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R. Shane Tubbs, Andrew J. DeNardo, and Aaron A. Cohen-Gadol

Intercavernous communication between the left and right internal carotid arteries is an uncommon entity. The authors report a case involving a pediatric patient who was found to have such a vascular anomaly. Such variations should be known by the neurosurgeon so as to avoid misdiagnosis and potential iatrogenic injury.

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R. Shane Tubbs, Martin M. Mortazavi, Andrew J. Denardo, and Aaron A. Cohen-Gadol

The artery of Desproges-Gotteron is rarely mentioned in the literature and is unfamiliar to most neurosurgeons. The authors report a unique case of an arteriovenous malformation (AVM) of the conus in an adult woman, which received blood supply from an artery of Desproges-Gotteron. The patient presented with intermittent pain radiating down the right posterior thigh and foot and transient bladder incontinence. On examination, there was weakness of the right lower limb with hypalgesia of the plantar aspect of the right foot. Magnetic resonance imaging revealed a mass near the anterior aspect of the conus medullaris and angiography confirmed a spinal AVM at the L-1 level and a shunt located at the inferior L-3 level. The patient underwent transarterial embolization, and at 2-year follow-up, repeat angiography demonstrated no evidence of residual or recurrent spinal AVM, intermittent and tolerable pain without treatment interventions, and a normal neurological examination. The artery of Desproges-Gotteron appears to be a rare arterial variation. Moreover, the authors believe this to be the first case of a conal AVM supplied by such an artery. The anatomy and implications of such an arterial variant are discussed.

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Nicolas W. Villelli, David M. Lewis, Thomas J. Leipzig, Andrew J. DeNardo, Troy D. Payner, and Charles G. Kulwin

OBJECTIVE

Intraoperative angiography can be a valuable tool in the surgical management of vascular disorders in the CNS. This is typically accomplished via femoral artery puncture; however, this can be technically difficult in patients in the prone position. The authors describe the feasibility of intraoperative angiography via the popliteal artery in the prone patient.

METHODS

Three patients underwent intraoperative spinal angiography in the prone position via vascular access through the popliteal artery. Standard angiography techniques were used, along with ultrasound and a micropuncture needle for initial vascular access. Two patients underwent intraoperative angiography to confirm the obliteration of dural arteriovenous fistulas. The third patient required unexpected intraoperative angiography when a tumor was concerning for a vascular malformation in the cervical spine.

RESULTS

All 3 patients tolerated the procedure without complication. The popliteal artery was easily accessed without any adaptation to typical patient positioning for these prone-position cases. This proved particularly beneficial when angiography was not part of the preoperative plan.

CONCLUSIONS

Intraoperative angiography via the popliteal artery is feasible and well tolerated. It presents significant benefit when obtaining imaging studies in patients in a prone position, with the added benefit of easy access, familiar anatomy, and low concern for catheter thrombosis or kinking.

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Troy D. Payner, Terry G. Horner, Thomas J. Leipzig, John A. Scott, Richard L. Gilmor, and Andrew J. DeNardo

The benefit of using intraoperative angiography (IA) during aneurysm surgery is still uncertain.

Object. In this prospective study, the authors evaluate the radiographically demonstrated success of surgical treatment in 151 consecutive patients harboring 173 aneurysms who selectively underwent IA examination. The authors also assess the frequency with which IA led to repositioning of the aneurysm clip.

Methods. Intraoperative angiography was used selectively in this series, based on the surgeon's concern about the potential for residual aneurysm, distal branch occlusion, or parent vessel stenosis. Specific variables were analyzed to determine their impact on the incidence of clip repositioning and the accuracy of IA was evaluated by direct comparison with postoperative angiography (PA) in 90% of the cases in which IA was used.

Conclusions. The selective use of IA led to successful treatment as shown by PA, with a low incidence of unexpected residual aneurysm (3.2%), distal branch occlusion (1.9%), and parent vessel stenosis (0%). Intraoperative angiography led to immediate repositioning of the aneurysm clip in 27% of the cases. Anterior cerebral artery aneurysms required clip repositioning less often and superior hypophyseal artery aneurysms required repositioning more often than aneurysms in other locations. Large and giant aneurysms required clip repositioning more often than small aneurysms; however, they were also more likely to display false success on IA as determined by PA. Aneurysms arising along the internal carotid artery were more likely to display successful clipping on IA, as determined by PA, than were aneurysms in other locations.

The results of this series support the selective use of IA in the treatment of complex aneurysms, particularly large and giant aneurysms as well as superior hypophyseal artery aneurysms. As measured by PA, IA will improve the outcome of these patients.

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Todd D. Vogel, Charles G. Kulwin, Andrew J. DeNardo, Troy D. Payner, Joel C. Boaz, and Daniel H. Fulkerson

Aneurysms in children are rare and potentially devastating lesions. The authors report the case of a 16-year-old girl with a complicated medical history related to a chiasmal glioma diagnosed at 18 months of age. She had previously received multiple modalities of radiation treatment, including external beam, proton therapy, and Gamma Knife. She presented with hemorrhage centered in the tumor and extending into the ventricular space. There was no subarachnoid blood. Magnetic resonance imaging demonstrated the hemorrhage and tumor anatomy. Magnetic resonance angiography revealed an aneurysm at the internal carotid artery bifurcation, but the lesion was more clearly delineated on CT angiography. A comparison MR imaging study obtained 6 months earlier, even in retrospect, did not show evidence of an aneurysm. This case illustrates the salient point that the clinician must search for vascular lesions in the patient with spontaneous “tumor bleeding,” especially if that patient has risk factors for aneurysm formation. The authors also suggest that a CT angiogram is better at radiographically demonstrating an intratumoral aneurysm than an MR angiogram in this scenario.

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