Paula Eboli

Management of Multifocal and Multicentric Gliomas

The diffuse nature of gliomas has long confounded attempts at achieving a definitive cure. The advent of computed tomography and magnetic resonance imaging made it increasingly apparent that gliomas could have a multifocal or multicentric appearance. Treating these tumors is the summit of an already daunting challenge, because the obstacles that must be surmounted to treat gliomas in general, namely, their heterogeneity, diffuse nature, and ability to insidiously invade normal brain, are more conspicuous in this subset of tumors.

Evolving role of endovascular treatment for MCA bifurcation aneurysms: case series of 184 aneurysms and review of the literature

Abstract Objective: This study evaluates the role of endovascular therapy for middle cerebral artery (MCA) aneurysms and its evolution over time. We are reporting a large case series of 184 MCA aneurysms and comparative analysis of the literature. Methods: This was a retrospective review of a prospectively maintained database including all patients with MCA bifurcation aneurysms embolized between 2000 and 2013. There were 184 aneurysms in 166 patients, with 71 ruptured and 113 nonruptured aneurysms. Results: Stent assistance was required in 70 cases (38·0%) and 3 cases (1·6%) required ‘Y’ stenting. The initial rate of total aneurysm occlusion was 59·8% and at delayed follow up was 90·1%. Seven embolizations resulted in thrombo-embolic complications (3·8%), with no cases of aneurysm re-bleeding, wire perforations, or other hemorrhages. Three patients with ruptured aneurysms died of causes unrelated to the embolization, and none with nonruptured aneurysms died in the follow-up period (total mortality 1·6% at 30 days post-procedure). A total of seven aneurysms (3·9%) required retreatment with an average follow up of 41 months. Prior to dedicated aneurysm stents, 68·8% of patients underwent embolization with the remainder surgically treated. Following the introduction of aneurysm stents in 2002, 92·0% of MCA aneurysms treated were embolized. Conclusions: During the past decade we have seen a treatment paradigm shift in MCA aneurysm treatment from surgical treatment to endovascular treatment. Developments in 3D angiography, more compliant balloons, dedicated aneurysm stents, complex coils, and antiplatelet therapy regimes have led to this transition for safe and effective management of these patients.

Differentiation of Benign Angiomatous and Microcystic Meningiomas with Extensive Peritumoral Edema from High Grade Meningiomas with Aid of Diffusion Weighted MRI

Objective. To determine whether angiomatous and microcystic meningiomas which mimic high grade meningiomas based on extent of peritumoral edema can be reliably differentiated as low grade tumors using normalized apparent diffusion coefficient (ADC) values. Methods. Preoperative magnetic resonance imaging (MRI) of seventy patients with meningiomas was reviewed. Morphologically, the tumors were divided into 3 groups. Group 1 contained 12 pure microcystic, 3 pure angiomatoid and 7 mixed angiomatoid and microcystic tumors. Group 2 included World Health Organization (WHO) grade II and WHO grade III tumors, of which 28 were atypical and 9 were anaplastic meningiomas. Group 3 included WHO grade I tumors of morphology different than angiomatoid and microcystic. Peritumoral edema, normalized ADC, and cerebral blood volume (CBV) were obtained for all meningiomas. Results. Edema index of tumors in group 1 and group 2 was significantly higher than in group 3. Normalized ADC value in group 1 was higher than in group 2, but not statistically significant between groups 1 and 3. CBV values showed no significant group differences. Conclusion. A combination of peritumoral edema index and normalized ADC value is a novel approach to preoperative differentiation between true aggressive meningiomas and mimickers such as angiomatous and microcystic meningiomas.

Acute Obstructive Hydrocephalus due to a Large Posterior Third Ventricle Choroid Plexus Cyst

We present the case of a child in whom acute hydrocephalus developed secondary to obstruction of the foramen of Monro by a choroid plexus cyst. The patient was seen in the emergency department with fevers, acute onset of headaches, and lethargy. Computed tomography demonstrated dilated lateral and third ventricles with a relatively normal-sized fourth ventricle. An external ventricular drain was placed. Despite decompression of the lateral ventricles, follow-up magnetic resonance imaging demonstrated a dilated third ventricle with a possible thin-walled mass extending from the foramen of Monro into the posterior portion of the third ventricle. The patient subsequently underwent endoscopic fenestration of the cyst with endoscopic third ventriculostomy. Although two other cases of symptomatic choroid plexus cysts of the third ventricle have been previously reported in children, our paper highlights the possibility of endoscopic cyst fenestration together with a third ventriculostomy as a treatment option in cases where the cyst extends into the posterior third ventricle. Despite adequate decompression, we were concerned that due to CSF pulsations the remnant cyst wall could result in acute aqueduct obstruction and subsequent hydrocephalus.

General Technical Considerations for the Endovascular Management of Cerebral Aneurysms

Cerebral aneurysms pose a threat to patients because of their risk of rupture causing subarachnoid hemorrhage, and the goal of treatment is the exclusion of the aneurysm from the circulation to prevent bleeding (in the case of unruptured aneurysms) or rebleeding. This article analyzes the general technical factors associated with the endovascular treatment of cerebral aneurysms. It discusses issues with transarterial access; imaging of aneurysm size, morphology, and regional anatomy to determine the endovascular plan; the techniques for the major endovascular aneurysm devices; and periprocedural management issues to reduce potential treatment-related complications.

The Neurointerventional Toolkit

There is a wide variety of commercially available products on the market. This chapter categorizes the “toolkit” of specialized products commonly used for neurointerventional procedures. Understanding the basic differences in the uses and actions of these products is intended to assist providers in evaluating and choosing the appropriate agent or device.

Mechanical Revascularization with Embolectomy Devices

Mechanical thrombectomy devices have been in rapid evolution over the past 10 years from their early inception as memory-shaped, nitinol wires to a new generation of devices, utilizing a multi-modal tool box of aspiration catheters, complex stent-shaped retrievers, adjunctive distal access intermediate catheters and proximal balloon occlusion catheters to swiftly and safely revascularize acutely occluded cerebral arteries. These second and third generation devices have improved the acute endovascular revascularization rates from the 40 to 50 % successful revascularization rate of the early devices to 80–90 % with the current iterations in acute ischemic stroke, and have greatly reduced the groin puncture to revascularization times. The clinical trials of these latter generation devices have demonstrated improved clinical outcomes compared to the first generation technology that have been statistically significant.

Surgical Management and Role of Medical Therapy in Ruptured Aneurysmal Neurocysticercosis A Case Report and Review of the Literature

We describe the case of an 80-year-old Hispanic male with an acute subarachnoid hemorrhage (SAH) due to an inflammatory middle cerebral artery (MCA) aneurysm rupture. Two years prior to this episode, the patient had undergone a resection of a left intracranial neurocysticercosis lesion. A current CT, CTA and MRI showed significant SAH, a left MCA aneurysm and a cystic lesion compatible with neurocysticercosis. Intraoperatively, this aneurysm was found to be adjacent to a neurocysticercosis cyst, a diagnosis confirmed by surgical pathology. Only a few cases of subarachnoid hemorrhage due to an inflammatory brain aneurysm have been reported. Due to the associated higher incidence of intraoperative rupture and difficulty clipping, our paper highlights the importance of considering an inflammatory origin in patients with a history of neurocysticercosis and subarachnoid hemorrhage. This is the oldest patient on record reported for this diagnosis and surgery.

E-050 Stent assisted coil embolization for large and giant fusiform dissecting aneurysms: a series of 38 cases

Introduction Fusiform aneurysms present a challenge for treatment since their dome to neck ratios are often less than 1. These are cases that are excluded from most aneurysm series, and prior to intracranial stents were thought not to be treatable by embolization, except by parent artery occlusion. Methods This is a retrospective analysis of a prospectively collected database of 38 patients who had stent assisted coil embolization of a large or giant fusiform aneurysms. A total of 21 patients had two telescoping stents placed and four patients had three telescoping stents. There is an analysis of the procedure related complications, re-treatments, symptomatology and delayed follow-up. Results The average aneurysm size treated was 21.4 mm (range 12–61), with an average neck of 18.6 mm. In the periprocedural period there was a 10% complication rate with two strokes and two increased cranial neuropathies. Nine of the patients required re-treatment during a mean follow-up time of 38 months. There were two deaths in the follow-up period: one due to subarachnoid hemorrhage, another presumed due to respiratory arrest. Conclusions Although stand alone flow diversion devices are being developed and evaluated, stent assisted coil embolization is an effective alternative to fusiform and fusiform dissecting aneurysms. The periprocedural complication rates are reasonable (10%), and although re-treatment is frequently necessary, the long term outcomes are better than the natural history of this disease.