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Kyle P. O’Connor and Bradley N. Bohnstedt

A 67-year-old male presented to the hospital with a left anterior cranial fossa arteriovenous fistula connecting the anterior ethmoidal artery to the cavernous sinus and superior sagittal sinus. After failed embolization, the patient was taken for a supra-orbital (eyebrow) craniotomy for surgical dissection and clipping of the fistula. An intraoperative angiogram confirmed successful fistula ligation. The patient was discharged without complications.

The video can be found here: https://youtu.be/79Pk11SEkJg.

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Brandon Lane, Bradley N. Bohnstedt and Aaron A. Cohen-Gadol

OBJECT

The authors prospectively analyzed 2 microscope-integrated videoangiography techniques using intravenous indocyanine green (ICG) and fluorescein for assessment of cerebral aneurysm obliteration and adjacent vessel patency.

METHODS

The authors prospectively enrolled 22 patients who underwent clip ligation of their aneurysm and used intraoperative videoangiography to assess obliteration of the aneurysmal sac and patency of the adjacent branching and perforating arteries. Patients underwent ICG videoangiography (ICG-VA) and the newly developed fluorescein videoangiography (FL-VA) using microscope-integrated fluorescence modules. Two independent observers compared the videoangiography recordings for value and quality to assess aneurysm exclusion and the patency of adjacent arteries.

RESULTS

All 22 patients first underwent FL-VA and then ICG-VA after clip application. In 7 cases (32%), FL-VA provided superior detail to assess perforating arteries (4 cases), distal branches (2 cases), and both (1 case); such detail was not readily available on ICG-VA. In 1 patient, ICG-VA offered better visualization of posterior communicating artery aneurysm occlusion than FL-VA because of staining artifact on the aneurysm dome from the adjacent tentorium. In 2 patients, FL-VA offered the needed advantage of real-time manipulation of the vessels and flow assessment by visualization through the operating microscope oculars. In 2 other cases, ICG-VA was more practical for repeat usage because of its more efficient clearance from the intravascular space. The ICG-VA image quality was often degraded at higher magnification in deep operative fields, partly due to chromatic aberration. Both ICG-VA and FL-VA afforded restricted views of vasculature based on the angle of surgical approach and obscuration by blood clot, aneurysm, or brain tissue.

CONCLUSIONS

Compared with ICG-VA, FL-VA can potentially provide an improved visualization of vasculature at high magnification in deep surgical fields. ICG-VA is more effective for repeated use during clip repositioning due to ICG's minimal vascular wall extravasation. Therefore, in certain cases, FL-VA may offer some advantages and play a complementary role along with ICG-VA in intraoperative fluorescence evaluation during microsurgical management of aneurysms.

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Bradley N. Bohnstedt, Charles G. Kulwin, Mitesh V. Shah and Aaron A. Cohen-Gadol

OBJECT

Surgical exposure of the peritrigonal or periatrial region has been challenging due to the depth of the region and overlying important functional cortices and white matter tracts. The authors demonstrate the operative feasibility of a contralateral posterior interhemispheric transfalcine transprecuneus approach (PITTA) to this region and present a series of patients treated via this operative route.

METHODS

Fourteen consecutive patients underwent the PITTA and were included in this study. Pre- and postoperative clinical and radiological data points were retrospectively collected. Complications and extent of resection were reviewed.

RESULTS

The mean age of patients at the time of surgery was 39 years (range 11–64 years). Six of the 14 patients were female. The mean duration of follow-up was 4.6 months (range 0.5–19.6 months). Pathology included 6 arteriovenous malformations, 4 gliomas, 2 meningiomas, 1 metastatic lesion, and 1 gray matter heterotopia. Based on the results shown on postoperative MRI, 1 lesion (7%) was intentionally subtotally resected, but ≥ 95% resection was achieved in all others (93%) and gross-total resection was accomplished in 7 (54%) of 13. One patient (7%) experienced a temporary approach-related complication. At last follow-up, 1 patient (7%) had died due to complications of his underlying malignancy unrelated to his cranial surgery, 2 (14%) demonstrated a Glasgow Outcome Scale (GOS) score of 4, and 11 (79%) manifested a GOS score of 5.

CONCLUSIONS

Based on this patient series, the contralateral PITTA potentially offers numerous advantages, including a wider, safer operative corridor, minimal need for ipsilateral brain manipulation, and better intraoperative navigation and working angles.

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Bradley N. Bohnstedt, Matthew Tomcik, Todd Eads, Matthew C. Hagen and Mitesh Shah

The differential diagnosis for masses involving the clivus is broad. The authors present a case of myoepithelial carcinoma metastatic to the clivus, a lesion that has not been reported to their knowledge. This 14-year-old girl with a history of myoepithelial carcinoma originating in the soft tissues of the left hip and metastatic to the lung presented with left lateral gaze palsy. Imaging demonstrated a 3 × 3–cm osteolytic mass in the clivus. Microscopic transsphenoidal resection with endoscopic assistance was performed. Pathological findings were consistent with the previously diagnosed myoepithelial carcinoma. Within 4 weeks postoperatively and 2 weeks into a chemotherapeutic regimen, the tumor exhibited progression. Radiation therapy was started and growth of the tumor was halted.

Myoepithelial carcinoma should be included in the differential diagnosis for clival masses, especially in patients with previously diagnosed myoepithelial carcinoma. The primary management of this tumor should be with chemotherapy and radiation, with surgery serving only for decompression.

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Charles Kulwin, Bradley N. Bohnstedt, John A. Scott and Aaron Cohen-Gadol

A cerebral dural arteriovenous fistula (DAVF) is an acquired abnormal arterial-to-venous connection within the leaves of the intracranial dura with a wide range of clinical presentations and natural history. The Cognard classification correlates venous drainage patterns with neurological course, identifying 5 DAVF types with increasing rates of symptomatic presentation. A spinal DAVF occurs when a radicular artery makes a direct anomalous shunt with a radicular vein within the dural leaflets of the nerve root sleeve. A cervical DAVF is a rare entity, as most spinal DAVFs present as thoracolumbar lesions with myelopathy. In this paper the authors present 2 patients presenting initially with brainstem dysfunction rather than myelopathy secondary to craniocervical DAVF. The literature is then reviewed for similar rare aggressive DAVFs at the craniocervical junction presenting with brainstem symptomatology.

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Ryan P. Morton, Louis J. Kim and Laligam N. Sekhar

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Bradley N. Bohnstedt, Mary Ziemba-Davis, Rishabh Sethia, Troy D. Payner, Andrew DeNardo, John Scott and Aaron A. Cohen-Gadol

OBJECTIVE

The deep and difficult-to-reach location of basilar apex aneurysms, along with their location near critical adjacent perforating arteries, has rendered the perception that microsurgical treatment of these aneurysms is risky. As a result, these aneurysms are considered more suitable for treatment by endovascular intervention. The authors attempt to compare the immediate and long-term outcomes of microsurgery versus endovascular therapy for this aneurysm subtype.

METHODS

A prospectively maintained database of 208 consecutive patients treated for basilar apex aneurysms between 2000 and 2012 was reviewed. In this group, 161 patients underwent endovascular treatment and 47 were managed microsurgically. The corresponding records were analyzed for presenting characteristics, postoperative complications, discharge status, and Glasgow Outcome Scale (GOS) scores up to 1 year after treatment and compared using chi-square and Student t-tests.

RESULTS

Among these 208 aneurysms, 116 (56%) were ruptured, including 92 (57%) and 24 (51%) of the endovascularly and microsurgically managed aneurysms, respectively. The average Hunt and Hess grade was 2.4 (2.4 in the endovascular group and 2.2 in the microsurgical group; p = 0.472). Postoperative complications of cranial nerve deficits and hemiparesis were more common in patients treated microsurgically than endovascularly (55.3% vs 16.2%, p < 0.05; and 27.7% vs 10.6%, p < 0.05, respectively). However, aneurysm remnants and need for retreatment were more common in the endovascular than the microsurgical group (41.3% vs 2.3%, p < 0.05; and 10.6% vs 0.0%, p < 0.05, respectively). Stent placement significantly reduced the need for retreatment. Rehemorrhage rates and average GOS score at discharge and 1 year after treatment were not statistically different between the two treatment groups.

CONCLUSIONS

Patients with basilar apex aneurysms were significantly more likely to be treated via endovascular management, but compared with those treated microsurgically, they had higher rates of recurrence and need for retreatment. The current study did not detect an overall difference in outcomes at discharge and 1 year after either treatment modality. Therefore, in a select group of patients, microsurgical treatment continues to play an important role.

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Daniel H. Fulkerson, Shobhan Vachhrajani, Bradley N. Bohnstedt, Neal B. Patel, Akash J. Patel, Benjamin D. Fox, Andrew Jea and Joel C. Boaz

Object

Premature, low-birth-weight infants with posthemorrhagic hydrocephalus have a high risk of shunt obstruction and infection. Established risk factors for shunt failure include grade of the hemorrhage and age at shunt insertion. There is anecdotal evidence that the amount of red blood cells or protein levels in the CSF may affect shunt performance. However, this has not been analyzed specifically for this cohort of high-risk patients. Therefore, the authors performed this study to examine whether any statistical relationship exists between the CSF constituents and the rate of shunt malfunction or infection in this population.

Methods

A retrospective cohort study was performed on premature infants born at Riley Hospital for Children from 2000 to 2009. Inclusion criteria were a CSF sample analyzed within 2 weeks prior to shunt insertion, low birth weight (< 1500 grams), prematurity (birth prior to 37 weeks estimated gestational age), and shunt insertion for posthemorrhagic hydrocephalus. Data points included the gestational age at birth and shunt insertion, weight at birth and shunt insertion, history of CNS infection prior to shunt insertion, shunt failure, shunt infection, and the levels of red blood cells, white blood cells, protein, and glucose in the CSF. Statistical analysis was performed to determine any association between shunt outcome and the CSF parameters.

Results

Fifty-eight patients met the study entry criteria. Ten patients (17.2%) had primary shunt failure within 3 months of insertion. Nine patients (15.5%) had shunt infection within 3 months. A previous CNS infection prior to shunt insertion was a statistical risk factor for shunt failure (p = 0.0290) but not for shunt infection. There was no statistical relationship between shunt malfunction or infection and the CSF levels of red blood cells, white blood cells, protein, or glucose before shunt insertion.

Conclusions

Low-birth-weight premature infants with posthemorrhagic hydrocephalus have a high rate of shunt failure and infection. The authors did not find any association of shunt failure or infection with CSF cell count, protein level, or glucose level. Therefore, it may not be useful to base the timing of shunt insertion on CSF parameters.

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Mason A. Brown, Jonathan Parish, Cristian F. Guandique, Troy D. Payner, Terry Horner, Thomas Leipzig, Karishma V. Rupani, Richard Kim, Bradley N. Bohnstedt and Aaron A. Cohen-Gadol

OBJECTIVE

With the recent evolution of endovascular therapies, objective evaluation of the efficacy of clip ligation for cerebral aneurysms should be performed. This study was undertaken to evaluate the durability of microsurgical clip ligation, identify risk factors for recurrence, and assess the need for long-term follow-up imaging.

METHODS

A retrospective review of medical records identified 616 consecutive patients (156 male and 460 female patients; mean age 48.4 ± 12.4 years; range 6–90 years) who underwent microsurgical clip ligation and follow-up imaging at least 1 year after discharge between 1990 and 2010 at our institution. Of a total of 926 aneurysms in 616 patients, 758 aneurysms were microsurgically clip-ligated. At presentation, 431 of these aneurysms were ruptured and 327 aneurysms were unruptured. All patients underwent postoperative baseline imaging within the 1st month of their operation. A logistic regression analysis was performed to identify which variables are more likely to predict recurrence.

RESULTS

Late follow-up angiographic imaging was obtained at a mean of 7.2 ± 4.7 years postdischarge (median 5.7 years; range 1–23 years). Of the 699 clipped aneurysms without residua, late follow-up angiography revealed only 1 (0.14%) recurrent aneurysm. Of the 59 residual aneurysms that remained after initial clip ligation on early postoperative imaging, 8 (13.6%) demonstrated growth. All of these aneurysms required treatment. None of the recurrences were due to broken or delayed displacement of clips. A total of 111 patients presented with multiple aneurysms. De novo aneurysm formation occurred in 8 (0.97%) patients, all of whom initially presented with multiple aneurysms.

CONCLUSIONS

This study provides additional evidence to support the long-term efficacy of aneurysm clip ligation. The chance of aneurysm recurrence after complete clip ligation is very small. However, there is a regrowth risk of 1.83% per year for aneurysm remnants after incomplete clip ligation. These findings support the necessity for continued followup, late angiographic imaging, and the potential need for further intervention of incompletely ligated aneurysms. Furthermore, completely clip-ligated aneurysms may not require additional surveillance imaging unless multiple aneurysms were evident at presentation.