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Mohamed Samy Elhammady, Eric C. Peterson and Mohammad Ali Aziz-Sultan

The treatment of indirect carotid cavernous fistulas (CCFs) is challenging and primarily accomplished by endovascular means utilizing a variety of embolic agents. Transvenous access to the cavernous sinus is the preferred method of embolizaiton of indirect CCFs as they are frequently associated with numerous small-caliber meningeal branches. Although the inferior petrosal sinus is the simplest, shortest, and most commonly used venous route to the cavernous sinus, the superior ophthalmic vein, superior petrosal sinus, basilar plexus, and pterygoid plexus present other endovenous options. Occasionally, however, use of these venous routes may not be possible due to vessel tortuosity or sinus thrombosis and occlusion.

The authors report a case of an indirect CCF that could not be treated endovascularly due to inability to access the cavernous sinus via a transfemoral transvenous approach. Angiography revealed a small, deeply located superior ophthalmic vein that was thought to be suboptimal for a direct cutdown. The cavernous sinus was cannulated directly via a transorbital approach using fluoroscopic guidance with a 3D skull reconstruction overlay. The fistula was subsequently obliterated using ethylene vinyl alcohol copolymer (Onyx). The technique and advantages of both 3D osseous reconstruction as well as Onyx embolization are discussed.

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Sudheer Ambekar, Brandon G. Gaynor, Eric C. Peterson and Mohamed Samy Elhammady

OBJECT

Dural arteriovenous fistulas (DAVFs) are complex lesions consisting of abnormal connections between meningeal arteries and dural venous sinuses and/or cerebral veins. The goal of treatment is surgical or endovascular occlusion of the fistula or fistulous nidus or at least the disconnection of the feeding vessels and the draining veins. Delayed angiographic data on previously embolized dural fistulas is lacking. The authors report their experience and the long-term angiographic results with embolization of intracranial DAVF using Onyx.

METHODS

All cases of DAVF treated primarily with Onyx at the authors’ institution from 2006 to 2013 were retrospectively reviewed. Patient demographics, fistula characteristics, embolization details, and angiographic follow-up were analyzed.

RESULTS

Fifty-eight patients with DAVFs were treated during the study period. Twenty-two patients were treated with open surgery with or without prior embolization. Thirty-six patients were treated with embolization alone, of whom 26 underwent an attempt at curative embolization and are the subject of this review. All but 2 of these patients were treated in a single session. Angiographic “cure” was achieved in all cases following treatment. Follow-up angiography was performed in 21 patients at a mean of 14 months after treatment (range 2–39 months). Asymptomatic angiographic recurrence of the fistula was evident in 3 of the 21 patients (14.3%). On reviewing the procedural angiograms of the cases in which the DAVFs recurred, it was observed that the Onyx cast did not reach the venous portion in 1 case, whereas it did reach the vein in the other 2 cases.

CONCLUSIONS

Recurrence following initial angiographic cure of DAVF is not uncommon. Incomplete penetration of the embolic material into the proximal portion of the venous outlet may lead to delayed recurrence. Long-term angiographic follow-up is highly recommended.

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Florian Roser, Luigi Rigante and Mohamed Samy Elhammady

Procedures on cavernous malformations of the brainstem are challenging due to their eloquent location. This accounts especially for recurrent cavernomas as surgical scars, adhesions, and functional shift might have occurred since primary surgery. We report on a 38-year-old female patient with a large recurrent brainstem cavernoma, who underwent previous successful surgery and experienced recurrent bleeding about 2 years later. She harbored a large associated developmental venous anomaly (DVA) traversing the cavernoma through the midline of the brainstem. In order to visualize complete resection and preservation of the DVA at the same time, endoscopic-assisted resection within the brainstem after decompression in the semisitting position was performed.

The video can be found here: https://youtu.be/K1p-Sx7jUpA.

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Sumedh S. Shah, Zachary C. Gersey, Mohamed Nuh, Hesham T. Ghonim, Mohamed Samy Elhammady and Eric C. Peterson

OBJECTIVE

Blood-blister aneurysms (BBAs) of the internal carotid artery (ICA) have a poor natural history associated with high morbidity and mortality. Currently, both surgical and endovascular techniques are employed to treat BBAs; thus, the authors sought to perform a meta-analysis to compare the efficacy and safety of these approaches.

METHODS

A literature search of PubMed, MEDLINE, and Google Scholar online databases was performed to include pertinent English-language studies from 2005 to 2015 that discussed the efficacy and safety of either surgical or endovascular therapies to treat BBAs.

RESULTS

Thirty-six papers describing 256 patients with BBAs treated endovascularly (122 procedures) or surgically (139 procedures) were examined for data related to therapeutic efficacy and safety. Pooled analysis of 9 papers demonstrated immediate and late (mean 20.9 months) aneurysm occlusion rates of 88.9% (95% CI 77.6%–94.8%) and 88.4% (95% CI 76.7%–94.6%), respectively, in surgically treated patients. Pooled analysis of 12 papers revealed immediate and late aneurysm obliteration rates of 63.9% (95% CI 52.3%–74.1%) and 75.9% (95% CI 65.9%–83.7%), respectively, in endovascularly treated aneurysms. Procedure-related complications and overall poor neurological outcomes were slightly greater in the surgically treated cases than in the endovascularly treated cases (27.8% [95% CI 19.6%–37.8%] vs 26.2% [95% CI 18.4%–35.8%]), indicating that endovascular therapy may provide better outcomes.

CONCLUSIONS

Blood-blister aneurysms are rare, challenging lesions with a poor prognosis. Although surgical management potentially offers superior aneurysm obliteration rates immediately after treatment and at the long-term follow-up, endovascular therapy may have a better safety profile and provide better functional outcomes than surgery. A registry of patients treated for BBAs may be warranted to better document the natural course of the disease as well as treatment outcomes.

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Simon Buttrick, Jacques J. Morcos, Mohamed S. Elhammady and Anthony C. Wang

Extradural anterior clinoidectomy is a versatile technique to increase exposure of the sellar and parasellar region. It is of particular use in the resection of clinoidal meningiomas, as sphenoidal and clinoidal hyperostosis can cause compression of the optic nerve. Extradural clinoidectomy follows a series of steps, consisting of (1) unroofing of the superior orbital fissure, (2) unroofing of the optic canal, (3) removal of the optic strut, and (4) removal of the anterior clinoid process. The authors show these steps in detail, as well as their application to the resection of a large clinoidal meningioma.

The video can be found here: https://youtu.be/O1Fcef29ETg.

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Mohamed Samy Elhammady and Roberto C. Heros

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Mohamed Samy A. Elhammady, Hamad Farhat, Habib Ziayee and Mohammad Ali Aziz-Sultan

Carotid body tumors (CBTs) are rare highly vascular lesions that frequently require preoperative embolization to minimize surgical morbidity secondary to blood loss. Embolization has typically been performed via a transarterial route. However, this frequently results in incomplete devascularization of the tumor due to the complex angioarchitecture of the feeding arteries. Direct intralesional embolization has been used to gain easier accesses to the tumor vasculature and thus increase the likelihood of complete embolization. Cyanoacrylate glue has been the most commonly used embolic agent. The authors present a case of CBT that underwent direct intralesional embolization using Onyx (ev3; ethylene vinyl alcohol copolymer). To their knowledge, there have been no previous reports of direct percutaneous embolization of a CBT with this agent.

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Mohamed Samy Elhammady and Roberto C. Heros

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Mohamed Samy A. Elhammady, Mustafa K. Baskaya and Roberto C. Heros

Object

The management of non–life threatening spontaneous intraparenchymal hemorrhage with no obvious medical etiology in patients and the lack of findings on images has not been clearly defined. In general, the current practice is to treat these patients conservatively and repeat studies to rule out a treatable cause 6 weeks to 3 months later; more often than not these repeated studies fail to reveal any findings, and the patient is treated conservatively. For years, the senior author (R.C.H.) has treated these patients with early surgical exploration. This study was undertaken prospectively to ascertain the frequency of positive findings during surgical exploration.

Methods

Between 2000 and 2007, the authors prospectively collected data from 9 cases (4 cerebellar, 4 lobar, and 1 caudate head) of unexplained intraparenchymal hemorrhages. The patient age ranged from 18 to 45 years (mean 31.2 years). All patients were normotensive, had no underlying medical problems explaining such a hemorrhage, and failed to exhibit findings on cerebral angiograms. Magnetic resonance images with contrast showed no abnormal vasculature or enhancement. Eight patients underwent elective surgical exploration in the subacute stage, and urgent decompression of the clot was necessary in 1.

Results

In 7 (77.8%) of the 9 cases, histopathological examination revealed a cause for the hemorrhage (3 “cryptic” arteriovenous malformations, 3 cavernomas, and 1 neoplasm). A good outcome was achieved in all 8 patients who underwent elective surgery.

Conclusions

The authors recommend elective surgical exploration of intracerebral hematomas of unknown etiology provided that the hematoma is surgically accessible and the patient is relatively young and healthy. Early exploration and resection can provide a cure and eliminate the risk of rebleeding when a vascular lesion is found or guide further treatment in cases of tumor.

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Mohamed Samy Elhammady and Roberto C. Heros