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Open access

Spontaneous development and involution of a de novo pseudoaneurysm at the superficial temporal artery–middle cerebral artery bypass anastomotic site in a patient with moyamoya disease: illustrative case

Kristine Ravina, Biraj Patel, and Benjamin Yim

BACKGROUND

De novo pseudoaneurysm formation is a rare complication of extracranial-intracranial bypass surgery.

OBSERVATIONS

The authors report the case of a 28-year-old male who presented with new-onset right temporal and occipital ischemia who was found to have bilateral proximal internal carotid artery occlusion with collateral vasculature formation consistent with moyamoya disease. The patient underwent bilateral superficial temporal artery–middle cerebral artery bypasses. A de novo pseudoaneurysm was found at the left-sided bypass distal anastomotic site recipient vessel 1 month after the surgery. The pseudoaneurysm demonstrated a progressive reduction in size and eventual complete involution at 6 months after surgery.

LESSONS

Limited literature reports extracranial-intracranial bypass-associated aneurysms treated primarily with either clipping or resection and reanastomosis. The authors demonstrate, for the first time, a progressively benign natural history course of an extracranial-intracranial bypass distal anastomotic site pseudoaneurysm.

Open access

Sternocleidomastoid muscle-splitting method for high cervical carotid endarterectomy: illustrative cases

Atsushi Sato, Tetsuo Sasaki, Toshihiro Ogiwara, Kazuhiro Hongo, and Tetsuyoshi Horiuchi

BACKGROUND

The number of cervical carotid endarterectomies (CEAs) has decreased as carotid artery stenting (CAS) has increased. However, CEA and CAS both have advantages and disadvantages; therefore, appropriate procedures must be selected for individual patients. High-positioned carotid artery stenosis presents technical challenges for CEA and is occasionally managed by performing CAS. However, CAS is associated with a high risk of thrombosis in patients with soft plaques, suggesting a clinical need for a better procedure. Consequently, appropriate surgical treatment for patients requiring high-level CEAs is essential.

OBSERVATIONS

In this study, a novel and straightforward method was devised. The primary concept underlying this technique is separation of the sternocleidomastoid muscle (SCM) from other anatomical structures to ensure a wider surgical field. By anatomically separating the SCM into the sternal and clavicular head groups, the objective of the wider surgical field can be met. Herein, we report technical innovations in high-positioned carotid artery stenosis and evaluate their efficacy in two patients.

LESSONS

In conclusion, high CEA surgery using this new method is valuable and may eliminate barriers to more advanced approaches.

Open access

Disconnection of a jugular foramen dural arteriovenous fistula with cortical venous reflux via an intradural retrosigmoid approach: illustrative case

Richard Shaw, Johnny Wong, Hugo Andrade, and Ivan Radovanovic

BACKGROUND

Jugular foramen dural arteriovenous fistulas (DAVFs) are rare and challenging lesions. Described methods of treatment include embolization and microsurgical disconnection through a far lateral transcondylar approach. The authors present the case of a Borden type III jugular foramen DAVF, which was treated with a novel, less invasive retrosigmoid approach with intradural skeletonization and packing of the sigmoid sinus.

OBSERVATIONS

The patient presented with headache and visual field deficit. Neuroimaging demonstrated a right temporal intracerebral hematoma with mass effect. This was due to a Borden type III jugular foramen DAVF with cortical venous reflux into the vein of Labbe secondary to recanalization of a previously thrombosed sigmoid sinus. Microsurgical disconnection was performed via a retrosigmoid approach, in which the sigmoid sinus was identified intradurally at the jugular foramen. The sigmoid sinus was isolated by drilling at the pre- and retrosigmoid spaces to permit packing and clip ligation. Postoperative angiography revealed complete occlusion of the DAVF.

LESSONS

Jugular foramen DAVFs are rare entities, which have been traditionally treated through a far lateral transcondylar approach. An intradural retrosigmoid approach is a safe, less invasive alternative, which involves less soft tissue and bony dissection and does not have the associated morbidity of craniocervical instability and hypoglossal neuropathy.

Open access

High-flow bypass for giant dolichoectatic vertebrobasilar aneurysms: illustrative cases

Richard Shaw, Alistair Kenneth Jukes, and Rodney Stewart Allan

BACKGROUND

Giant fusiform dolichoectatic vertebrobasilar artery aneurysms are challenging lesions with a poor natural history. When there is progressive brainstem compression from these lesions, endovascular treatment can be insufficient, and bypass surgery remains a possible salvage option. High-flow bypass surgery with proximal occlusion can potentially arrest aneurysm growth, promote aneurysm thrombosis, and reduce rupture risk. The authors describe their experience in two patients with giant fusiform dolichoectatic vertebrobasilar artery aneurysms treated with high-flow bypass.

OBSERVATIONS

Both patients presented with enlarging giant dolichoectatic vertebrobasilar aneurysms causing symptomatic brainstem compression. The authors performed staged treatment involving high-flow bypass from the external carotid artery to the posterior cerebral artery using a saphenous vein graft, Hunterian proximal vertebrobasilar occlusion, and finally posterior fossa decompression with or without direct aneurysm thrombectomy and debulking. Postoperative angiography revealed successful flow reversal, aneurysm exclusion, and no brainstem stroke. Clinically, one patient had improvement in their modified Rankin Scale (mRS) score from 3 preoperatively to 1 at 12-month follow-up. The second patient had a deterioration in their mRS score from 4 to 5 at 12-month follow-up.

LESSONS

High-flow bypass strategies remain high risk but can be a viable last resort in patients with neurological deficits and enlarging giant fusiform dolichoectatic vertebrobasilar artery aneurysms.

Open access

Surgically treated intracranial arteriovenous fistulas with hemorrhage, resulting in complete obliteration: illustrative cases

Ako Matsuhashi, Kei Yanai, Satoshi Koizumi, and Gakushi Yoshikawa

BACKGROUND

Intracranial arteriovenous fistula (AVF) is a rare disease, defined as anastomoses between cerebral or meningeal arteries and dural venous sinuses or cortical veins. With the development of new agents and devices, endovascular embolization has been considered safe and effective in a majority of cases. However, cases that require direct surgery do exist. Herein, the authors present 3 cases of intracranial AVFs that presented with hemorrhage and were treated with direct surgery, achieving complete obliteration and favorable outcomes.

OBSERVATIONS

Intracranial AVFs that present with hemorrhage require immediate and complete obliteration. When AVFs involve the dural sinus, transvenous embolization is usually the first choice of treatment. AVFs with single cortical venous drainage are best treated with interruption of the draining vein close to the fistula. Transarterial embolization can be a curative treatment if there are no branches supplying cranial nerves or an association with pial feeders. In cases in which endovascular treatment is technically challenging or has resulted in incomplete occlusion, surgical treatment is indicated.

LESSONS

Despite the recent rise in endovascular treatment, it is important to recognize situations in which such treatment is not suitable for intracranial AVFs. Direct surgery is effective in such cases to offer the best possible outcome.

Open access

Intraoperative intraarterial indocyanine green video-angiography for disconnection of a perimedullary arteriovenous fistula: illustrative case

Youngkyung Jung, Antti Lindgren, Syed Uzair Ahmed, Ivan Radovanovic, Timo Krings, and Hugo Andrade-Barazarte

BACKGROUND

Intraarterial (IA) indocyanine green (ICG) angiography is an intraoperative imaging technique offering special and temporal characterization of vascular lesions with very fast dye clearance. The authors’ aim is to demonstrate the use of IA ICG angiography to aid in the surgical treatment of a perimedullary thoracic arteriovenous fistula (AVF) in a hybrid operating room (OR).

OBSERVATIONS

A 31-year-old woman with a known history of spinal AVF presented with 6 weeks of lower-extremity weakness, gait imbalance, and bowel/bladder dysfunction. Magnetic resonance imaging revealed an extensive series of flow voids across the thoracic spine, most notably at T11–12. After partial embolization, she was taken for surgical disconnection in a hybrid OR. Intraoperative spinal digital subtraction angiography was performed to identify feeding vessels. When the target arteries were catheterized, 0.05 mg of ICG in 2 mL of saline was injected, and the ICG flow in each artery was recorded using the microscope. With an improved surgical understanding of the contributing feeding arteries, the authors achieved complete in situ disconnection of the AVF.

LESSONS

IA ICG angiography can be used in hybrid OR settings to illustrate the vascular anatomy of multifeeder perimedullary AVFs and confirm its postoperative disconnection with a fast dye clearance.

Open access

Aneurysm appearing at the anastomosis site 11 years after superficial temporal artery–middle cerebral artery bypass surgery: moyamoya disease with a rapidly growing aneurysm. Illustrative case

Hiroki Eguchi, Koji Arai, and Takakazu Kawamata

BACKGROUND

Superficial temporal artery–middle cerebral artery (STA-MCA) bypass surgery is performed to prevent ischemia and hemorrhage in patients with moyamoya disease. Only a few reports have described aneurysms appearing around the anastomosis site after bypass surgery, and the underlying mechanism remains unknown.

OBSERVATIONS

The present case involved a 62-year-old woman who underwent STA-MCA bypass surgery for ischemic quasi-moyamoya disease at 46 years of age. Postoperatively, she underwent annual magnetic resonance imaging examinations. At 11 years after STA-MCA bypass surgery, a 3-mm aneurysm appeared at the anastomosis site. Four years later, headache developed and the aneurysm had grown to 5 mm. Craniotomy clipping was performed to prevent rupture. The patient was discharged home 2 weeks after surgery without any apparent complications.

LESSONS

Long-term observation is crucial after direct bypass surgery for moyamoya disease. Measures to prevent rupture should be considered for cases involving aneurysm complications.

Open access

Late-developing posttraumatic dural arteriovenous fistula of the vertebral artery: illustrative case

Hanna E Schenck, Thomas B Fodor, Bart A. J. M Wagemans, and Roel H. L Haeren

BACKGROUND

A dural arteriovenous fistula (dAVF) involving the vertebral artery (VA) is a rare vascular pathology that can result from damage to the VA, most frequently following cervical spine trauma. In most traumatic cases, the dAVF develops and manifests shortly after trauma.

OBSERVATIONS

A patient was admitted after a fall from the stairs causing neck pain. Computed tomography of the cervical spine revealed a Hangman’s fracture, and angiography showed a left VA dissection. The patient was treated with a cervical brace and clopidogrel. Three weeks after trauma, the patient was admitted because of bilateral leg ataxia, dizziness, and neck pain. Repeat imaging revealed increased displacement of the cervical fracture and a dAVF from the left VA with retrograde filling of the dAVF from the right VA. Embolization of the dAVF using coils proximally and distally to the dAVF was performed prior to placing a halo brace. At 6 months, all symptoms had disappeared and union of the cervical spine fracture had occurred.

LESSONS

This case report emphasizes the need for follow-up angiography after traumatic VA injury resulting from cervical spine fracture and underlines important treatment considerations for successful obliteration of a dAVF of the VA.

Open access

Asymptomatic subarachnoid hemorrhage following carotid endarterectomy: illustrative case

Shin Nemoto, Takuma Maeda, Keiichi Yamashita, Taro Yanagawa, Masataka Torii, Masaru Kiyomoto, Masaki Tanaka, Eishi Sato, Yoichi Harada, Toru Hatayama, Takuji Kono, and Hiroki Kurita

BACKGROUND

Carotid endarterectomy (CEA) and carotid artery stenting are common surgical interventions for internal carotid artery stenosis. Cerebral hyperperfusion syndrome (CHS) is a well-known complication of both procedures that can lead to intracranial hemorrhage and worsen clinical outcomes. Here, the authors report a rare case of non-aneurysmal subarachnoid hemorrhage (SAH) following CEA and review the relevant literature.

OBSERVATIONS

A 70-year-old woman with hypertension and diabetes presented with progressive visual loss in the right eye and was diagnosed with ocular ischemic syndrome. Imaging revealed severe right cervical carotid artery stenosis. CEA was performed with no complications. Postoperatively, the patient’s blood pressure was tightly controlled, with no evidence of CHS. However, an asymptomatic SAH was detected on postoperative day 7. Careful observation and blood pressure control were maintained. Since follow-up magnetic resonance imaging (MRI) showed no enlarging of the SAH and the patient was asymptomatic, she was discharged on postoperative day 15 with a modified Rankin scale score of 0.

LESSONS

This case highlights the potential occurrence of non-aneurysmal SAH as a rare complication of CEA, even in asymptomatic patients. Repeated postoperative MRI is necessary to detect such complications. It is crucial to carefully control blood pressure after CEA regardless of symptoms.

Open access

Extra-axial cavernous malformations of the foramen magnum: illustrative cases

Bo-Han Yao, Da Li, Liang Wang, and Zhen Wu

BACKGROUND

Extra-axial cavernous malformations involving the foramen magnum are rare, and preoperative diagnosis becomes difficult when they mimic meningiomas.

OBSERVATIONS

The authors present 2 cases of extra-axial cavernous malformations involving the foramen magnum. Surgical removal of the lesions was performed via far lateral craniotomy. The authors investigate the disease and elaborate the differential diagnosis.

LESSONS

The authors recommend that extra-axial cavernous malformations should be considered in the differential diagnosis of lesions in the foramen magnum region. Intraoperative frozen sections are helpful to the diagnosis, and resection warranted a favorable long-term outcome.