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Osman Ocal, Mustafa Yilmaz, Bora Peynircioglu, Burcak Bilginer, Ahmet Peker and Anil Arat

Aneurysms of the extracranial internal carotid artery (ICA) in pediatric patients are rare and mostly treated surgically. The authors present the case of a child with a giant extracranial ICA aneurysm presenting with gradual airway compression. A plan was made to explore the aneurysm surgically and straighten the associated carotid artery kinks during the operation to enable further endovascular treatment if primary reconstruction of the carotid artery proved not to be possible. Finally, the aneurysm was successfully treated with staged hybrid intervention, which consisted of surgical correction of parent artery kinks followed by endovascular implantation of stent grafts. The child tolerated the procedure well without adverse events. A craniocervical CT angiogram at 5 months showed patency of the stent construct and relief of airway compression. However, a follow-up CT angiogram at 14 months showed total occlusion of the ipsilateral carotid artery without clinical sequelae and complete cessation of airway compression. The management of this was unique since the patient is the first reported case of clopidogrel hyporesponsiveness in a child undergoing neurovascular intervention with prasugrel monotherapy. Point-of-care testing–based adjustment of prasugrel necessitated education of the patient’s family regarding the loss of effect of the prasugrel tablets upon crushing and contact with air.

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M. Necmettin Pamir, Koray Özduman, Alp Dinçer, Erdem Yildiz, Selçuk Peker and M. Memet Özek

Object

The authors describe the first shared-resource, 3-T intraoperative MR (ioMR) imaging system and analyze its impact on low-grade glioma (LGG) resection with an emphasis on the use of intraoperative proton MR spectroscopy.

Methods

The Acibadem University ioMR imaging facility houses a 3-T Siemens Trio system and consists of interconnected but independent MR imaging and surgical suites. Neurosurgery is performed using regular ferromagnetic equipment, and a patient can be transferred to the ioMR imaging system within 1.5 minutes by using a floating table. The ioMR imaging protocol takes < 10 minutes including the transfer, and the authors obtain very high–resolution T2-weighted MR images without the use of intravenous contrast. Functional sequences are performed when needed. A new 5-pin headrest–head coil combination and floating transfer table were specifically designed for this system.

Results

Since the facility became operational in June 2004, 56 LGG resections have been performed using ioMR imaging, and > 19,000 outpatient MR imaging procedures have been conducted. First-look MR imaging studies led to further resection attempts in 37.5% of cases as well as a 32.3% increase in the number of gross-total resections. Intraoperative ultrasonography detected 16% of the tumor remnants. Intraoperative proton MR spectroscopy and diffusion weighted MR imaging were used to differentiate residual tumor tissue from peritumoral parenchymal changes. Functional and diffusion tensor MR imaging sequences were used both pre- and postoperatively but not intraoperatively. No infections or other procedure-related complications were encountered.

Conclusions

This novel, shared-resource, ultrahigh-field, 3-T ioMR imaging system is a cost-effective means of affording a highly capable ioMR imaging system and increases the efficiency of LGG resections.