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Sean D. Lavine

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Ricardo J. Komotar, J Mocco, Sean D. Lavine and Robert A. Solomon

✓Hunterian ligation is a well-known treatment for complex aneurysms not amenable to direct microsurgical clip application. After proximal parent vessel occlusion, cerebral angiography is typically used to confirm aneurysm thrombosis. The authors report on a vertebral artery (VA) aneurysm that had progressively expanded and caused brainstem compression after hunterian ligation, despite nondiagnostic findings on both conventional and computed tomography (CT) angiography at multiple time points.

This 64-year-old woman underwent hunterian ligation of a 1.8-cm VA aneurysm at the origin of the right posterior inferior cerebellar artery. An immediately postoperative conventional angiogram and follow-up CT angiograms obtained 5 and 6 years postligation confirmed complete obliteration of the lesion. Nine years after the initial surgery, however, the patient experienced neurological deterioration. Although CTs showed substantial aneurysm enlargement together with pontine compression, angiograms once again demonstrated complete right VA occlusion with no retrograde filling of the aneurysm. On reexploration, the aneurysm was effectively debulked, clipped, and obliterated. Arterial bleeding was found in the lesion neck, as was evidence of microrecanalization.

Hunterian ligation for complex aneurysms carries the risk of microrecanalization and lesion expansion despite non-diagnostic angiography. Although this ligation procedure remains a viable treatment option in carefully selected patients, an extended follow-up evaluation period may be required even when imaging suggests aneurysm obliteration.

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Sean D. Lavine, Lena S. Masri, Michael L. Levy and Steven L. Giannotta

The risk of focal infarction secondary to the induced reversible arrest of local arterial flow during microsurgical dissection of middle cerebral artery (MCA) aneurysms was evaluated further to define the optimal approach to temporary arterial occlusion. To compare the effectiveness of brain-protection anesthetics, a group of patients treated with the intravenous agents, propofol, etomidate, and pentobarbital, administered individually or in combination, was compared to a group treated with the inhalational agent isoflurane.

Forty-nine consecutive MCA aneurysm surgeries involving the temporary clipping of the parent vessel were retrospectively reviewed. Thirty-eight patients received intravenous brain-protection (IVBP) anesthesia. Groups of patients with and without infarctions, and receiving and not receiving IVBP, were compared based on the duration and nature of temporary arterial occlusion. Postoperative radiographic evidence of new infarction was used as the threshold for failure of occlusion tolerance. The overall infarction rate was 22.4% (11 of 49 patients), including 15.8% (six of 38 patients) in the IVBP group versus 45.5% (five of 11 patients) in the isoflurane (ISO) group. In the ISO group, the mean duration of temporary occlusion was 3.9 ± 2.2 minutes for patients without infarction versus 12.2 ± 4.3 minutes for patients with focal infarction (p < 0.01). In contrast, the mean duration was 13.6 ± 10.6 minutes for patients without infarction and 18.5 ± 9.9 minutes for patients with infarction in the IVBP group. All patients in the ISO group who underwent occlusion lasting 10 minutes or longer suffered an infarction versus five of 23 patients in the IVBP group. Patients with multiple aneurysms were found to be at increased risk of developing focal infarction, whereas those treated with intermittent temporary clip application were at a decreased risk.

It is concluded that patients in whom focal iatrogenic ischemia is induced during MCA aneurysm clip ligation have a significant advantage compared with those receiving ISO when they are given pentobarbital as the primary neuroprotective agent or when they receive propofol or etomidate titrated to achieve electroencephalographic burst suppression, particularly if more than 10 minutes of occlusion time is required. It is also concluded that 10 minutes is a general guideline for safe, temporary occlusion of the MCA. The use of intermittent temporary arterial occlusion and patients with multiple aneurysms need further evaluation before specific recommendations can be made.

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Sean D. Lavine, Lena S. Masri, Michael L. Levy and Steven L. Giannotta

✓ The risk of focal infarction secondary to the induced reversible arrest of local arterial flow during microsurgical dissection of middle cerebral artery (MCA) aneurysms was evaluated further to define the optimal approach to temporary arterial occlusion. To compare the effectiveness of potential brain-protection anesthetics, a group of patients treated with the intravenous agents propofol, etomidate, and pentobarbital, administered individually or in combination, was compared to a group treated with the inhalational agent isoflurane.

Forty-nine consecutive MCA aneurysm surgeries involving the temporary clipping of the parent vessel were retrospectively reviewed. Thirty-eight patients received intravenous brain-protection (IVBP) anesthesia. Groups of patients with and without infarctions, and receiving and not receiving IVBP anesthesia, were compared based on the duration and nature of temporary arterial occlusion. Postoperative radiographic evidence of new infarction was used as the threshold for failure of occlusion tolerance. The overall infarction rate was 22.4% (11 of 49 patients), including 15.8% (six of 38 patients) in the IVBP group versus 45.5% (five of 11 patients) in the group that did not receive brain protection (NBP). In the NBP group, the mean duration of temporary occlusion was 3.9 ± 2.2 minutes for patients without infarction versus 12.2 ± 4.3 minutes for patients with focal infarction (p < 0.01). In contrast, the mean duration was 13.6 ± 10.6 minutes for patients without infarction and 18.5 ± 9.9 minutes for patients with infarction in the IVBP group. All patients (four of four) in the NBP group who underwent occlusion lasting 10 minutes or longer suffered an infarction versus five of 23 patients in the IVBP group (p < 0.0001). Patients with multiple aneurysms were found to be at increased risk of developing focal infarction, whereas those treated with intermittent temporary clip application were at decreased risk.

It is concluded that patients in whom focal iatrogenic ischemia is induced during MCA aneurysm clip ligation have a significant advantage compared with those receiving isoflurane when they are given pentobarbital as the primary neuroprotective agent or when they receive propofol or etomidate titrated to achieve electroencephalographic burst suppression, particularly if more than 10 minutes of occlusion time is required. It is also concluded that 10 minutes is a general guideline for safe, temporary occlusion of the MCA. The use of intermittent temporary arterial occlusion and its use in patients with multiple aneurysms need further evaluation before specific recommendations can be made.

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Christopher S. Eddleman, H. Hunt Batjer and Sean Lavine

This issue of Neurosurgical Focus comes at an exciting and perhaps transformational time for those neuroscientists and clinicians involved in the study and treatment of complex cerebrovascular disease. Our diagnostic and therapeutic practices have seen dramatic advances. Imaging capabilities, both anatomical and functional, have improved at a dramatic rate and include neuronavigation modalities for intraoperative guidance, the application of new MR imaging sequences to cerebrovascular disease, and fluorescence angiography to aid in intraoperative decision making.

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Kaith K. Almefty, Andrew F. Ducruet, R. Webster Crowley, Ruth Bristol, Sean D. Lavine and Felipe C. Albuquerque

The authors report the presentation and management of a 13-year-old girl with Schimmelpenning syndrome, a rare neurocutaneous syndrome; this patient suffered hemorrhage of a spinal arteriovenous malformation. This is the first case of a spinal arteriovenous malformation reported in association with Schimmelpenning syndrome. Neurosurgeons should be aware of this rare phacomatosis as well as of the various neurological disorders associated with this diagnosis. The threshold for imaging the neuraxis in these patients should be low.

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Christopher P. Kellner, Raqeeb M. Haque, Philip M. Meyers, Sean D. Lavine, E. Sander Connolly Jr. and Robert A. Solomon

Object

Complex aneurysms of the basilar artery (BA) apex can be successfully treated using surgical occlusion of the proximal BA. Since the introduction of the Guglielmi detachable coil in 1991, the focus on treating BA aneurysms has been on using endovascular techniques. Outcomes with endovascular techniques have been less than optimal for large and complex aneurysms. The authors therefore report on their current 22-year experience with surgical BA occlusion for complex BA aneurysms and long-term outcome.

Methods

Fifteen patients underwent surgical BA occlusion at Columbia University Medical Center for complex basilar apex aneurysms between 1987 and 2009. The clinical records of each patient were reviewed for details of presentation, hospital course, operative intervention, and outcome.

Results

Postoperatively, all patient encounters were recorded at discharge, at the 1-month and 1-year follow-up evaluations, and at long-term outcome. Twelve (80%) of 15 patients experienced no new postoperative neurological deficits. Three patients presenting with severe neurological impairment (modified Rankin Scale [mRS] score > 3) made excellent recoveries (mRS Scores 1–2) at long-term follow-up. One patient died, 1 suffered a stroke during the postoperative angiogram which resulted in hemiparesis, and 1 suffered internuclear ophthalmoplegia which resolved by the 1-month follow-up. Long-term follow-up occurred at an average of 3 ± 4.5 years, ranging from 2 months (for a recently treated patient) to 18 years. The average mRS score at long-term follow-up was 1 ± 1.5. No patient experienced postoperative hemorrhage, rebleeding, or delayed neurological deterioration.

Conclusions

Surgical occlusion of the BA is an effective treatment option offering a high rate of angiographic cure in a single procedure for patients with complex BA aneurysms. The ability to surgically perform point occlusion of the BA without impairment of brainstem perforators, while maintaining collateral blood flow to the posterior circulation branch vessels, may provide an advantage compared with endovascular treatments.

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J Mocco, Ricardo J. Komotar, Sean D. Lavine, Philip M. Meyers, E. Sander Connolly and Robert A. Solomon

Since the publication of preliminary results from the International Study of Unruptured Intracranial Aneurysms in 1998 there has been a great deal of debate concerning the natural history of these lesions and their attendant risk of aneurysmal subarachnoid hemorrhage. Therefore, the authors reviewed a selected number of crucial studies concerning this topic to determine the best evidence-based estimate of a rupture rate for these lesions. Based on this analysis, the yearly risk of bleeding for an unruptured intracranial aneurysm is estimated to be approximately 1% for aneurysms 7 to 10 mm in diameter. This risk of rupture increases with aneurysm size and it likewise diminishes as the size of the lesion decreases. This general rule serves as a reasonable interpretation of the results reported in the current body of literature.

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Ricardo J. Komotar, J Mocco, David A. Wilson, E. Sander Connolly Jr., Sean D. Lavine and Philip M. Meyers

A substantial number of strokes are caused by intracranial atherosclerosis, a disease that traditionally has been treated medically. Recent technological advancements, however, have revolutionized the treatment of this condition by enabling the use of endovascular methods. In this paper the authors focus on the internal carotid artery, and review relevant studies concerning angioplasty with stent placement for the management of intracranial atherosclerosis in this vessel. With continued experience and a multidisciplinary approach in the evaluation of these patients, favorable outcomes may be achieved.

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Ricardo J. Komotar, J Mocco, David A. Wilson, E. Sander Connolly Jr., Sean D. Lavine and Philip M. Meyers

Intracranial atherosclerosis is the cause of a significant number of strokes. Despite maximal medical therapy, this disease continues to carry a poor prognosis. The authors reviewed studies in which the outcomes after conservative management in patients with intracranial carotid artery atherosclerosis were reported. Analysis of the literature demonstrates that maximal medical therapy frequently fails with this disease, leaving patients at high risk for cerebral infarction and death. A better understanding of the pathophysiological aspects and natural history of this condition may serve to guide clinical decision making and the choice of therapeutic options in this patient population.