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At least 577 records · Page 32Linked to original sources
PubMed1998

Intraoperative color-coded duplex sonography for localization of a distal middle cerebral artery aneurysm: technical case report.

OBJECTIVE AND IMPORTANCE: We describe the surgical treatment of a small, distal, middle cerebral artery (MCA) aneurysm, performed using intraoperative color-coded duplex sonography for localization. CLINICAL PRESENTATION: A 55-year-old man presented with a sudden intense headache. Computed tomographic scans revealed a subarachnoid hemorrhage. Angiography demonstrated two MCA aneurysms, one arising from the proximal bifurcation of the right MCA and the other from its distal bifurcation. TECHNIQUE: On Day 1, the proximal MCA aneurysm was clipped via the standard transsylvian approach. The distal MCA aneurysm was identified with the aid of color-coded duplex sonography and was successfully clipped with minimal additional dissection of the sylvian fissure. CONCLUSION: Color-coded duplex sonography provides a two-dimensional image of the brain parenchyma and color-coded flow imaging of cerebral vessels in real time. It may be used for rapid intraoperative localization of small, distally located, cerebral aneurysms.

Cerebral Angiography↗
PubMed1998

Surgical removal of a choroid plexus adenoma using the argon beam coagulator: technical case report.

OBJECTIVE AND IMPORTANCE: Choroid plexus tumors may be extremely vascular, limiting surgical resection. A case of a choroid plexus adenoma is presented in which the argon beam coagulator (System 6500; ConMed Corp., Utica, NY) was used as a surgical adjunct. CLINICAL PRESENTATION: A 12-year-old male patient with a giant tumor of the lateral ventricle presented with visual loss and was found to have a large intraventricular tumor. At surgery, the tumor was extremely vascular, and the pathological finding was consistent with a choroid plexus adenoma. TECHNIQUE: Because of its vascularity, the tumor was resected in stages with the aid of the argon beam coagulator. CONCLUSION: We conclude that this device may have application in selected neurosurgical operations.

Adenoma↗
PubMed1998

Combined endovascular stent implantation and endosaccular coil placement for the treatment of a wide-necked vertebral artery aneurysm: technical case report.

OBJECTIVE AND IMPORTANCE: We describe a case in humans of the combined application of endovascular stent placement and Guglielmi detachable coil packing in the management of a wide-necked intracranial aneurysm. CLINICAL PRESENTATION: A 56-year-old woman suffered a subarachnoid hemorrhage secondary to a large wide-necked left vertebral artery aneurysm. Because of the size of the neck of the aneurysm and the extent of its calcification evident on computed tomographic scans, it was deemed unsuitable for surgical intervention or for conventional endovascular coiling. Instead, a combined surgical and endovascular therapy was instituted. INTERVENTION: The left vertebral artery was surgically exposed and cannulated to allow for the placement of an endovascular stent across the neck of the aneurysm to act as a buttress against which Guglielmi detachable coils could be packed. The patient suffered no ill effects as a result of this procedure and made a slow but steady recovery. CONCLUSION: This report describes a case of a wide-necked intracranial artery aneurysm treated using a combination of endovascular stent implantation across an aneurysm neck and endosaccular coil placement to obliterate the aneurysm. The technique described provides another treatment to better manage the difficult entity of wide-necked intracranial aneurysms that may be unsuitable for clipping.

Angioplasty, Balloon↗
PubMed1998

Treatment of a vertebral dissecting aneurysm with stents and coils: technical case report.

OBJECTIVE AND IMPORTANCE: A clinical case of a dissecting aneurysm of the intracranial vertebral artery successfully treated with a combination of stents and coils is presented. The importance of long-term follow-up and the development of suitable materials and devices are emphasized. CLINICAL PRESENTATION: This 48-year-old man with a history of progressive bilateral loss of vision caused by glaucoma developed sudden headache, nausea, and vomiting. At admission, he presented with psychomotor agitation and neck pain. A neurological examination showed bilateral IInd and VIth cranial nerve palsy and neck stiffness. Computed tomography demonstrated a diffuse subarachnoid hemorrhage. Digital subtraction angiography showed a fusiform dilation of Segment IV of the left vertebral artery, with a double lumen sign. TECHNIQUE: A bifemoral intra-arterial approach was used. A FasTracker 18 (Target Therapeutics, Fremont, CA) microcatheter was advanced through the true arterial lumen and was then replaced by a self-expandable metallic wall stent. Because of reduced radiopacity, a balloon-expandable metallic stent was then placed as well. Next, with a FasTracker 10 advanced through the stent mesh, the aneurysm was embolized using Guglielmi detachable coils. CONCLUSION: We applied a new technique to treat a dissecting aneurysm of the intracranial portion of the vertebral artery with a combination of stents and coils. Further work is required on the tracking, flexibility, and thrombogenic properties of diverse materials and devices. This evolving technology may play a role in the near future as the alternative of choice in some cases of aneurysm treatment via the endovascular route.

Aortic Dissection↗
PubMed1998

Reversibility of severe sagittal sinus thrombosis with open surgical thrombectomy combined with local infusion of tissue plasminogen activator: technical case report.

OBJECTIVE: To explore the controversial issue of anticoagulant therapy and indications for surgery in association with severe sinus thrombosis. METHODS: During the last 4 years, we have treated three patients with severe sinus thrombosis of the dural sinuses. All three patients received systemic anticoagulant therapy and, after experiencing neurological deterioration, underwent open thrombectomy and local thrombolysis. After the operation, aggressive intensive care was given and included cerebral perfusion monitoring, barbiturate administration, hyperventilation, and osmotherapy. The treatment was guided by repeated neuroradiological investigations. RESULTS: All three patients returned to their normal lives. CONCLUSION: Intracranial sinus thrombosis, even in the worst neurological state, should be treated aggressively. A cornerstone in treatment is systemic anticoagulant therapy and repeated neuroradiological studies. When, despite adequate anticoagulant therapy and intensive care, neurological deterioration occurs, a combination of open thrombectomy and local thrombolytic therapy should be considered.

Adult↗
PubMed1998

Traumatic intraventricular hemorrhage treated with intraventricular recombinant-tissue plasminogen activator: technical case report.

OBJECTIVE AND IMPORTANCE: Traumatic intraventricular hemorrhage (IVH) can result in association with acute obstructive hydrocephalus, repetitive malfunction of external ventricular drains (EVDs), and uncontrollable increased intracranial pressure. We report a case showing the safe and effective use of intraventricular recombinant-tissue plasminogen activator in a child with severe brain injury and acute hydrocephalus from IVH. CLINICAL PRESENTATION: A 15-year-old male patient presented to us after a motor vehicle accident with bilateral extensor posturing, intracerebral and IVH, and acute obstructive hydrocephalus. INTERVENTION: A right EVD was placed and functioned only transiently. A left EVD was placed and functioned only transiently. Because of the inability to maintain ventricular drainage, rising intracranial pressure, and worsening clinical status, 5 mg of recombinant-tissue plasminogen activator was injected through each EVD. Excellent EVD function was obtained quickly, with control of intracranial pressure and improvement in clinical status and without hemorrhagic complication. CONCLUSION: With obstructive hydrocephalus secondary to acute traumatic IVH that cannot be controlled with EVD because of recurrent obstruction from intraventricular blood, intraventricular recombinant-tissue plasminogen activator can be effective and safe, despite preexisting multiple hemorrhagic intracranial injuries.

Adolescent↗
PubMed1998

Staged volume radiosurgery followed by microsurgical resection: a novel treatment for giant cerebral arteriovenous malformations: technical case report.

OBJECTIVE AND IMPORTANCE: We describe the successful treatment of symptomatic giant arteriovenous malformations (AVMs) using staged volume radiosurgery followed by microsurgical resection. CLINICAL PRESENTATION: A 57-year-old man presented with Spetzler-Martin Grade 5 AVMs, with persistent headaches and seizures. He had previously undergone eight attempts at AVM embolization and a craniotomy for attempted AVM resection; he had suffered four episodes of brain hemorrhaging but had made a good neurological recovery. INTERVENTION: Because of the persistent symptoms of the patient and his history of hemorrhaging, a treatment plan based on staged radiosurgical treatments of different portions of the AVMs (three sessions, spaced 6 mo apart), followed by delayed microsurgical removal of the much-reduced residual AVMs (3 years later), was undertaken. The patient did not suffer any additional hemorrhaging episodes, his AVMs were completely removed, and he has made a good recovery. CONCLUSION: Staged volume radiosurgery followed by microsurgical resection of the residual AVMs represents a novel treatment strategy for the management of Grade 5 AVMs that might be untreatable by any single treatment method used alone.

Cerebral Angiography↗
PubMed1998

Endoscopic treatment of mesencephalic ependymal cysts: technical case report.

OBJECTIVE: To evaluate the results of different neuroendoscopic surgical procedures for the treatment of mesencephalic ependymal cysts. METHODS: The clinical records of five patients treated for symptomatic mesencephalic ependymal cysts were retrospectively studied. Two patients had been operated on using an endoscope-assisted microsurgical technique and three patients using a pure endoscopic procedure. RESULTS: Adequate fenestration of the cysts was achieved in all of the patients. Two of the patients were symptom-free, and the other three had improved significantly after a mean follow-up duration of 14 months. There was no surgical morbidity. CONCLUSION: Mesencephalic ependymal cysts can be treated adequately, resulting in a low morbidity rate, using neuroendoscopy or endoscope-assisted microsurgery. This specific surgical technique is presented.

Adult↗
PubMed1999

Combined pretemporal and endovascular approach to the cavernous sinus for the treatment of carotid-cavernous dural fistulae: technical case report.

OBJECTIVE AND IMPORTANCE: The endovascular treatment of carotid-cavernous dural fistulae is becoming the prominent treatment modality for these lesions. The intractability of these lesions and their tendency to recur, especially after previous endovascular treatment sessions, exhausts the available routes and tends to present a difficulty in accessing the cavernous sinus. To avoid the risks associated with a direct surgical approach, an alternative, less invasive route to the cavernous sinus using a pretemporal extradural approach is combined with a direct endovascular approach. CLINICAL PRESENTATION: A 38-year-old woman presented with a history of right visual and ocular symptoms related to a Type D cavernous carotid dural fistula, which was fed by internal carotid and external carotid branches. The fistula was initially treated with embolization of the external carotid arterial supply. After a transient improvement, the patient's visual acuity worsened. A follow-up angiogram showed the major supply from the intracavernous internal carotid branches and draining through the inferior ophthalmic vein. The transvenous route was not accessible. An attempt to cannulate the intracavernous branches was not successful. The combined pretemporal and endovascular approach was then used. INTERVENTION: The pretemporal extradural region of the superior orbital fissure was exposed. Using microsurgical techniques and Doppler flow guidance, the anterior cavernous sinus was cannulated through the orbital venous drainage channels. Using intraoperative angiography, thrombogenic coils were deployed at the level of the fistula. Intraoperative angiography confirmed complete obliteration of the fistula. CONCLUSION: The combined pretemporal (extradural) and endovascular approach to the cavernous sinus is a less invasive alternative for the treatment of intractable carotid-cavernous dural fistulae.

Adult↗
PubMed1999

Cervical intrathecal catheter placement for cerebrospinal fluid drainage: technical case report.

OBJECTIVE AND IMPORTANCE: The purpose of this report is to describe the placement and use of a cervical subarachnoid catheter for cerebrospinal fluid diversion. This technique provides an important alternative drainage system for patients whose clinical situations preclude lumbar spinal fluid diversion. CLINICAL PRESENTATION: Two patients were involved in accidents that resulted in traumatic dural tears. Both patients required thoracolumbar spinal reconstruction with instrumentation. Cerebrospinal fistulae developed, which were refractory to surgical reexploration. TECHNIQUE: A commercially available catheter was successfully placed in the cervical subarachnoid space under fluoroscopic guidance using a C1-C2 approach in both patients. Spinal fluid drainage was maintained for 5 days via this route, and this proved effective in resolving the cerebrospinal fluid fistula. No complications were observed with the placement or maintenance of the catheter. CONCLUSION: Cervical spinal fluid drainage is a feasible alternative for patients in whom lumbar access cannot be obtained or is contraindicated.

Adult↗
PubMed1999

Endovascular stenting of an acutely thrombosed basilar artery: technical case report and review of the literature.

OBJECTIVE AND IMPORTANCE: The goal of this report was to describe the successful percutaneous endovascular use of a Gianturco-Roubin-2 coronary stent in the treatment of an acute atherothrombotic occlusion of the basilar artery. To our knowledge, the percutaneous endovascular deployment of an intra-arterial stent for the treatment of an acute atherothrombotic occlusion of the basilar artery and the percutaneous endovascular placement of a Gianturco-Roubin-2 stent in the basilar artery have not been previously reported. CLINICAL PRESENTATION: An 83-year-old man presented with a recurrent, transient, locked-in syndrome resulting from a lower basilar artery occlusion caused by vertebrobasilar thrombosis superimposed on severe proximal basilar artery atheromatous stenosis. INTERVENTION: After successful superselective intra-arterial thrombolysis of the vertebrobasilar clot, balloon angioplasty of the underlying basilar artery stenosis was performed, without significant angiographic improvement. Percutaneous endovascular deployment of a Gianturco-Roubin-2 coronary stent of 4-mm diameter was subsequently performed, with excellent angiographic results. CONCLUSION: The patient made a very good neurological recovery but unfortunately died as a result of cardiogenic shock and sepsis. Detailed neuropathological follow-up results are presented; stent patency was revealed in the postmortem examination. The anatomic and pathophysiological considerations of basilar artery stent placement for the treatment of acute basilar artery occlusion related to atherosclerotic stenosis are discussed.

Acute Disease↗
PubMed1999

The use of Gore-Tex membrane for adhesion prevention in tethered spinal cord surgery: technical case reports.

OBJECTIVE: The incidence of retethering caused by postoperative adhesions at the repair site after initial tethered spinal cord surgery is not uncommon. To assess the effectiveness of a Gore-Tex membrane in preventing these adhesions, only clinical radiological and experimental animal evaluation has been reported. In this report, we describe two cases in which Gore-Tex membrane was implanted at the initial untethering surgery and in which we were able to confirm the real effectiveness of the Gore-Tex membrane during a second operation. METHODS: In the first patient, Gore-Tex membrane was used for dural repair in the untethering surgery of the split spinal cord malformation. Because of the suspicion of a thickened filum terminale, repeated surgery was indicated 10 months after the initial procedure. In the second patient, Gore-Tex membrane was implanted during the initial untethering surgery for a lipomyeloschisis and a dermal sinus. Because of a persistent fistula of the dermal sinus, a second operation was necessary 1 year after the first operation. RESULTS: During the repeated surgery, a thorough inspection of the implanted Gore-Tex membrane revealed no adhesions between the Gore-Tex membrane and the intradural content in both cases. CONCLUSION: We support the use of Gore-Tex membrane in the prevention of postoperative dural adhesions in the repair of spinal dysraphism.

Child, Preschool↗
PubMed1999

Adenosine-induced cardiac pause for endovascular embolization of cerebral arteriovenous malformations: technical case report.

OBJECTIVE: Extremely high flow through arteriovenous malformations (AVMs) may limit the safety and effectiveness of endovascular glue therapy. To achieve a more controlled deposition of glue, we used transient but profound systemic hypotension afforded by an intravenously administered bolus of adenosine to induce rapidly reversible high-degree atrioventricular block. METHODS AND CASE REPORT: A patient with a large high-flow occipital AVM fed primarily by the posterior cerebral artery underwent n-butyl cyanoacrylate glue embolization. Nitroprusside-induced systemic hypotension did not adequately reduce flow through the nidus, as determined by contrast injection in the feeding artery. In a dose-escalation fashion, boluses of adenosine were administered to optimize the dose and verify that there was no flow reversal in the AVM and no other unexpected hemodynamic abnormalities by arterial pressure measurements and transcranial Doppler monitoring of the posterior cerebral artery feeding the AVM. Thereafter, 64 mg of adenosine was rapidly injected as a bolus to provide 10 to 15 seconds of systemic hypotension (approximately 20 mm Hg). Although there were conducted beats and some residual forward flow through the AVM during this time, the mean systemic and feeding artery pressures were roughly similar and remained relatively constant. A slow controlled injection of n-butyl cyanoacrylate glue was then performed, with excellent filling of the nidus. CONCLUSION: Adenosine-induced cardiac pause may be a viable method of partial flow arrest in the treatment of cerebral AVMs. Safe, deep, and complete embolization with a permanent agent may increase the likelihood of endovascular therapy's being curative or may further improve the safety of microsurgical resection.

Adenosine↗
PubMed1999

Resection of a large arteriovenous fistula of the brain using low-flow deep hypothermic cardiopulmonary bypass: technical case report.

OBJECTIVE AND IMPORTANCE: We present the second report in the literature on the use of low-flow hypothermic cardiopulmonary bypass to aide in the surgical resection of a large intraparenchymal arteriovenous fistula. CLINICAL PRESENTATION: The patient was a 46-year-old man who was found to have a left sylvian arteriovenous fistula with a giant varix during a workup for chronic left frontal headaches and was referred to our center for management. A cardiac workup revealed a cardiac output of 9 L per minute. INTERVENTION: Endovascular embolization of the lesion was initially attempted without success because of the high flow within the lesion and the large diameter of the feeding arteries. We then planned combined and staged endovascular and surgical approaches to gradually eliminate the fistula. Endovascular embolization, both transarterial and transvenous, could not be performed because of the high flow in the fistula. Despite the stepwise reduction of flow during the course of several weeks via surgical exposures and arterial ligations, the fistula remained difficult to remove because of its size and the turgor of the varix. Once hypothermic low-flow circulatory bypass was used, however, decompression of the sac allowed access to the afferent vasculature. CONCLUSION: The use of low-flow hypothermic circulatory bypass can facilitate the surgical extirpation of certain large intraparenchymal arteriovenous fistulas.

Arteriovenous Fistula↗