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Fabio A. Frisoli, Joshua S. Catapano, Jacob F. Baranoski and Michael T. Lawton

The anterior and posterior communicating arteries are natural connections between arteries that enable different adjacent circulations to redistribute blood flow instantly in response to changing supply and demand. An analogous communication does not exist in the middle cerebral circulation. A middle communicating artery (MCoA) can be created microsurgically between separate middle cerebral artery (MCA) trunks, enabling flow to redistribute in response to changing supply and demand. The MCoA would draw blood flow from an adjacent circulation such as the external carotid circulation. The MCoA requires the application of fourth-generation techniques to reconstruct bi- and trifurcations after occluding complex MCA trunk aneurysms. In this report, the authors describe two recent cases of complex MCA bi- and trifurcation aneurysms in which the occluded efferent trunks were revascularized by creating an MCoA.

The first MCoA was created with a “double-barrel” superficial temporal artery–M2 segment bypass and end-to-end reimplantation of the middle and inferior MCA trunks. The second MCoA was created with an external carotid artery–radial artery graft–M2 segment interpositional bypass and end-to-side reimplantation of the inferior trunk onto the superior trunk. Both aneurysms were occluded, and both patients experienced good outcomes.

This report introduces the concept of the MCoA and demonstrates two variations. Angioarchitectural and technical elements include the donation of flow from an adjacent circulation, a communicating bypass, the application of fourth-generation bypass techniques, and a minimized ischemia time. The MCoA construct is ideally suited for rebuilding bi- and trifurcated anatomy after trapping or distally occluding complex MCA aneurysms.

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Alexander C. Whiting, Tsinsue Chen, Kyle I. Swanson, Corey T. Walker, Jakub Godzik, Joshua S. Catapano and Kris A. Smith

OBJECTIVE

Debate continues over proper surgical treatment for mesial temporal lobe epilepsy (MTLE). Few large comprehensive studies exist that have examined outcomes for the subtemporal selective amygdalohippocampectomy (sSAH) approach. This study describes a minimally invasive technique for sSAH and examines seizure and neuropsychological outcomes in a large series of patients who underwent sSAH for MTLE.

METHODS

Data for 152 patients (94 women, 61.8%; 58 men, 38.2%) who underwent sSAH performed by a single surgeon were retrospectively reviewed. The sSAH technique involves a small, minimally invasive opening and preserves the anterolateral temporal lobe and the temporal stem.

RESULTS

All patients in the study had at least 1 year of follow-up (mean [SD] 4.52 [2.57] years), of whom 57.9% (88/152) had Engel class I seizure outcomes. Of the patients with at least 2 years of follow-up (mean [SD] 5.2 [2.36] years), 56.5% (70/124) had Engel class I seizure outcomes. Preoperative and postoperative neuropsychological test results indicated no significant change in intelligence, verbal comprehension, perceptual reasoning, attention and processing, cognitive flexibility, visuospatial memory, or mood. There was a significant change in word retrieval regardless of the side of surgery and a significant change in verbal memory in patients who underwent dominant-side resection (p < 0.05). Complication rates were low, with a 1.3% (2/152) permanent morbidity rate and 0.0% mortality rate.

CONCLUSIONS

This study reports a large series of patients who have undergone sSAH, with a comprehensive presentation of a minimally invasive technique. The sSAH approach described in this study appears to be a safe, effective, minimally invasive technique for the treatment of MTLE.

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Jacob F. Baranoski, Ankush Bajaj, Colin J. Przybylowski, Joshua S. Catapano, Fabio A. Frisoli, Michael J. Lang and Michael T. Lawton

Supracerebellar transtentorial (SCTT) approaches have become a popular option for treatment of a variety of pathologies in the medial and basal temporal and occipital lobes and thalamus. Transtentorial approaches provide numerous advantages over transcortical approaches, including obviating the need to traverse eloquent cortex, not requiring parenchymal retraction, and circumventing critical vascular structures. All of these approaches require a tentorial opening, and numerous techniques for retraction of the incised tentorium have been described, including sutures, fixed retractors, and electrocautery. However, all of these techniques have considerable drawbacks and limitations. The authors describe a novel application of clip retraction of the tentorium to the supracerebellar approaches in which an aneurysm clip is used to suspend the tentorial flap, and an illustrative case is provided. Clip retraction of the tentorium is an efficient, straightforward adaptation of an established technique, typically used for subtemporal approaches, that improves visualization and surgical ergonomics with little risk to nearby venous structures. The authors find this technique particularly useful for the contralateral SCTT approaches.

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Jan-Karl Burkhardt, Ethan A. Winkler, Joshua S. Catapano, Robert F. Spetzler and Michael T. Lawton

OBJECTIVE

Studies of resection of brain arteriovenous malformations (AVMs) in the elderly population are scarce. This study examined factors influencing patient selection and surgical outcome among elderly patients.

METHODS

Patients 65 years of age and older who underwent resection of an unruptured or ruptured brain AVM treated by two surgeons at two centers were identified. Patient demographic characteristics, AVM characteristics, clinical presentation, and outcomes measured using the modified Rankin Scale (mRS) were analyzed. For subgroup analyses, patients were dichotomized into two age groups (group 1, 65–69 years old; group 2, ≥ 70 years old).

RESULTS

Overall, 112 patients were included in this study (group 1, n = 61; group 2, n = 51). Most of the patients presented with hemorrhage (71%), a small nidus (< 3 cm, 79%), and a low Spetzler-Martin (SM) grade (grade I or II, 63%) and were favorable surgical candidates according to the supplemented SM grade (supplemented SM grade < 7, 79%). A smaller AVM nidus was statistically significantly more likely to be present in patients with infratentorial AVMs (p = 0.006) and with a compact AVM nidus structure (p = 0.02). A larger AVM nidus was more likely to be treated with preoperative embolization (p < 0.001). Overall outcome was favorable (mRS scores 0–3) in 71% of the patients and was statistically independent from age group or AVM grading. Patients with ruptured AVMs at presentation had significantly better preoperative mRS scores (p < 0.001) and more favorable mRS scores at the last follow-up (p = 0.04) than patients with unruptured AVMs.

CONCLUSIONS

Outcomes were favorable after AVM resection in both groups of patients. Elderly patients with brain AVMs treated microsurgically were notable for small nidus size, AVM rupture, and low SM grades. Microsurgical resection is an important treatment modality for elderly patients with AVMs, and supplemented SM grading is a useful tool for the selection of patients who are most likely to achieve good neurological outcomes after resection.

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Joshua S. Catapano, Andrew F. Ducruet, Fabio A. Frisoli, Candice L. Nguyen, Christopher E. Louie, Mohamed A. Labib, Jacob F. Baranoski, Tyler S. Cole, Alexander C. Whiting, Felipe C. Albuquerque and Michael T. Lawton

OBJECTIVE

Takotsubo cardiomyopathy (TC) in patients with aneurysmal subarachnoid hemorrhage (aSAH) is associated with high morbidity and mortality. Previous studies have shown that female patients presenting with a poor clinical grade are at the greatest risk for developing TC. Intra-aortic balloon pumps (IABPs) are known to support cardiac function in severe cases of TC, and they may aid in the treatment of vasospasm in these patients. In this study, the authors investigated risk factors for developing TC in the setting of aSAH and outcomes among patients requiring IABPs.

METHODS

The authors retrospectively reviewed the records of 1096 patients who had presented to their institution with aSAH. Four hundred five of these patients were originally enrolled in the Barrow Ruptured Aneurysm Trial, and an additional 691 patients from a subsequent prospectively maintained aSAH database were analyzed. Medical records were reviewed for the presence of TC according to the modified Mayo Clinic criteria. Outcomes were determined at the last follow-up, with a poor outcome defined as a modified Rankin Scale (mRS) score > 2.

RESULTS

TC was identified in 26 patients with aSAH. Stepwise multivariate logistic regression analysis identified female sex (OR 8.2, p = 0.005), Hunt and Hess grade > III (OR 7.6, p < 0.001), aneurysm size > 7 mm (OR 3, p = 0.011), and clinical vasospasm (OR 2.9, p = 0.037) as risk factors for developing TC in the setting of aSAH. TC patients, even with IABP placement, had higher rates of poor outcomes (77% vs 47% with an mRS score > 2, p = 0.004) and mortality at the last follow-up (27% vs 11%, p = 0.018) than the non-TC patients. However, aggressive intra-arterial endovascular treatment for vasospasm was associated with good outcomes in the TC patients versus nonaggressive treatment (100% with mRS ≤ 2 at last follow-up vs 53% with mRS > 2, p = 0.040).

CONCLUSIONS

TC after aSAH tends to occur in female patients with large aneurysms, poor clinical grades, and clinical vasospasm. These patients have significantly higher rates of poor neurological outcomes, even with the placement of an IABP. However, aggressive intra-arterial endovascular therapy in select patients with vasospasm may improve outcome.