should be avoided in patients with multiple anatomic risk factors. High presenting National Institutes of Health Stroke Scale score and renal disease also increase the complication risk. The CAS scoring system devised here is simple, reproducible, and clinically valuable in predicting complications risk in symptomatic patients undergoing CAS.

Ventriculitis after metrizamide lumbar myelography

A 62-year-old man underwent lumbar metrizamide myelography complicated initially by a bout of aseptic chemical meningitis. Afterward, he suffered persistent headache, nausea, and blurred vision and, 12 weeks after his myelography, computed tomographic scans showed abnormalities consistent with a chronic ventriculitis. The case is presented; its pathological substrate and clinical implications are discussed.

Testing the Boundaries of Neurosurgical Innovation … Twice: An Account of One Patient's Unique Intracranial Aneurysm Treatment

BACKGROUND The treatment of intracranial aneurysms has evolved over the past several decades and has profited by the ingenuity and expertise of generations of innovative neurosurgeons. CASE DESCRIPTION A 79-year-old man presented with symptoms related to recurrence of his previously ruptured basilar bifurcation aneurysm 35 years after undergoing the first awake hunterian ligation for the same aneurysm performed by Dr. Charles Drake. CONCLUSIONS This report details the treatment strategies applied in the management of the patients aneurysm then and now, offering us a glimpse into the evolution of neurosurgical treatment for basilar bifurcation aneurysms in a patient who was able to benefit from neurosurgical innovation twice in his lifetime.

Endovascular Therapy for the Treatment of Cerebrovascular Disease

This chapter discusses the use of endovascular therapy for treatment of cerebrovascular disease. Recent developments in microcatheter technology have enabled endovascular therapists to penetrate the cerebrovascular circulation with greater accuracy and precision than ever before. Improved access has facilitated rapid and safe delivery of liquid adhesives (histoacryl) into the nidus of arteriovenous malformations using flow directed catheters. Endovascular therapy has been used to treat atherosclerotic stenosis of the cervical carotid bifurcation. This therapy may offer an alternative to carotid endarterectomy. Most centers reserve endovascular therapy for patients who have severe comorbid illness or who have surgically inaccessible aneurysms. Partial or complete coil occlusion of a freshly ruptured aneurysm may prevent early rebleeding. The treatment of symptomatic cerebral vasospasm has been facilitated by endovascular techniques. If clinical improvement is not realized within hours after initiation of hypervolemic hyperdynamic therapy, endovascular therapy may be employed.