✓ Arteriovenous malformations (AVM's) of lateral and sigmoid sinuses are acquired lesions evolving from a previously thrombosed dural sinus. Their natural history is usually that of gradual progression and hence surgery is frequently necessary. The preferred surgical treatment is complete excision coupled with packing of the sigmoid sinus. The operative approach is illustrated and discussed in detail. Results and complications are reviewed in 27 patients whose symptomatology had progressed under conservative management; 22 of these cases harbored primary lesions and five had recurrences. There were 22 excellent, one good, and two poor results (both of the latter from blindness that preceded surgery). There were two deaths, both in patients previously operated on with incomplete removal or obliteration of the AVM by attempted embolization.
Thoralf M. Sundt Jr. and David G. Piepgras
Part 1: Repair of Segmental Defects with Clip-Grafts; Laboratory Studies and Clinical Correlations
Thoralf M. Sundt Jr. and John D. Nofzinger
Thomas J. Rosenbaum and Thoralf M. Sundt Jr.
✓ Various straight-jawed aneurysm clips were tested for occluding capabilities on a vascular tissue model. Occluding pressures varied markedly among the clip styles and were altered by changes in the lumen and tissue composition of the model. Mechanical characteristics are highly variable between clip styles, but fall within a narrow range for clips of a similar style. The complex interplay of the unique aspects of clip design and force generated by the spring in conjunction with tissue characteristics and precise clip placement upon the tissue are major variables in the apparent ability of a particular clip to occlude the neck of an aneurysm.
Operative experience with 80 cases
Thoralf M. Sundt Jr. and David G. Piepgras
✓ The authors report experience with the surgical management of 80 giant intracranial aneurysms (> 2.5cm in diameter) during a 10-year period in which they performed 594 operations for aneurysms. The overall incidence of giant aneurysms was 13% but varied according to location: 20% of aneurysms of the internal carotid artery (ICA); 13% of middle cerebral artery (MCA) aneurysms; 1% of anterior cerebral artery (ACA) aneurysms; 15% of aneurysms of the basilar artery caput (BAC); and 18% of vertebrobasilar trunk(VB) aneurysms. Twenty-five patients had a subarachnoid hemorrhage (SAH), 49 had mass effect from the aneurysm, and six had ischemic events. There was no apparent difference in results related to the presence or absence of an SAH. Poor results were attributable to the operation except in the two cases of ACA aneurysm in which preexisting dementia persisted. Mortality was 4% and morbidity was 14%, varying from a combined low morbidity-mortality of 8% for ICA lesions to a high of 50% for BAC aneurysms. During the period of the study, different techniques were developed in an attempt to lower the risks of surgery.Ultimately ICA aneurysms were monitored with cerebral blood flow measurements and electroencephalography before and after temporary ICA ligation, then approached following resection of the anterior clinoid or treated with bypass in combination with ICA ligation. Aneurysms of the MCA were either opened during temporary MCA occlusion or resected in combination with a bypass procedure. Bypass grafts and circulatory arrest with extracorporeal circulation may have a role in giant aneurysms of the posterior circulation.
Edward R. Laws Jr., Patrick J. Kelly and Thoralf M. Sundt Jr.
✓ A method is described for the protection of the trigeminal root from recurrent vascular irritation or compression after posterior fossa microvascular decompression. A vascular clip-graft, using a Sundt clip of suitable size, is applied to the sensory root of the trigeminal nerve. The technique has proven safe and effective in a series of nine patients followed for up to 28 months.
Part 2. Clinical studies: an adjunctive measure for hemostasis in resection of arteriovenous malformations
Robert E. Wharen Jr., Robert E. Anderson and Thoralf M. Sundt Jr.
✓ The Nd:YAG laser has been used safely to aid in the resection of 10 cases of parenchymal arteriovenous malformations (AVM's). The laser was, found helpful for: 1) defining the plane between the AVM and the brain; 2) coagulating any dural component of the AVM; and 3) achieving hemostasis of the bed following resection of the lesion. However, its overall benefit in the resection of AVM's remains to be determined, as it could not arrest active high-flow bleeding from the thin-walled vessels feeding the deep portion of the AVM. This was attributed to the inherent characteristics of these vessels, since the instrument has been effective in non-AVM arteries of similar dimensions containing contractile elements in the vessel walls. Future refinements in focusing instrumentation and operative technique should enhance its capabilities and usefulness. When used within the recommended power range, the Nd:YAG laser is safe and its penetration predictable. The fiberoptic cable light delivery system allows excellent mobility of the handpiece, but the protective eyewear laser-light filters reduce the available light to the surgeon. The instrument appears promising but more work is required.
Phyo Kim, Thoralf M. Sundt Jr. and Paul M. Vanhoutte
✓ The purpose of this study was to examine the hypotheses that structural stiffening of the arterial wall contributes to chronic cerebral vasospasm, and that alteration in properties of smooth muscle takes place after subarachnoid hemorrhage (SAH). Subarachnoid hemorrhage and subsequent chronic vasospasm were induced in dogs by two cisternal injections of autologous blood (on Day 0 and Day 2). Vasospasm was confirmed by angiography performed on Day 0 and Day 7. Animals in the control group underwent angiography only. On Day 8, the mechanical properties of the basilar arteries were studied in vitro. Passive compliance, measured under total inhibition of spontaneous myogenic tone with diltiazem (10−4 M) plus papaverine (10−4 M) was smaller in the SAH group. The length-contraction curve was shifted to the left and the optimum length for maximum contraction (Lmax) was significantly shorter in the spastic blood vessels. The spontaneous myogenic tone was augmented in the SAH group, resulting in an increase in resting tension at each length. By contrast, the maximum contractions in response to KCl and uridine 5′-triphosphate were markedly reduced in the SAH group, without changes in sensitivity to these agents. These differences in mechanical properties were observed in rings both with and without endothelium. The results indicate that, in chronic vasospasm, stiffening of the noncontractile component of the vasculature takes place as well as alterations in the contractile component, both of which presumably contribute to the shift in resting length-tension relationship and length-contraction relationship of the artery. The decreased distensibility, the increase in resting tension, and the shortening of the Lmax all favor a smaller diameter of the artery after SAH, possibly contributing to vasospasm.
Fredric B. Meyer, David G. Piepgras, Thoralf M. Sundt Jr. and Takehiko Yanagihara
✓ Twenty cases treated with emergency embolectomy for acute occlusion of the middle cerebral artery were reviewed. There were 10 males and 10 females, with an average age of 55 years. The left middle cerebral artery was involved in 17 patients and the right in three. Flow was restored in 16 patients (75%). The embolus originated in the heart in seven, the carotid artery in seven, the aorta in three, an aneurysm in one, and an indeterminate source in two. It was technically most difficult to achieve patency with atheromatous emboli from the aorta. Two patients (10%) had an excellent result with no neurological deficit, five (25%) were left with a minimal deficit but were employable, seven (35%) had a fair result but were still independent and employable, four (20%) did poorly, and two (10%) died. Patients with an associated ipsilateral carotid artery occlusion did poorly. Collateral flow, as judged from preoperative angiograms, was the best predictor of outcome.
Phyo Kim, Thoralf M. Sundt Jr. and Paul M. Vanhoutte
✓ To investigate the alteration of endothelium-dependent responses in chronic vasospasm after subarachnoid hemorrhage (SAH), experiments were carried out in the double-hemorrhage canine model. After the presence of vasospasm was confirmed by cerebral angiography on Days 0 and 7, pharmacological studies on the basilar artery were conducted in vitro on Day 8. In the SAH group, endothelium-dependent relaxation was abolished in response to arginine vasopressin and was significantly reduced in response to thrombin. Endothelium-independent relaxation in the SAH group was preserved in response to papaverine and was minimally reduced in response to sodium nitroprusside. Endothelium-dependent contraction in response to arachidonic acid, acetylcholine, the calcium ionophore A23187, adenosine diphosphate, mechanical stretching, and hypoxia persisted in the SAH group. The maximal contraction to KCl and uridine triphosphate, which is endothelium-independent, was diminished in the SAH group, but no changes in sensitivity were noted in the concentration-response relationships. A significant correlation was observed between the degree of vasospasm determined angiographically and the loss of endothelium-dependent relaxation. The loss of endothelium-dependent relaxation and the persistence of endothelium-dependent contraction suggest that the deterioration in the endothelium-dependent responses may be an important component in the pathogenesis of cerebral vasospasm.