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Open access

Daigo Kojima, Yosuke Akamatsu, Jun Yoshida, Kenya Miyoshi, Hiroshi Kashimura, and Kuniaki Ogasawara

BACKGROUND

The authors report a patient with sagittal sinus thrombosis that was resistant to reported endovascular treatments but successfully recanalized by dragging out the thrombus using a large balloon fixed with an aspiration catheter.

OBSERVATIONS

A 57-year-old man presented with the persistent headache and a simple partial seizure. Diagnostic study with computed tomography and angiography demonstrated the superior sagittal sinus (SSS) thrombosis. Due to the neurological worsening even after systemic heparinization, the patient underwent mechanical thrombectomy. Despite six passes of stent retrievers and a large-bore aspiration catheter, functional recanalization was not achieved. Therefore, the so-called dental floss technique was attempted using a large compliant balloon catheter (Transform 7 × 7 mm). However, the balloon catheter just wobbled along the lesion without recanalization. To restrict the movement of the balloon catheter, the distal shaft of the balloon catheter was fixed with the aspiration catheter, and both the balloon and the aspiration catheter were slowly pulled to drag the thrombus out, resulting in recanalization of cortical veins as well as the SSS.

LESSONS

Dragging the thrombus using a large balloon fixed with an aspiration catheter was a useful technique to retrieve sticky thrombus in the patients with the sinus thrombosis.

Open access

Sarah E. Blitz, J. Tanner McMahon, Joshua I. Chalif, Casey A. Jarvis, David J. Segar, Weston T. Northam, Jason A. Chen, Regan W. Bergmark, Jennifer M. Davis, Sigal Yawetz, and Omar Arnaout

BACKGROUND

Hypercoagulability with thrombosis and associated inflammation has been well-documented in COVID-19, and catastrophic cerebral venous sinus thromboses (CVSTs) have been described. Another COVID-19–related complication is bacterial superinfection, including sinusitis. Here, the authors reported three cases of COVID-19–associated sinusitis, meningitis, and CVST and summarized the literature about septic intracranial thrombotic events as a cause of headache and fever in COVID-19.

OBSERVATIONS

The authors described three adolescent patients with no pertinent past medical history and no prior COVID-19 vaccinations who presented with subacute headaches, photosensitivity, nausea, and vomiting after testing positive for COVID-19. Imaging showed subdural collections, CVST, cerebral edema, and severe sinus disease. Two patients had decline in mental status and progression of neurological symptoms. In all three, emergency cranial and sinonasal washouts uncovered pus that grew polymicrobial cultures. After receiving broad-spectrum antimicrobials and various additional treatments, including two of three patients receiving anticoagulation, all patients eventually became neurologically intact with varying ongoing sequelae.

LESSONS

These cases demonstrated similar original presentations among previously healthy adolescents with COVID-19 infections, concurrent sinusitis precipitating CVST, and subdural empyemas. Better recognition and understanding of the multisystem results of severe acute respiratory syndrome coronavirus 2 and the complicated sequelae allows for proper treatment.

Open access

Vivek P. Buch, Emily A. Mirro, David A. Purger, Michael Zeineh, Kaitlyn Wilmer-Fierro, Babak Razavi, and Casey H. Halpern

BACKGROUND

The resective surgery plus responsive neurostimulation (RNS) system is an effective treatment for patients with refractory focal epilepsy. Furthermore, the long-term intracranial electroencephalography data provided by the system can inform a future resection or ablation procedure. RNS patients may undergo 1.5-T magnetic resonance imaging (MRI) under the conditions specified in the RNS system MRI guidelines; however, it was unknown if the MRI artifact would limit intraoperative laser interstitial thermal therapy (LITT) in a patient with a fully implanted RNS system.

OBSERVATIONS

The authors were able to complete a successful awake LITT of epileptogenic tissue in a 1.5-T MRI scanner on the ipsilateral side to an implanted RNS system.

LESSONS

If a future LITT procedure is probable, the neurostimulator should be placed contralateral to the side of the potential ablation. Using twist drill holes versus burr holes for depth lead placement may assist in future laser bone anchor seating. Before a LITT procedure in a patient with the neurostimulator ipsilateral to the ablation, 1.5-T MRI thermography scanning should be scheduled preoperatively to assess artifact in the proposed ablation zone. Per the RNS system MRI guidelines, the patient must be positioned supine and awake, with no more than 30 minutes of active scan time before a 30-minute pause.

Open access

Alessia Imperato, Maria Allegra Cinalli, Fernanda Servodio Iammarrone, Claudio Ruggiero, and Giuseppe Cinalli

BACKGROUND

Spinal arachnoid cysts (SAC) are rare, especially in children. Patients can be asymptomatic or present symptoms of spinal cord compression. In this latter case, surgery is indicated to relieve the compression. Different surgical techniques have been described to treat these cysts, endoscopic or endoscopy-assisted fenestration being the least invasive. Tetrasomy 18p describes the condition in which two copies of the short arms of chromosome 18 are present. It is an extremely rare pathology with a variable phenotype, including 100% of cases cognitive impairment and developmental delay. Different central nervous system (CNS) abnormalities have been found in these patients.

OBSERVATIONS

The authors describe the case of a 3-year-old boy with a tetrasomy 18p and a wide spinal arachnoid cyst that received an endoscope-assisted treatment with a significantly improved motor outcome.

LESSONS

Tetrasomy 18p is an extremely rare pathology and different CNS abnormalities have been described in association with, but to date spinal arachnoid cyst has never been reported. These children typically show global hypotonia and cognitive impairment. The authors recommend a thorough neurological assessment with cranio-spinal magnetic resonance imaging to rule out any possible malformation that could be improved by surgery.

Open access

Izumi Yamaguchi, Yasuhisa Kanematsu, Kenji Shimada, Nobuaki Yamamoto, Kazuhisa Miyake, Takeshi Miyamoto, Shu Sogabe, Eiji Shikata, Manabu Ishihara, Yuki Yamamoto, Kazutaka Kuroda, and Yasushi Takagi

BACKGROUND

Dural arteriovenous fistula (DAVF) can present with massive hematoma, which sometimes requires emergent removal. Therefore, a surgical strategy for single-session hematoma removal and shunt occlusion in the same surgical field is important.

OBSERVATIONS

A 73-year-old man was transferred to the authors’ hospital with a headache. Brain computed tomography (CT) revealed an intracerebral hematoma in the right temporoparietal lobe (hematoma volume 12 ml). A cerebral angiogram revealed a right isolated transverse-sigmoid sinus (TSS)-DAVF fed by the occipital artery and middle meningeal artery. There was cortical venous reflux into the Labbé vein and posterior parietal vein. Percutaneous transarterial and transvenous embolization were unsuccessful. The following day, his consciousness level acutely declined with a headache, and brain CT showed hematoma expansion (hematoma volume 41 ml) with a midline shift. Therefore, the authors performed single-session hematoma removal and a transcortical venous approach for coil embolization of an isolated TSS-DAVF in a hybrid operating room. His postoperative course was uneventful. No recurrence was observed 3 months postoperatively on cerebral angiography.

LESSONS

Single-session hematoma removal and a transcortical venous approach for coil embolization of an isolated TSS-DAVF is considered in cases with massive hematoma. This strategy is useful, considering recent developments in hybrid operating rooms.

Open access

Christian I. Rios-Vicil, Daniela Barbery, Phuong Dang, and Walter C. Jean

BACKGROUND

Cranioplasties are routinely performed to restore cosmesis and to protect intracranial contents after trauma, resection of tumors, or other pathologies. Traditionally done as a second-stage procedure, new single-stage cranioplasty protocols have been developed to minimize recovery periods, decrease complications, and improve patient satisfaction. These protocols, however, still require the use of larger than planned implants or use larger than ideal incisions to accommodate three-dimensional (3D) templates, which may not be optimal in regions with complex bony anatomy.

OBSERVATIONS

A 50-year-old woman with a painful and progressively enlarging hemangioma of the left frontal bone underwent a single-stage resection followed by custom cranioplasty using a new extended reality (XR)-based workflow. Excellent cosmetic results, decreased operative time, and a feasible workflow were achieved.

LESSONS

The use of an XR-based visualization platform allows the surgeon to treat lesions and perform custom cranioplasties in one session while avoiding common pitfalls of current single-stage workflows, such as increased operative times for tailoring implants, as well as minimizing the use of 3D overlay models, which may not appropriately conform to complex regional bony anatomy intraoperatively.

Restricted access

Tadashi Yamaguchi, Takeshi Miyamoto, Eiji Shikata, Izumi Yamaguchi, Kenji Shimada, Kenji Yagi, Yoshiteru Tada, Masaaki Korai, Keiko T. Kitazato, Yasuhisa Kanematsu, and Yasushi Takagi

OBJECTIVE

Subarachnoid hemorrhage (SAH) due to intracranial aneurysm (IA) rupture is often a devastating event. Since the incidence of SAH increases especially in menopause, it is crucial to clarify the detailed pathogenesis of these events. The activation of vascular nucleotide-binding oligomerization domain–like receptor family pyrin domain–containing 3 (NLRP3) inflammasomes has been studied in ischemic stroke and cardiovascular disease. However, the role of NLRP3 in IA rupture still needs to be explained. The authors sought to test their hypothesis that, under estrogen-deficient conditions, activation of NLRP3 inflammasomes via downregulation of the estrogen receptor (ER) facilitates IA rupture.

METHODS

Ten-week-old female Sprague Dawley rats with and without oophorectomy were subjected to hemodynamic changes and hypertension (OVX+/HT and OVX/HT, respectively) and fed a high-salt diet. Separately, using human brain endothelial cells (HBECs) and human brain smooth muscle cells (HBSMCs), the authors tested the effect of NLRP3 under estrogen-free conditions and in the presence of estradiol or of ER agonists.

RESULTS

In OVX+/HT rats, the frequency of IA rupture was significantly higher than in OVX/HT rats (p = 0.03). In the left posterior cerebral artery prone to rupture in OVX+/HT rats, the levels of the mRNAs encoding ERα and Sirt1, but not of that encoding ERβ, were decreased, and the levels of the mRNAs encoding NLRP3, interleukin-1β (IL-1β), and matrix metalloproteinase 9 (MMP-9) were elevated. Immunohistochemical analysis demonstrated that the expression profiles of these proteins correlated with their mRNA levels. Treatment with an ER modulator, bazedoxifene, normalized the expression profiles of these proteins and improved SAH-free survival. In HBECs and HBSMCs under estrogen-free conditions, the depletion of ERα and Sirt1 and the accumulation of NLRP3 were counteracted by exposure to estradiol or to an ERα agonist but not to an ERβ agonist.

CONCLUSIONS

To the authors’ knowledge, this work represents the first demonstration that, in an aneurysm model under estrogen-deficient conditions, the depletion of ERα and Sirt1 may contribute to activation of the NLRP3/IL-1β/MMP-9 pathway, facilitating the rupture of IAs in the estrogen-deficient rat IA rupture model.

Restricted access

Penny K. Sneed, Jason W. Chan, Lijun Ma, Steve E. Braunstein, Philip V. Theodosopoulos, Shannon E. Fogh, Jean L. Nakamura, Lauren Boreta, David R. Raleigh, Benjamin P. Ziemer, Olivier Morin, Shawn L. Hervey-Jumper, and Michael W. McDermott

OBJECTIVE

The authors previously evaluated risk and time course of adverse radiation effects (AREs) following stereotactic radiosurgery (SRS) for brain metastases, excluding lesions treated after prior SRS. In the present analysis they focus specifically on single-fraction salvage SRS to brain metastases previously treated with SRS or hypofractionated SRS (HFSRS), evaluating freedom from progression (FFP) and the risk and time course of AREs.

METHODS

Brain metastases treated from September 1998 to May 2019 with single-fraction SRS after prior SRS or HFSRS were analyzed. Serial follow-up magnetic resonance imaging (MRI) and surgical pathology reports were reviewed to score local treatment failure and AREs. The Kaplan-Meier method was used to estimate FFP and risk of ARE measured from the date of repeat SRS with censoring at the last brain MRI.

RESULTS

A total of 229 retreated brain metastases in 124 patients were evaluable. The most common primary cancers were breast, lung, and melanoma. The median interval from prior SRS/HFSRS to repeat SRS was 15.4 months, the median prescription dose was 18 Gy, and the median duration of follow-up imaging was 14.5 months. At 1 year after repeat SRS, FFP was 80% and the risk of symptomatic ARE was 11%. The 1-year risk of imaging changes, including asymptomatic RE and symptomatic ARE, was 30%. Among lesions that demonstrated RE, the median time to onset was 6.7 months (IQR 4.7–9.9 months) and the median time to peak imaging changes was 10.1 months (IQR 5.6–13.6 months). Lesion size by quadratic mean diameter (QMD) showed similar results for QMDs ranging from 0.75 to 2.0 cm (1-year FFP 82%, 1-year risk of symptomatic ARE 11%). For QMD < 0.75 cm, the 1-year FFP was 86% and the 1-year risk of symptomatic ARE was only 2%. Outcomes were worse for QMDs 2.01–3.0 cm (1-year FFP 65%, 1-year risk of symptomatic ARE 24%). The risk of symptomatic ARE was not increased with tyrosine kinase inhibitors or immunotherapy before or after repeat SRS.

CONCLUSIONS

RE on imaging was common after repeat SRS (30% at 1 year), but the risk of a symptomatic ARE was much less (11% at 1 year). The results of repeat single-fraction SRS were good for brain metastases ≤ 2 cm. The authors recommend an interval ≥ 6 months from prior SRS and a prescription dose ≥ 18 Gy. Alternatives such as HFSRS, laser interstitial thermal therapy, or resection with adjuvant radiation should be considered for recurrent brain metastases > 2 cm.

Restricted access

Takeshi Hara, Toshinori Matsushige, Michitsura Yoshiyama, Yukishige Hashimoto, Shohei Kobayashi, and Shigeyuki Sakamoto

OBJECTIVE

Recent histopathological studies of unruptured intracranial aneurysms (UIAs) have confirmed that aneurysm wall enhancement (AWE) on MR vessel wall imaging (VWI) is related to wall degeneration with in vivo inflammatory cell infiltration. Therefore, pretreatment aneurysm wall status on VWI may be associated with recurrence after endovascular treatment.

METHODS

VWI with gadolinium was performed on 67 consecutive saccular UIAs before endovascular treatment between April 2017 and June 2021. The mean (range) follow-up period after treatment was 24.4 (6–54) months. AWE patterns were classified as circumferential AWE (CAWE), focal AWE (FAWE), and negative AWE (NAWE). The authors retrospectively investigated the relationship between aneurysm recurrence and AWE patterns, as well as conventional risk factors.

RESULTS

Sixty-seven patients with 67 saccular UIAs were eligible for the present study. AWE patterns were as follows: 10 CAWE (14.9%), 20 FAWE (29.9%), and 37 NAWE (55.2%). Follow-up MRA detected aneurysm recurrence in 18 of 69 cases (26.1%). Univariate analysis identified maximum diameter (mean ± SD 5.8 ± 2.2 mm in patients with stable aneurysms vs 7.7 ± 3.8 mm in those with unstable aneurysms, p = 0.02), aspect ratio (1.4 ± 0.5 vs 1.1 ± 0.4, p < 0.01), aneurysm location in posterior circulation (4.1% vs 27.8%, p < 0.01), volume embolization ratio (29.6% ± 7.8% vs 25.2% ± 6.1%, p = 0.02), and AWE pattern (p = 0.04) as significant predictive factors of recurrence. Among the 3 AWE patterns, CAWE was significantly more frequent in the unstable group, but no significant differences in stability of the treated aneurysms were observed with the FAWE and NAWE patterns. In multivariate logistic regression analysis, CAWE pattern (OR 14.2, 95% CI 1.8–110.8, p = 0.01) and volume embolization ratio ≥ 25% (OR 8.6, 95% CI 2.1–34.3, p < 0.01) remained as significant factors associated with aneurysm stability after coiling.

CONCLUSIONS

VWI before coiling provides novel insights into the stability of treated aneurysms. Aneurysms with the CAWE pattern on VWI before coiling may be less stable after treatment.

Restricted access

Po-Wei Huang, Syu-Jyun Peng, David Hung-Chi Pan, Huai-Che Yang, Jo-Ting Tsai, Cheng-Ying Shiau, I-Chang Su, Ching-Jen Chen, Hsiu-Mei Wu, Chung-Jung Lin, Wen-Yuh Chung, Wan-Yuo Guo, Wei-Lun Lo, Shao-Wen Lai, and Cheng-Chia Lee

OBJECTIVE

The goal of the study was to define and quantify brain arteriovenous malformation (bAVM) compactness and to assess its effect on outcomes after Gamma Knife radiosurgery (GKRS) for unruptured bAVMs.

METHODS

Unsupervised machine learning with fuzzy c-means clustering was used to differentiate the tissue constituents of bAVMs on T2-weighted MR images. The percentages of vessel, brain, and CSF were quantified. The proposed compactness index, defined as the ratio of vasculature tissue to brain tissue, categorized bAVM morphology into compact, intermediate, and diffuse types according to the tertiles of this index. The outcomes of interest were complete obliteration and radiation-induced changes (RICs).

RESULTS

A total of 209 unruptured bAVMs treated with GKRS were retrospectively included. The median imaging and clinical follow-up periods were 49.2 and 72.3 months, respectively. One hundred seventy-three bAVMs (82.8%) achieved complete obliteration after a median latency period of 43.3 months. The rates of RIC and permanent RIC were 76.1% and 3.8%, respectively. Post-GKRS hemorrhage occurred in 14 patients (6.7%), resulting in an annual bleeding risk of 1.0%. Compact bAVM, smaller bAVM volume, and exclusively superficial venous drainage were independent predictors of complete obliteration. Diffuse bAVM morphology, larger bAVM volume, and higher margin dose were independently associated with RICs.

CONCLUSIONS

The compactness index quantitatively describes the compactness of unruptured bAVMs. Moreover, compact bAVMs may have a higher obliteration rate and a smaller risk of RICs than diffuse bAVMs. This finding could help guide decision-making regarding GKRS treatment for patients with unruptured bAVMs.