Yunbao Guo

An intraventricular meningioma and recurrent astrocytoma collision tumor: a case report and literature review

BackgroundIntracranial meningioma and glioma collision tumors are relatively uncommon and are even more rarely located within the ventricles.Case presentationHere, we report a case of a patient with an intraventricular meningioma and astrocytoma collision tumor. A 39-year-old man previously underwent excision of an astrocytoma in the triangle area of the lateral ventricle and exhibited good post-surgery recovery. The astrocytoma recurred in situ six years after the surgery, and the case was complicated by a malignant meningioma. The patient recovered well after surgery to treat the recurrence and was administered radiotherapy after discharge. In addition to reporting on this case, we conducted a literature review of collision tumors; based on this review, we propose several hypotheses regarding the formation of collision tumors.ConclusionsWe conclude that a possible cause of the collision tumor formation between the intracranial meningioma and the astrocytoma was the recurrence of an astrocytoma-induced malignancy of the arachnoid cells in the choroid plexus.

Current status of the treatment of blood blister-like aneurysms of the supraclinoid internal carotid artery: A review

Currently, the treatment of blood blister-like aneurysms (BBAs) of the supraclinoid internal carotid artery (ICA) is challenging and utilizes many therapeutic methods, including direct clipping and suturing, clipping after wrapping, clipping after suturing, coil embolization, stent-assisted coil embolization, multiple overlapping stents, flow-diverting stents, covered stents, and trapping with or without bypass. In these therapeutic approaches, the optimal treatment method for BBAs has not yet been defined based on the current understanding of BBAs of the supraclinoid ICA. Therefore, in this study, we aimed to review the literature from PubMed to discuss and analyze the pros and cons of the above approaches while adding our own viewpoints to the discussion. Among the surgical methods, direct clipping was the easiest method if the compensation of the collateral circulation of the intracranial distal ICA was sufficient or direct clipping did not induce stenosis in the parent artery. In addition, the clipping after wrapping technique should be chosen as the optimal surgical modality to prevent rebleeding from these lesions. Among the endovascular methods, multiple overlapping stents (≥3) with coils may be a feasible alternative for the treatment of ruptured BBAs. In addition, flow-diverting stents appear to have a higher rate of complete occlusion and a lower rate of retreatment and are a promising treatment method. Finally, when all treatments failed or the compensation of the collateral circulation of the intracranial distal ICA was insufficient, the extracranial-intracranial (EC-IC) arterial bypass associated with surgical or endovascular trapping, a complex and highly dangerous method, was used as the treatment of last resort.

Progress on Complications of Direct Bypass for Moyamoya Disease

Moyamoya disease (MMD) involves progressive occlusion of the intracranial internal carotid artery resulting in formation of moyamoya-like vessels at the base of the brain. It can be characterized by hemorrhage or ischemia. Direct vascular bypass is the main and most effective treatment of MMD. However, patients with MMD differ from those with normal cerebral vessels. MMD patients have unstable intracranial artery hemodynamics and a poor blood flow reserve; therefore, during the direct bypass of superficial temporal artery (STA)-middle cerebral artery (MCA) anastomosis, perioperative risk factors and anesthesia can affect the hemodynamics of these patients. When brain tissue cannot tolerate a high blood flow rate, it becomes prone to hyperperfusion syndrome, which leads to neurological function defects and can even cause intracranial hemorrhage in severe cases. The brain tissue is prone to infarction when hemodynamic equilibrium is affected. In addition, bypass vessels become susceptible to occlusion or atrophy when blood resistance increases. Even compression of the temporalis affects bypass vessels. Because the STA is used in MMD surgery, the scalp becomes ischemic and is likely to develop necrosis and infection. These complications of MMD surgery are difficult to manage and are not well understood. To date, no systematic studies of the complications that occur after direct bypass in MMD have been performed, and reported complications are hidden among various case studies; therefore, this paper presents a review and summary of the literature in PubMed on the complications of direct bypass in MMD.

Clinical importance of the middle meningeal artery: A review of the literature.

The middle meningeal artery (MMA) is a very important artery in neurosurgery. Many diseases, including dural arteriovenous fistula (DAVF), pseudoaneurysm, true aneurysm, traumatic arteriovenous fistula (AVF), moyamoya disease (MMD), recurrent chronic subdural hematoma (CSDH), migraine and meningioma, can involve the MMA. In these diseases, the lesions occur in either the MMA itself and treatment is necessary, or the MMA is used as the pathway to treat the lesions; therefore, the MMA is very important to the development and treatment of a variety of neurosurgical diseases. However, no systematic review describing the importance of MMA has been published. In this study, we used the PUBMED database to perform a review of the literature on the MMA to increase our understanding of its role in neurosurgery. After performing this review, we found that the MMA was commonly used to access DAVFs and meningiomas. Pseudoaneurysms and true aneurysms in the MMA can be effectively treated via endovascular or surgical removal. In MMD, the MMA plays a very important role in the development of collateral circulation and indirect revascularization. For recurrent CDSHs, after burr hole irrigation and drainage have failed, MMA embolization may be attempted. The MMA can also contribute to the occurrence and treatment of migraines. Because the ophthalmic artery can ectopically originate from the MMA, caution must be taken to avoid causing damage to the MMA during operations.

Study and Therapeutic Progress on Intracranial Serpentine Aneurysms.

An intracranial serpentine aneurysm (SA) is a clinically rare entity, and very few multi-case studies on SA have been published. The present study reviewed the relevant literature available on PubMed. The studied information included the formation mechanism and natural history of SA as well as its clinical manifestation, imaging characteristics, and current treatments. After reviewing the literature, we conclude that intracranial SA can be managed surgically and by endovascular embolization, but the degree of blood flow in normal brain tissue distal to the SA must be evaluated. A balloon occlusion test (BOT) or cross compression test is recommended for this evaluation. If the collateral circulation is sufficiently compensatory, direct excision or embolization can be performed. However, if the compensatory collateral circulation is poor, a bypass surgery is necessary. Satisfactory results can be achieved in the majority of SA patients after treatment. However, the size of the aneurysm may increase in some patients after endovascular treatment. Special attention should be paid to cases exhibiting a significant mass effect to avoid subsequent SA excision due to an intolerable mass effect. Satisfactory results can be achieved with careful treatment of SA.

Suturing and Dural Wrapping for a Blood Blister–Like Aneurysm on the Supraclinoid Segment of the Internal Carotid Artery due to Dissection

BACKGROUND Internal carotid artery (ICA) reconstruction is still the most effective treatment for a blood blister-like aneurysm (BBA) on the supraclinoid segment of the ICA, and clipping after wrapping has the most precise effects. However, the materials used are most often artificial. This study examined the use of autologous dura to replace the artificial materials used for wrapping after suturing a BBA. CASE DESCRIPTION A 38-year-old man was hospitalized for subarachnoid hemorrhage. Computed tomography angiography of the head and digital subtraction angiography showed a BBA on the dorsal supraclinoid segment of the ICA. A right frontotemporal craniotomy with extradural resection of the anterior clinoid was adopted. The aneurysm was trapped with temporary clips and was found to be derived from dissection of the ICA. The separated adventitia and vascular wall were sutured to reconstruct the vascular wall first, and then the dura was cut and shaped to wrap the supraclinoid segment of the ICA. The dura was sutured onto the ICA wall to prevent dislocation. A 6-month follow-up digital subtraction angiography review showed that the supraclinoid segment of the ICA was well reconstructed, the vascular cavity exhibited slight stenosis, and BBA did not recur. Postoperative follow-up magnetic resonance imaging showed satisfying images. CONCLUSIONS The method we adopted is new and showed satisfactory curative results, suggesting that ICA suturing with dura mater wrapping may become a method for the treatment of a BBA on the supraclinoid segment. The dura could potentially replace the artificial materials used for wrapping the ICA.

Traumatic arteriovenous fistula between the extracranial middle meningeal artery and the pterygoid plexus: A case report and literature review

The formation of a traumatic arteriovenous fistula (AVF) between the extracranial middle meningeal artery (MMA) and the pterygoid plexus (PP) is very rare, and understanding of this condition is limited. This paper reports the case of an 8-year-old who suffered minor injuries after a high fall four months prior to admission and showed good recovery after one month. However, the child gradually developed exophthalmos of the left eye and conjunctival redness one month prior to admission. Auscultation revealed an intracranial murmur near the left side of the face, in the temporal region. A digital subtraction angiography (DSA) showed rupture of the left extracranial MMA and an AVF between the MMA and the PP. The blood drained toward the cavernous sinus, resulting in retrograde blood flow into the ophthalmic vein and the cortical vein. The diagnosis was an AVF between the MMA and the PP, and a combination of coils and Onyx liquid embolic agent was employed to perform AVF embolization. Follow-up six months later indicated no recurrence of the AVF, and the patient showed good recovery with a normal-appearing left eye. The AVF in this case drained toward the cavernous sinus, and symptoms of increased intracranial venous system pressure were apparent, similar to those produced by fistulas between the internal carotid artery and the cavernous sinus. This condition is very rare, and the use of coils in combination with Onyx for AVF embolization is novel, warranting the reporting of the current case.

Dural Arteriovenous Fistula Between the Inferolateral Trunk and Cavernous Sinus Draining to Ophthalmic Vein

BACKGROUND Formation of a dural arteriovenous fistula (DAVF) between the inferolateral trunk (ILT) and cavernous sinus (CS) is rare. CASE DESCRIPTION This study presents a case of ILT-CS DAVF. A 64-year-old male patient had exophthalmos of the left eye with redness and swelling. Digital subtraction angiography revealed a connection between the ILT and the CS that formed a high-flow DAVF, which was drained only to the ophthalmic vein and no other parts of the CS. The ILT was chosen as the transarterial path for treatment because it was enlarged. The microcatheter was navigated into the ILT, and 2 coils were then used to occlude the ILT. After occlusion of the ILT, no image of the DAVF indicated that the ILT-CS DAVF was completely cured. The patients symptoms improved gradually after surgery. At the 6-month follow-up visit, digital subtraction angiography showed no sign of ILT-CS DAVF and the patients eye symptoms had disappeared. CONCLUSIONS Although ILT-CS DAVF is rare, it can still be seen in clinical practice. Coiling the ILT via a transarterial approach is a good option for treatment.

Delayed Establishment of Collateral Circulation from Posterior Meningeal Artery After Proximal Occlusion of Posterior Inferior Cerebellar Artery: Case Report and Literature Review

BACKGROUND A dissecting aneurysm on the posterior inferior cerebellar artery (PICA) is a rare entity, and endovascular embolization is often adopted. During the procedure, if the parent artery is occluded, the distal PICA is usually supplied by the ipsilateral anterior inferior artery or contralateral PICA. In extremely rare circumstances, the distal PICA can establish collateral circulation by transdural anastomosis with the posterior meningeal artery (PMA). CASE DESCRIPTION A 29-year-old woman was admitted complaining of thunderclap headache, nausea, and vomiting for 3 hours. Head computed tomography and digital subtraction angiography revealed subarachnoid hemorrhage and a dissecting aneurysm located at the tonsillomedullary segment of PICA. The parent artery distal to the aneurysm had no collateral circulation from the adjacent arteries. Selective endovascular coiling of the aneurysm with preservation of the parent artery was adopted for treatment. The patient experienced an uneventful postprocedural recovery. To our surprise, follow-up digital subtraction angiography 6 months later revealed complete occlusion of the aneurysm and parent artery at the site of aneurysm formation. A rare anastomosis between the distal PICA and PMA was established. CONCLUSIONS A report about this rare condition suggested that after occlusion of the PICA trunk, the distal PICA can form collateral circulation with the PMA. A potential collateral circulation may be present in advance between the PICA and PMA. When ischemia occurs in the distal PICA, this collateral circulation may open and could be reconstructed and enlarged to provide blood supply.

Acute rerupture after coil embolization of ruptured intracranial saccular aneurysms: A literature review:

Acute rerupture after coil embolization is defined as rerupture within three days after treatment; its prognosis is worse than that of rebleeding at other time periods. However, to date, little is known about complications during the acute phase. Therefore, we used the PubMed database to perform a review of acute rerupture after coil embolization of ruptured intracranial saccular aneurysms and increase our understanding. After reviewing the complications, we found that the cause of acute rerupture is unclear, but the following risk factors are involved: incomplete occlusion of the initial aneurysm, the presence of a hematoma adjacent to a ruptured aneurysm, an aneurysmal outpouching, poor Hunt-Hess grade at the time of treatment, and the location of the aneurysm in an anterior communicating artery. In addition, intraoperative rupture is a non-negligible cause. Acute rerupture after coil embolization mainly occurs within the first 24 hours after the procedure. Brain computed tomography is the gold standard for diagnosing acute rebleeding of a coiled aneurysm. For acute rerupture after coil embolization, prevention is critical, and complete occlusion of the aneurysm in the first session is the best protection against acute rebleeding. In addition, a restricted postembolization anticoagulation strategy is recommended for patients with high-risk aneurysms. For patients with an adjacent hematoma, surgical clipping is recommended. Most patients present no changes immediately after acute rebleeding because of their poor condition. However, surgical or endovascular treatments can be attempted if the patient is in an acceptable condition. Even so, the outcomes are typically unsatisfactory.