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Judith Marcoux, Daniel ROY, and Michel W. Bojanowski

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Alexis Victorien Konan, Jean Raymond, and Daniel Roy

✓ The authors sought to show the feasibility and discuss the rationale of embolization of aneurysms associated with spinal cord arteriovenous malformations (SCAVMs). The authors reviewed the clinical presentation, magnetic resonance (MR) images, spinal angiograms, and clinical evolution of four patients treated for aneurysms associated with an SCAVM. Aneurysms were located on branches of the anterior spinal artery in three patients and on radiculopial arteries in two patients; one patient harbored two lesions. Treatment consisted of superselective bucrylate embolization of the branches harboring the aneurysms, with preservation of the arterial axis. Follow-up angiograms were obtained at 3 to 6 months postembolization in all patients.

All patients presented with hemorrhagic events. Hematomyelia was clearly related to a sulcocommissural or a vasa corona aneurysm in two patients. Another sulcocommissural aneurysm and multiple radiculopial aneurysms were presumed to be the cause of subarachnoid hemorrhage in two other patients. One patient harbored aneurysms on a sulcocommissural artery and on a radiculopial artery. All aneurysms were permanently obliterated. In one patient with a single fistula, the SCAVM was cured. The SCAVM was only partially obliterated (95, 50, and 20% in apparent volume) in three other patients. There were no complications or rebleeding episodes during a follow-up period of 17 to 37 months.

Aneurysms associated with SCAVMs can be eradicated by supraselective embolization, even on the anterior spinal artery territory. For patients presenting with hemorrhage and prohibitive risk of complete resection, embolization of aneurysms may decrease the risk of further rebleeding.

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Roy Thomas Daniel and Vedantam Rajshekhar

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Giulia Cossu, Tyler Atkins, Steven D. Hajdu, Francesco Puccinelli, Roy T. Daniel, and Mahmoud Messerer

Carotid-cavernous fistula (CCF) is a rare complication after transsphenoidal surgery with only 10 cases published (Ahuja et al., 1992; Cinar et al., 2013; Cossu et al., 2020; Dolenc et al., 1999; Kalia et al., 2009; Karaman et al., 2009; Kocer et al., 2002; Koitschev et al., 2006; Pigott et al., 1989; Takahashi et al., 1969). Intraoperative findings vary from unrecognized events to life-threatening hemorrhages.

We provide a description of the management of an acute CCF occurring during sphenoidotomy in a patient with pituitary apoplexy. Osteotomy performed in the rostrum resulted in a fracture, which extended toward the intracavernous carotid artery.

Bleeding was managed with mechanical compression. Endovascular treatment allowed closure of the fistula through transarterial coiling and glue. Arterial patency was preserved and the patient had no new neurological deficit.

Drilling should be considered over osteotomy for the anterior sphenoidotomy.

The video can be found here: https://youtu.be/0Me23xIVeNI.

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Daniele Starnoni, Roy Thomas Daniel, Constantin Tuleasca, Mercy George, Marc Levivier, and Mahmoud Messerer

OBJECTIVE

During the last decade, the primary objective for large vestibular schwannoma (VS) management has progressively shifted, from tumor excision to nerve preservation by using a combined microsurgical and radiosurgical approach. The aim of this study was to provide a systematic review and meta-analysis of the available literature regarding the combined strategy of subtotal resection (STR) followed by stereotactic radiosurgery (SRS) for large VSs.

METHODS

The authors performed a systematic review and meta-analysis in compliance with the PRISMA guidelines for article identification and inclusion using the PubMed, Embase, and Cochrane databases. Established inclusion criteria were used to screen all identified relevant articles published before September 2017 without backward date limit.

RESULTS

The authors included 9 studies (248 patients). With a weighted mean follow-up of 46 months (range 28–68.8 months), the pooled rate of overall tumor control was 93.9% (95% CI 91.0%–96.8%). Salvage treatment (second STR and/or SRS) was necessary in only 13 (5.24%) of 18 patients who experienced initial treatment failure. According to the House-Brackmann (HB) grading scale, functional facial nerve preservation (HB grade I–II) was achieved in 96.1% of patients (95% CI 93.7%–98.5%). Serviceable hearing after the combined approach was preserved in 59.9% (95% CI 36.5%–83.2%).

CONCLUSIONS

A combined approach of STR followed by SRS was shown to have excellent clinical and functional outcomes while still achieving a tumor control rate comparable to that obtained with a total resection. Longer-term follow-up and larger patient cohorts are necessary to fully evaluate the rate of tumor control achieved with this approach.

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Jean Raymond, Daniel Roy, Michel Bojanowski, Robert Moumdjian, and Georges L'Espérance

✓ The surgical treatment of basilar bifurcation aneurysms is difficult and the need for an alternative approach is frequently stated. To assess the efficacy and safety of endovascular treatment of aneurysms located at the basilar bifurcation, the authors prospectively studied angiographic results, clinical results, and complications in 31 patients treated with Guglielmi detachable coils (GDCs). Patients treated acutely after subarachnoid hemorrhage (SAH) were graded according to the Hunt and Hess classification and clinical outcome was determined at 1- and 6-month intervals according to the Glasgow Outcome Scale (GOS).

There were 18 women and 13 men, ranging in age from 34 to 67 years (mean age 48 years). Twenty-three were treated acutely after SAH. Clinical Hunt and Hess grades at presentation were as follows: Grade I, six patients; Grade II, three; Grade III, 11; Grade IV, two; and Grade V, one. The GOS score for the group of patients treated acutely was: GOS I, 18 patients; GOS II, III, and IV, one patient each; and GOS V, two patients. There were seven technical complications in this group, most often asymptomatic, but one patient died after aneurysm rupture during treatment and one had residual diplopia at 4 months. Eight patients were treated for incidental basilar bifurcation aneurysms. One technical complication with no neurological deficit occurred in this group of patients with incidental aneurysms.

Immediate angiographic results were considered to be satisfactory in 94% of patients, with complete obliteration in 42% and residual neck and dog ears in 52%. There was no bleeding episode after treatment during clinical follow-up periods ranging from 3 to 42 months (mean 15.5 months in 29 surviving patients). Angiographic results were available for 27 patients at 6 months and were as follows: 30% of the lesions were completely obliterated, 59% presented some residual neck, and 11% showed some opacification of the aneurysm sac. During the follow-up period of up to 42 months, a total of seven recurrences were noted, necessitating retreatment with GDCs in five patients.

Endovascular treatment of basilar bifurcation aneurysms prevented rebleeding and could be performed without clinically significant complications in 94% of patients. Clinical results after SAH compared favorably with surgical series. Morphological results appear less satisfactory, and long-term angiographic follow-up review is mandatory to detect recurrences.

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Pascale Lavoie, Jean Raymond, Daniel Roy, François Guilbert, and Alain Weill

✓The authors report the case of a 12-year-old boy with spinal cord arteriovenous malformation (AVM) and an associated anterior spinal artery (ASA) aneurysm treated with selective coil placement in the context of subarachnoid hemorrhage (SAH).

The patient presented with headache. Head computed tomography scanning revealed no abnormal findings. The cerebrospinal fluid was sampled and analyzed and a diagnosis of SAH was established. Investigation, including magnetic resonance imaging of the cord as well as cerebral and spinal angiography, revealed a conus medullaris AVM and a saccular aneurysm located on the ASA at the T-11 level. The aneurysm was thought to be responsible for the bleeding.

Superselective ASA angiography showed that the aneurysm was at the bifurcation between a large coronal artery supplying the AVM and the ASA. The relation of the aneurysm's neck to the main spinal axis and the aneurysm's morphological features indicated that the lesion was suited for endosaccular coil therapy. The aneurysm was selectively occluded, using electrodetachable bare platinum coils. Follow-up angiography immediately after surgery and at 6 months thereafter demonstrated complete occlusion of the aneurysm and a perfectly patent anterior spinal axis. On clinical follow-up examination, the patient remained neurologically intact.

When the morphological features of a spinal aneurysm and its relation with the anterior spinal axis are favorable, selective endosaccular coil placement can successfully be achieved.

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Jean Raymond, François Guilbert, Alain Weill, and Daniel Roy