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Thomas J. Leipzig and Sean F. Mullan

✓ A carotid-cavernous fistula was occluded by a detachable latex balloon. Because of technical problems, the contrast-filled balloon was left in a precarious position in the ostium of the fistula. Premature deflation of the balloon would have resulted in intra-arterial migration of the device. Approximately 1 week is required for the balloon to become secured in place by fibrous attachment to the vascular wall. For success, if the ligature is adequate, a detachable Debrun balloon should remain inflated for this period of time. The deflation process was monitored radiographically in this patient. The balloon remained inflated for at least 2 weeks. A short summary of the experience with deflation of various contrast-containing balloon devices in the treatment of carotid-cavernous fistulas is given. Metrizamide may be the best contrast agent for use in these devices.

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Thomas J. Leipzig and Sean F. Mullan

✓ Reversible sympathetic blocks diagnostically relieve causalgic pain. At times, repeated blocks may be therapeutic. Causalgic pain of the left hand was successfully treated in a nonsurgical candidate by a continuous infusion of local anesthetic (procaine) into the region of the stellate ganglion. This technique was performed without significant complication and gave relief from the causalgia for extended periods of time. It may provide an effective alternative to surgical sympathectomy in high-risk patients.

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Thomas J. Leipzig and John F. Mullan

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John A. Scott, Terry G. Horner and Thomas J. Leipzig

✓ A large ophthalmic artery aneurysm was ligated using a modification of the retrograde suction technique described by Batjer and Samson. Temporary proximal occlusion of the internal carotid artery was accomplished with a double-lumen balloon catheter, and distal occlusion was performed with a temporary clip. The aneurysm was collapsed by gentle aspiration through the distal lumen of the balloon catheter. This greatly facilitated dissection and clip ligation of the aneurysm.

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Thomas J. Leipzig, Kathleen Redelman and Terry G. Horner

✓ Previous studies on the initial nonoperative management of aneurysmal subarachnoid hemorrhage (SAH) demonstrated that antifibrinolytic therapy reduced the risk of rebleeding by approximately 50%; however, prolonged antifibrinolytic treatment was associated with an increase in the incidence of hydrocephalus and delayed ischemic deficit. When early surgical intervention became routine for ruptured aneurysms, the use of antifibrinolytic therapy diminished. However, early surgery is generally performed in the first several days after SAH and the risk of rebleeding remains until the aneurysm is obliterated. Based on a review of the literature, the authors formed two hypotheses: 1) the high-dose intravenous administration of epsilon-aminocaproic acid (EACA), an antifibrinolytic agent, might reduce the risk of recurrent hemorrhage in the interval between SAH and early surgical intervention, and 2) a short course of EACA might not produce the increase in complications previously associated with its prolonged administration.

The use of preoperative high-dose EACA therapy was evaluated in 307 patients to determine its safety and efficacy in reducing the incidence of rebleeding before early aneurysm surgery. All patients were admitted within 3 days of their SAH and were classified as Hunt and Hess Grades I to III. Only four patients (1.3%) suffered a recurrent hemorrhage. This compares favorably to the rebleeding rate of 5.7% reported for the early surgery group in the International Cooperative Study on the Timing of Aneurysm Surgery.

The incidence of hydrocephalus or symptomatic vasospasm was not unduly elevated in patients receiving preoperative EACA. Thirty-five patients (11.4%) needed temporary cerebrospinal fluid drainage during their hospitalization and, overall, 8.8% required a ventriculoperitoneal shunt. The mean age of the patients who required a shunt was nearly 10 years older than the general study population. Seventy-one patients (23%) developed symptomatic vasospasm and 8.1% suffered a stroke.

This study indicates that a brief course of high-dose EACA is safe and may be beneficial in diminishing the risk of rebleeding in good-grade patients prior to early surgical intervention. Further investigation is planned based on these promising results.

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Giuseppe Lanzino

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Michael P. McIlhany, Lydia M. Johns, Thomas Leipzig, Nicholas J. Patronas, Frederick D. Brown and Sean F. Mullan

✓ Partially purified protein from washed and artificially hemolyzed erythrocytes, known to cause significant contractions of isolated canine cerebral vessels in vitro, was injected into the cisterna magna of intact anesthetized dogs. Cerebral blood flow, measured by the xenon-133 washout technique, decreased from a control value of 49.5 ± 1.17 ml/100 gm/min to an experimental value of 34.1 ± 1.65 ml/100 gm/min at 2 hours. Cerebral vascular resistance rose from a control value of 2.05 ± 0.17 PRU (peripheral resistance units) to an experimental value of 2.91 ± 0.25 PRU at 2 hours. Mean arterial blood pressure, heart rate, intracranial pressure, and cerebral perfusion pressure remained stable. Cardiac output also fell significantly (in 2-hour control animals it was 2.89 ± 0.37 liter/min, and in 2-hour experimental animals 1.43 ± 0.13 liter/min) and peripheral vascular resistance rose. These changes were evident by 10 minutes after the cisternal injection of the hemolysate protein, and remained for the duration of the 2-hour monitoring period. Serial vertebrobasilar angiograms demonstrated marked narrowing of the intracranial basilar artery when compared to control values. The narrowing persisted for several days in most animals, and tended to increase with time. Relaxation occurred by the 10th through the 14th day. The authors conclude that this experimental preparation may be a useful model for both in vitro and in vivo investigation of chronic cerebral vasospasm.

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Daniel H. Fulkerson, Jason M. Voorhies, Troy D. Payner, Thomas J. Leipzig, Terry G. Horner, Kathleen Redelman and Aaron A. Cohen-Gadol

Object

Pediatric intracranial aneurysms are rare lesions that differ from their adult counterparts. Aneurysms involving the middle cerebral artery (MCA) are particularly challenging to treat in children, as they are often fusiform and cannot undergo direct clipping alone. The authors recently treated a patient with a heavily calcified, dysplastic, left-sided MCA aneurysm. The present study was performed to evaluate the authors' previous operative and follow-up experience with these difficult lesions.

Methods

The authors performed a review of a prospectively maintained database of all aneurysms treated at Methodist Hospital in Indianapolis, Indiana, from January 1990 through November 2010. Relevant operative notes, clinical charts, and radiological reports were reviewed for all patients 18 years of age or younger.

Results

A total of 2949 patients with aneurysms were treated over the study period, including 28 children (0.95%). Seven children harbored MCA aneurysms. Five of these 7 aneurysms (71.4%) were fusiform. Two patients were treated with direct clipping, 2 underwent parent vessel occlusion without bypass, and 3 underwent aneurysm trapping with extracranial-intracranial vessel bypass. Long-term follow-up data were available in 6 cases. All 6 patients had a 1-year follow-up Glasgow Outcome Scale score of 5. Long-term radiological follow-up was available in 4 patients. One patient required a reoperation for a recurrent aneurysm 4 years after the initial surgery.

Conclusions

Middle cerebral artery aneurysms in children are often fusiform, giant, and incorporate the origins of proximal artery branches. Direct clipping may not be possible; trapping of the lesion may be required. Children seem to tolerate surgical trapping with or without bypass extremely well. Aggressive therapy of these rare lesions in children is warranted, as even patients presenting with a poor clinical grade may have excellent outcomes. Long-term surveillance imaging is necessary because of the risk of aneurysm recurrence.

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Nicolas W. Villelli, David M. Lewis, Thomas J. Leipzig, Andrew J. DeNardo, Troy D. Payner and Charles G. Kulwin

OBJECTIVE

Intraoperative angiography can be a valuable tool in the surgical management of vascular disorders in the CNS. This is typically accomplished via femoral artery puncture; however, this can be technically difficult in patients in the prone position. The authors describe the feasibility of intraoperative angiography via the popliteal artery in the prone patient.

METHODS

Three patients underwent intraoperative spinal angiography in the prone position via vascular access through the popliteal artery. Standard angiography techniques were used, along with ultrasound and a micropuncture needle for initial vascular access. Two patients underwent intraoperative angiography to confirm the obliteration of dural arteriovenous fistulas. The third patient required unexpected intraoperative angiography when a tumor was concerning for a vascular malformation in the cervical spine.

RESULTS

All 3 patients tolerated the procedure without complication. The popliteal artery was easily accessed without any adaptation to typical patient positioning for these prone-position cases. This proved particularly beneficial when angiography was not part of the preoperative plan.

CONCLUSIONS

Intraoperative angiography via the popliteal artery is feasible and well tolerated. It presents significant benefit when obtaining imaging studies in patients in a prone position, with the added benefit of easy access, familiar anatomy, and low concern for catheter thrombosis or kinking.