Ricardo Lourenço Caramanti

Microsurgical Clipping of Ruptured Distal Posterior Inferior Cerebellar Artery Aneurysm: 3-Dimensional Operative Video

The distal posterior inferior cerebellar artery (PICA) is a rare site of aneurysm formation. Only small case series and case reports regarding surgical treatment are found in the literature.The PICA is divided into 5 segments (anterior medullary, lateral medullary, tonsilomedullary, telovelotonsillary, and cortical), and the distal ones represent the most complex, due to anatomic variations. We present a case of a 69-yr-old female patient who has suffered from a sudden and intense occipital headache, associated with nausea and vomiting. CT scan showed intraventricular hemorrhage, and further investigation with MRI and MR Angiography revealed a small distal PICA aneurysm, at the superior part of the medial aspect of the left cerebellar tonsil. Digital angiography has demonstrated the aneurysm at the tonsilomedullary segment of the PICA. In this 3-dimensional video, the authors show the microsurgical clipping of a saccular distal PICA aneurysm in the close relation to a choroidal branch, performed by median suboccipital craniotomy. Step-by-step of the dissection, relevant surrounding anatomy and aneurysm clipping is demonstrated. The patient signed the Institutional Consent Form, which allows the use of his/her images and videos for any type of medical publications in conferences and/or scientific articles.

Microsurgery for Upper Basilar Tip Aneurysm With Intraoperative Rupture: 3-Dimensional Operative Video

In the last years, a shift from the microsurgical treatment to an endovascular therapy in patients with basilar apex aneurysm has been settled, part of this phenomenon is related to the significant tendency of vital perforators to be involved in the aneurysm dissection and clipping, which can implicate unfavorable outcomes. Nevertheless, microsurgical treatment remains the treatment that can provide the superior rates of stable and durable aneurysm occlusion, which is most important to young patients.In this video, we present the case of a 45-yr-old female patient who complained of a sudden and severe headache and presented with progressive lethargy during the following 3 d.At admission, computed tomography did not show abnormal findings. However, cerebrospinal fluid analysis showed erythrocytes and corroborated the clinical suspicion of spontaneous subarachnoid hemorrhage. The patient signed the Institutional Consent Form, which allows the use of his/her images and videos for any type of medical publications in conferences and/or scientific articles.Angiography and magnetic resonance imaging revealed a saccular basilar apex aneurysm. It showed a wide neck as well as a lobulated dome with upward and slightly left projection. The aneurysm did not involve angiographically visible thalamoperforator arteries, which allowed the microsurgical treatment by the fronto-orbitozygomatic approach. However, during the interpeduncular cistern dissection, an intraoperative rupture of the aneurysm occurred. This video exemplifies the steps required to manage an intraoperative rupture of a basilar apex aneurysm.

Microsurgical Clip Placement for a Giant Anterior Communicating Artery Aneurysm With Intraluminal Thrombus: 2-Dimensional Operative Video

Giant brain aneurysms account for approximately 5% of all intracranial aneurysms. Although treatment modalities can vary widely, none is ideal for every patient. Endovascular treatment is usually preferred, especially when the large size of the aneurysm limits visualization of the brain parenchyma and parent vessels that arise from the aneurysm, making surgical clip placement across the neck a difficult task. However, despite the higher chances of morbidity, microsurgery is an effective treatment modality due to lower recurrence rates. Surgically, a wide neck, calcifications, or atheroma are complicating factors to be considered while planning the best treatment. Thus, with an appropriate case selection, a favorable outcome is feasible in most cases. Here, we present the case of a 27-yr-old female who presented with a severe headache for 7 mo and 3 mo of progressive left temporal vision loss, which was confirmed by visual field perimetry using the Humphrey visual field analyzer. Magnetic resonance angiography and digital subtraction cerebral angiography showed an anterior communicating artery complex inferiorly and medially oriented aneurysm measuring 25.4xa0×xa016.5 mm, with a 3 mm neck. It was fed by the right A1, associated with a hypoplastic left A1, incorporating the proximal right and left A2 segments, with an intraluminal thrombus and causing mass effect on the optic chiasm and hypothalamus. This video demonstrates the microsurgical steps required to perform this operation, through a right orbitozygomatic craniotomy. At a 3-mo follow-up, the patient was neurological intact without complaints. u2003The patient signed the Institutional Consent Form, which allows the use of his/her images and videos for any type of medical publications in conferences and/or scientific articles.

Angular and metric analysis of the neural structures in the cerebellopontine angle

Abstract Introduction: The cerebellopontine angle (CPA) is a subarachnoid space in the lateral aspect of the posterior fossa. In this study, we propose a complementary analysis of the CPA from the cerebellopontine fissure. Methods: We studied 50 hemi-cerebelli in the laboratory of neuroanatomy and included a description of the CPA anatomy from the cerebellopontine fissure and its relationship with the flocculus and the 5th, 6th, 7th, and 8th cranial nerves (CN) origins. Results: The average distance from the 5th CN to the mid-line (ML) was 19.2u2009mm, 6th CN to ML was 4.4u2009mm, 7-8 complex to ML was 15.8u2009mm, flocculus to ML was 20.5u2009mm, and flocculus to 5th CN was 11.5u2009mm, additionally, and the diameter of the flocculus was 9.0u2009mm. The angle between the vertex in the flocculus and the V CN and the medullary-pontine line was 64.8 degrees. Discussion: The most common access to the CPA is through the retrosigmoid-suboccipital region and this approach can be done with the help of an endoscope. The anatomy of origins of neural structures tends to be preserved in cases of CPA lesions. Conclusion: Knowledge of the average distances between the neural structures in the cerebellar-pontine fissure and the angular relationships between these structures facilitates the use of surgical approaches such as microsurgery and endoscopy.

Posterior Inferior Cerebellar Artery Aneurysm: Surgical or EndovascularTreatment in a Case Report

Introduction: PICA aneurysms answer for 3% of all intracranial aneurysms. The patients generally present Hunt- Hess I or II and have intraventricular hemorrhage needing treatment. Case presentation: This is a case study about an elderly woman complaining about a sudden headache. She had an aneurysm in the distal segment of the PICA, which was treated by clipping. The woman progressed well despite her hydrocephalus. Discussion: Information about the aneurysm positioning and anatomy guided the therapeutic decisions. Age and clinical presentation are the most prominent factors in positive clinical evolution. An interdisciplinary team should choose between surgical and endovascular treatment.