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Ocular needlefish injury with cavernous sinus thrombosis and carotid-cavernous fistula: illustrative case

Anahita Malvea, Armaan K. Malhotra, Ann Schmitz, Whitney Parker, Leeor Yefet, Prakash Muthusami, James T. Rutka, and Peter Dirks

BACKGROUND

The Belonidae family of fish has been implicated in various penetrating injuries; to date, however, there have been limited reports of brain injury due to this species.

OBSERVATIONS

The authors present the case of a young patient who suffered an ocular penetrating injury from a needlefish with a resultant cavernous sinus thrombosis and concomitant carotid-cavernous fistula. This case highlights the interdisciplinary management of this rare condition through a strategy of anticoagulation titration to the endpoint of fistula closure.

LESSONS

Through this report the importance of a high index of suspicion for neurovascular injury and fistula formation in penetrating ocular injuries is highlighted as well as the importance of interdisciplinary management of patients with such injuries and their sequelae.

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Endoscopic endonasal approach to cholesterol granulomas of the petrous apex: a series of 17 patients

Clinical article

Alessandro Paluzzi, Paul Gardner, Juan C. Fernandez-Miranda, Carlos D. Pinheiro-Neto, Tiago Fernando Scopel, Maria Koutourousiou, and Carl H. Snyderman

Object

The aim of this study was to report the results in a consecutive series of patients who had undergone an endoscopic endonasal approach (EEA) for drainage of a petrous apex cholesterol granuloma (CG).

Methods

Seventeen cases with a confirmed diagnosis of petrous apex CG were identified from a database of more than 1600 patients who had undergone an EEA to skull base lesions at the authors' institution in the period from 1998 to 2011. Clinical outcomes were reviewed and compared with those in previous studies of open approaches.

Results

Nine patients underwent a transclival approach and 8 patients underwent a combined transclival and infrapetrous approach. A Silastic stent was used in 11 patients (65%), a miniflap in 4 (24%), and a simple marsupialization of the cyst in 3 (18%). All symptomatic patients had partial or complete improvement of their symptoms postoperatively and at the follow-up (mean follow-up 20 months, range 3–67 months). Complications developed in 3 patients (18%) including epistaxis, chronic serous otitis media, eye dryness, and a transient sixth cranial nerve palsy. Two patients (12%) had a symptomatic recurrence of the cyst requiring repeat endoscopic endonasal drainage. There were no instances of internal carotid artery injuries, CSF leaks, or new hearing loss. The mean postoperative hospital stay was 2 days (range 0.7–4.6 days). These results were comparable with those in previous studies of open approaches to petrous apex CGs.

There was a strong correlation between the size of the cyst and the type of approach chosen (Rpb [point biserial correlation coefficient] = +0.67, p = 0.003359) and a very strong correlation between the degree of medial extension (defined by the V-angle) and the choice of approach (Rpb = +0.81, p < 0.0001). Based on these observations, the authors developed an algorithm for guiding the choice of the most appropriate route of drainage.

Conclusions

The EEA is a safe and effective alternative to traditional open approaches to petrous apex CGs.

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Recanalization with subsequent near-total occlusion of an internal carotid artery aneurysm after immediate thrombotic occlusion using a flow-diverting stent

Case report

George Kwok Chu Wong, Simon Chun Ho Yu, Deyond Yung Woon Siu, and Wai Sang Poon

A flow-diverting stent is placed in the parent artery to reduce blood flow in the aneurysm sac to facilitate progressive thrombosis and neointimal remodeling while maintaining outflow in the side branches and perforators. All international multicenter registries have reported on the progressive occlusion of aneurysms with time and have implied that an occluded aneurysm would not recanalize given the protective effect of the altered hemodynamics. Recanalization of an occluded aneurysm after placement of a flow-diverting stent has not been reported in the literature. The authors here describe a case of aneurysm recanalization after immediate thrombotic occlusion of the aneurysm with a flow-diverting stent. A 46-year-old male chronic smoker with chronic hypertension and hypercholesterolemia had a recurrent internal carotid artery aneurysm 1 year after embolization. Immediate thrombotic occlusion of the aneurysm and cessation of blood flow to the posterior communicating artery (PCoA) occurred immediately after activating a flow-diverting stent, with corresponding ischemic complications. However, 3 months after insertion of the stent, follow-up MR angiography showed recanalization of the aneurysm as well as of the PCoA. Additional angiography studies at 6 months showed near-total occlusion of the aneurysm with the restoration of blood flow to the PCoA.

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Patency of the ophthalmic artery after flow diversion treatment of paraclinoid aneurysms

Clinical article

Ross C. Puffer, David F. Kallmes, Harry J. Cloft, and Giuseppe Lanzino

Object

In this study the authors determined the patency rate of the ophthalmic artery (OphA) after placement of 1 or more flow diversion devices across the arterial inlet for treatment of proximal internal carotid artery (ICA) aneurysms, and correlated possible risk factors for OphA occlusion.

Methods

Nineteen consecutive patients were identified (mean age 53.9 years, range 23–74 years, all female) who were treated for 20 ICA aneurysms. In all patients a Pipeline Embolization Device (PED) was placed across the ostium of the OphA while treating the target aneurysm. Flow through the OphA after PED placement was determined by immediate angiography as well as follow-up angiograms (mean 8.7 months), compared with the baseline study. Potential risk factors for OphA occlusion, including age, immediate angiographic flow through the ophthalmic branch, status of flow within the aneurysm after placement of PEDs, whether the ophthalmic branch originated from the aneurysm dome, and number of PEDs placed across the ophthalmic branch inlet were correlated with patency rate.

Results

Patients were treated with 1–3 PEDs (3 aneurysms treated with placement of 1 PED, 12 with 2 PEDs, and 5 with 3 PEDs). In 17 (85%) of 20 treated aneurysms, no changes in the OphA flow were noted immediately after placement of the device. Two (10%) of 20 patients had delayed antegrade filling immediately following PED placement and 1 patient (5%) had retrograde flow from collaterals to the OphA immediately after placement of the device. One patient (5%) experienced delayed asymptomatic ICA occlusion; this patient was excluded from analysis at follow-up. At follow-up the OphA remained patent with normal antegrade flow in 13 (68%) of 19 patients, patent but with slow antegrade flow in 2 patients (11%), and was occluded in 4 patients (21%). No visual changes or clinical symptoms developed in patients with OphA flow compromise. The mean number of PEDs in the patients with occluded OphAs or change in flow at angiographic follow-up was 2.4 (SEM 0.2) compared with 1.9 (SEM 0.18) in the patients with no change in OphA flow (p = 0.09). There was no significant difference between the patients with occluded OphAs compared with nonoccluded branches based on patient age, immediate angiographic flow through the ophthalmic branch, status of flow through the aneurysm after placement of PEDs, whether the ophthalmic branch originated from the aneurysm dome, or number of PEDs placed across the ophthalmic branch inlet.

Conclusions

Approximately one-quarter of OphAs will undergo proximal thrombosis when covered with flow diversion devices. Even though these events were well-tolerated clinically, our findings suggest that coverage of branch arteries that have adequate collateral circulation may lead to spontaneous occlusion of those branches.

Free access

Surgical results of the Carotid Occlusion Surgery Study

Clinical article

Robert L. Grubb Jr., William J. Powers, William R. Clarke, Tom O. Videen, Harold P. Adams Jr., Colin P. Derdeyn, and for the Carotid Occlusion Surgery Study Investigators

Object

The Carotid Occlusion Surgery Study (COSS) was conducted to determine if superficial temporal artery–middle cerebral artery (STA-MCA) bypass, when added to the best medical therapy, would reduce subsequent ipsilateral stroke in patients with complete internal carotid artery (ICA) occlusion and an elevated oxygen extraction fraction (OEF) in the cerebral hemisphere distal to the occlusion. A recent publication documented the methodology of the COSS in detail and briefly outlined the major findings of the trial. The surgical results of the COSS are described in detail in this report.

Methods

The COSS was a prospective, parallel-group, 1:1 randomized, open-label, blinded-adjudication treatment trial. Participants, who had angiographically demonstrated complete occlusion of the ICA causing either a transient ischemic attack or ischemic stroke within 120 days and hemodynamic cerebral ischemia indicated by an increased OEF measured by PET, were randomized to either surgical or medical treatment. One hundred ninety-five patients were randomized: 97 to the surgical group and 98 to the medical group. The surgical patients underwent an STA-MCA cortical branch anastomosis.

Results

In the intention-to-treat analysis, the 2-year rates for the primary end point were 21% for the surgical group and 22.7% for the medical group (p = 0.78, log-rank test). Fourteen (15%) of the 93 patients who had undergone an arterial bypass had a primary end point ipsilateral hemispheric stroke in the 30-day postoperative period, 12 within 2 days after surgery. The STA-MCA arterial bypass patency rate was 98% at the 30-day postoperative visit and 96% at the last follow-up examination. The STA-MCA arterial bypass markedly improved, although it did not normalize, the level of elevated OEF in the symptomatic cerebral hemisphere. Five surgically treated and 1 nonsurgically treated patients in the surgical group had a primary end point ipsilateral hemispheric stroke after the 30-day postoperative period. No baseline characteristics or intraoperative variables revealed those who would experience a procedure-related stroke.

Conclusions

Despite excellent bypass graft patency and improved cerebral hemodynamics, STA-MCA anastomosis did not provide an overall benefit regarding ipsilateral 2-year stroke recurrence, mainly because of a much better than expected stroke recurrence rate (22.7%) in the medical group, but also because of a significant postoperative stroke rate (15%). Clinical trial registration no.: NCT00029146.

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Endoscope or Microscope?

William T. Couldwell

, anterior, and lateral to the dorsum sella were quantified (see our Fig. 1 upper ). The mean distances were then used to calculate the volume of exposure achieved with each approach. F ig . 1. Upper: Diagram summarizing each of the approaches used: transethmoidal (A), transnasal–transsphenoidal (B), and sublabial–transsphenoidal (C). Note the differences in trajectory to the sella and suprasellar region. Inset a: Coronal view of the sella illustrating the zero point along the dorsum sella from which the right and left distances were measured. ICA = internal

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Surgical treatment of giant intracranial aneurysms

Takehide Onuma and Jiro Suzuki

) total 26 6 21 11 11 12 3 2 4 1 1 1 5 4 * SAH = subarachnoid hemorrhage; ICA = internal carotid artery; ACoA = anterior communicating artery; MCA = middle cerebral artery; ACA = anterior cerebral artery. Treatment Surgical treatment was undertaken in 28 cases (87.5%), 24 (75%) by direct operation and four (12.5%) by common carotid ligation. Conservative therapy was instituted in four cases. Direct surgery was applied whenever possible on all aneurysms except those on the infraclinoid portion of the internal

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Aneurysm of a persistent primitive olfactory artery

Case report

Takehisa Tsuji, Masamitsu Abe, and Kazuo Tabuchi

anomalous anterior cerebral artery (ACA) in this case. AChA = anterior choroidal artery; ACoA = anterior communicating artery; A-1 = ACA precommunicating segment; A-2 = ACA postcommunicating segment; CmA = callosomarginal arteries; ICA = internal carotid artery; MCA = middle cerebral artery; PCoA = posterior communicating artery; PericalA = pericallosal arteries. According to Padget, 6 the development of the ACA in the human embryo begins as the formation of a secondary branch of the primitive olfactory artery at 5 weeks gestation, and at 6 weeks, the ACA

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Familial intracranial aneurysms

Case report

John L. Fox

angiogram 11 1978 38, M − 0 ACoA clipped, excellent recovery 12 1978 49, M − ? status unknown 13 1981 57, F + 3 ACoA, rt ICA present case, died * SAH = subarachnoid hemorrhage; MCA = middle cerebral artery; ACoA = anterior communicating artery; ICA = internal carotid artery; — = no aneurysm. † Neurological grade on admission according to Hunt and Hess. 2 References 1. Fox JL , Ko JP : Familial intracranial aneurysms. Six cases among 13 siblings. J Neurosurg

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Management of ischemic complications after subarachnoid hemorrhage

Thoralf M. Sundt Jr.

of vasospasm. TABLE 1 Distribution of all surgical patients and of patients with ischemic symptoms by grade and location of symptomatic aneurysm * Preop. Grade Aneurysm Location ICA ACA MCA BAS PICA 1 2/39 3/11 3/8 0/6 0/3 2 6/17 1/10 2/5 0/3 0/2 3 4/12 8/13 2/10 0/4 0/0 4 1/4 1/6 0/4 2/2 0/0 total 13/72 13/40 7/27 2/15 0/5 * Shown as number of patients treated/all patients. ICA = internal carotid artery; ACA