Vijay Agarwal

Management of a Previously Coiled Anterior Cerebral Artery Aneurysm in a Child: 3-Dimensional Operative Video

We present the case of an 11-yr-old male who originally presented to an outside hospital with subarachnoid hemorrhage. He was discovered at that time to have a ruptured right A1-A2 junction anterior cerebral artery aneurysm just proximal to the anterior communicating artery. He underwent endovascular coiling at the outside center. While recovering at a rehabilitation center, he had a rehemorrhage and acute neurological decline. He was transferred to our service, where he underwent surgical exploration and clip reconstruction of what appeared to be a pseudoaneurysm. After a frontotemporal exposure, the right A1 segment was identified at the carotid bifurcation and followed medially. The aneurysm was significantly larger than on the original angiogram and the wall of the aneurysm was extraordinarily thin, consistent with a pseudoaneurysm. A small portion of the gyrus rectus was removed to expose the A2 segments and the remainder of the large, partially thrombosed and coiled sac of the aneurysm. Thrombus and the previously placed coils were removed in a piecemeal fashion. Two fenestrated clips were used to reconstruct the right A1, with the blades used to bring together normal tissue on the ventral surface to create a new lumen. A Doppler ultrasound was used to insunate both A1s and A2s to confirm patency. Intraoperative cerebral angiogram showed complete obliteration of the aneurysm and excellent reconstruction of the anterior cerebral complex.The patient did very well and was neurologically intact on discharge.All appropriate patient consents were obtained for this submission.

Microsurgical Treatment of Bowhunter's Syndrome: 3-Dimensional Operative Video

We present the case of a 56-yr-old previously healthy male who presented with an approximately 1-yr history of intermittent dizziness, near syncope, and holocephalic headaches when turning his head to the left side for a prolonged period of time. He had a distant history of a previous anterior cervical discectomy and fusion at the C6-7 level. He was neurologically intact. Static, dynamic, and vascular imaging confirmed hypoplasia of the right vertebral artery and dominance of the left vertebral artery that completely filled the posterior circulation. Dynamic imaging confirmed compression of the left vertebral artery just above the C5-6 disc space on full head rotation to the left. After an anterior cervical exposure, we dissected lateral to the C5-6 disc space to the transverse process. The anterior tubercle was identified, and a Doppler ultrasound was used to insonate the vertebral artery above the level of compression. The anterior wall of the transverse foramen was thinned with a high-speed drill under constant irrigation and Kerrison rongeurs used to expose the vertebral artery at the site of compression. Importantly, the fibrotic band at, above, and below the level of compression was also dissected and removed. The patient tolerated the procedure well, and was discharged from the hospital 2 d after surgery with no neurological deficits and with complete relief of his preoperative symptoms. Because his symptoms completely resolved and have not recurred, no postoperative imaging was performed. The etiology, presentation, and microsurgical treatment of this rare disease are discussed.All appropriate patient consents were obtained for this submission.© 2017 Department of Neurosurgery, Emory University Hospital. Used with permission.All Figures used with permission as above.

Microsurgical Management of a Blister Anterior Cerebral Artery Aneurysm: 3-Dimensional Operative Video

We present a case of a 54-yr-old woman who was transferred to our care from an outside emergency room after experiencing a spontaneous subarachnoid hemorrhage (SAH). Upon transfer to our institution, she was Hunt and Hess grade 4, was intubated, and underwent placement of a ventriculostomy. Angiography demonstrated a blister aneurysm on the A1 segment of the left anterior cerebral artery. Therapeutic options considered included endovascular or surgical sacrifice, but there was concern about perforating arteries in the vicinity of the aneurysm as well as the risk of eliminating a potential source of collateral in a patient at high risk of cerebral vasospasm. Flow diversion was considered, but we were concerned about the need for dual antiplatelet therapy in a patient with a fresh SAH and ventricular drain. We recommended surgical exploration the next day to reconstruct the artery. At the time of surgery, the segment of the A1 harboring the blister was exposed, and the A1 was repaired with a strip of Gortex (Gore & Associates Inc, Newark, Delaware) wrapped around the circumference of the Watch now at https://academic.oup.com/ons/article-lookup/doi/10.1093/ons/ opy015

Interhemispheric Approaches to Arteriovenous Malformations: 3-Dimensional Operative Video

We present 2 illustrative cases of interhemispheric approaches to right sided arteriovenous malformations (AVMs). The first patient is a healthy 54-yr-old female who presented with left-sided hearing loss and pulsatile tinnitus, and was neurologically intact. Imaging demonstrated a right sided interhemispheric AVM, fed by the anterior cerebral artery with superficial venous drainage to the superior sagittal sinus. The AVM was thought to be asymptomatic and the patient chose to have her AVM treated surgically to eliminate future risk of hemorrhage. We elected to approach this lesion via a contralateral interhemispheric approach to avoid retraction of the right hemisphere. Intraoperative angiogram demonstrated complete obliteration of the malformation and the patient was neurologically intact postoperatively. The second patient is a 41-yr-old healthy male who presented with progressive bifrontal headaches and was also neurologically intact. Imaging revealed a right interhemispheric AVM fed by the anterior cerebral artery and with superficial venous drainage to the superior sagittal sinus. Although the patients headaches may have been related, the patients decision to undergo surgical resection was primarily to eliminate future risk of hemorrhage. The difference with this patient was that imaging revealed the presence of two draining veins on the left side that would potentially be injured via a contralateral approach. As a result, we elected to approach this lesion ipsilaterally. Intraoperative angiogram showed complete obliteration of the malformation with intact venous drainage, and the patient was neurologically intact postoperatively. Contralateral vs ipsilateral interhemispheric approaches are compared and contrasted.

Microsurgical Treatment of Distal Anterior Cerebral Artery Aneurysms: 3-Dimensional Operative Video

Selecting appropriate patient position for surgery must take into consideration a variety of factors. For an interhemispheric approach to distal anterior cerebral artery (DACA) aneurysms, the patient may be positioned with the head either horizontal or vertical with respect to the floor. We preferentially place the patient in the supine position with the shoulder elevated and the head turned parallel to the floor with the side of the approach down and the vertex tilted 45° up. In this way, gravity is utilized to allow the right frontal lobe to fall away from the falx, eliminating the need for retraction. To demonstrate the importance of individualizing the choice of position to each patient, we present here 2 illustrative cases of DACA aneurysms in which different positioning was selected. One patient presented with a 7-mm bilobed pericallosal artery aneurysm; the aneurysm was approached with the head horizontal with respect to the floor. The second patient had a 3-mm DACA aneurysm and a right frontal proliferative angiopathy and developmental venous anomaly with evidence of prior hemorrhage. Due to the vascular anomaly, we positioned the head in a vertical position for surgery to clip the aneurysm, which was thought to be the source of hemorrhage. The videos illustrate the approach to DACA aneurysms, which typically exposes the aneurysm before complete exposure of the proximal parent artery is obtained. In one case, the use of both frameless guidance and intraoperative angiography was useful in identifying a small previously ruptured aneurysm.u2003All appropriate patient consents were obtained for this submission.u2003Video and Figures (0:57-1:16 and 6:30-6:37),

Tractography for Optic Radiation Preservation in Transcortical Approaches to Intracerebral Lesions

We present a case of intraventricular meningioma resected via a transcortical approach using tractography for optic radiation and arcuate fasciculus preservation. We include a review of the literature. A 54-year-old woman with a history of breast cancer presented with gait imbalance. Workup revealed a mass in the atrium of the left lateral ventricle consistent with a meningioma. Whole brain automated diffusion tensor imaging (DTI) was used to plan a transcortical resection while sparing the optic radiations and arcuate fasciculus. A left posterior parietal craniotomy was performed using the Synaptive BrightMatter™ frameless navigation (Synaptive Medical, Toronto, Canada) to minimally disrupt the white matter pathways. A gross total resection was achieved. Postoperatively, the patient had temporary right upper extremity weakness, which improved, and her visual fields and speech remained intact. Pathology confirmed a World Health Organization (WHO) Grade I meningothelial meningioma. While a thorough understanding of cortical anatomy is essential for safe resection of eloquent or deep-seated lesions, significant variability in fiber bundles, such as optic radiations and the arcuate fasciculus, necessitates a more individualized understanding of a patient’s potential surgical risk. The addition of enhanced DTI to the neurosurgeon’s armamentarium may allow for more complete resections of difficult intracerebral lesions while minimizing complications, such as visual deficit.