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nlm-article

Cover Neurosurgical Focus: Video

Extended middle fossa approach for resection of a petroclival meningioma and vestibular schwannoma

Robert C. Rennert, Karol P. Budohoski, Richard K. Gurgel, and William T. Couldwell

A 69-year-old woman with refractory left facial pain and subtle left hearing decline had a 13.0 × 8.1–mm left petrous apex/Meckel’s cave meningioma and an 8.8 × 5.6–mm left intracanalicular vestibular schwannoma. She was otherwise neurologically intact. The anterior petrous and middle fossa approaches provide ideal access to these lesions individually, so an extended middle fossa approach was used to resect both in the same setting. She was neurologically stable postoperatively, except for a transient abducens palsy. Hearing was preserved on audiogram, and 4-month MRI displayed no tumors. The extended middle fossa approach provides excellent exposure of the petrous apex and internal auditory canal.

The video can be found here: https://stream.cadmore.media/r10.3171/2022.1.FOCVID21258

Open access

nlm-article

Cover Neurosurgical Focus: Video

Treatment of a ruptured blister aneurysm of the left internal carotid artery with telescoping Pipeline Flex embolization devices with Shield Technology

Karol P. Budohoski, Robert C. Rennert, Vance Mortimer, William T. Couldwell, and Ramesh Grandhi

Ruptured blister aneurysms have significant rates of morbidity and mortality, but evidence of positive results with use of flow-diverting stents such as the Pipeline embolization device (PED) is growing. The authors describe the staged endovascular treatment of a ruptured left internal carotid artery blister aneurysm in a patient with a Hunt and Hess grade IV subarachnoid hemorrhage. PED placement was done via the common femoral artery using a triaxial delivery system. The telescoping stent technique performed over 48–72 hours achieved sufficient coverage of the aneurysm neck while limiting treatment time during the acute presentation and allowing interim dual antiplatelet treatment. A staged approach allows the targeting of a second PED placement in patients whose aneurysm continues to fill on the first follow-up angiogram. The authors have not experienced increased thromboembolic complications with this approach. Complete occlusion was achieved by postbleed day 8.

The video can be found here: https://stream.cadmore.media/r10.3171/2022.7.FOCVID2264

Free access

nlm-article

Cover Journal of Neurosurgery: Pediatrics

Initial experience with Pipeline embolization of intracranial pseudoaneurysms in pediatric patients

Karol P. Budohoski, Raj Thakrar, Zoya Voronovich, Robert C. Rennert, Craig Kilburg, Ramesh Grandhi, William T. Couldwell, Douglas L. Brockmeyer, and Philipp Taussky

OBJECTIVE

Flow-diverting devices have been used successfully for the treatment of complex intracranial vascular injuries in adults, but the role of these devices in treating iatrogenic and traumatic intracranial vascular injuries in children remains unclear. The authors present their experience using the Pipeline embolization device (PED) for treating intracranial pseudoaneurysms in children.

METHODS

This single-center retrospective cohort study included pediatric patients with traumatic and iatrogenic injuries to the intracranial vasculature that were treated with the PED between 2015 and 2021. Demographic data, indications for treatment, the number and sizes of PEDs used, follow-up imaging, and clinical outcomes were analyzed.

RESULTS

Six patients with a median age of 12 years (range 7–16 years) underwent PED placement to treat intracranial pseudoaneurysms. There were 3 patients with hemorrhagic presentation, 2 with ischemia, and 1 in whom a growing pseudoaneurysm was found on angiography. Injured vessels included the anterior cerebral artery (n = 2), the supraclinoid internal carotid artery (ICA, n = 2), the cavernous ICA (n = 1), and the distal cervical ICA (n = 1). All 6 pseudoaneurysms were successfully treated with PED deployment. One patient required re-treatment with a second PED within a week because of concern for a growing pseudoaneurysm. One patient experienced parent vessel occlusion without neurological sequelae.

CONCLUSIONS

Use of the PED is feasible for the management of iatrogenic and traumatic pseudoaneurysms of the intracranial vasculature in children, even in the setting of hemorrhagic presentation.

Free access

nlm-article

Cover Journal of Neurosurgery

Factors associated with hearing outcomes after a middle fossa approach in 131 consecutive patients with vestibular schwannomas

Karol P. Budohoski, Robert C. Rennert, Steven A. Gordon, Amol Raheja, Cameron Brandon, J. Curran Henson, Mohammed A. Azab, Neil S. Patel, Michael Karsy, Richard K. Gurgel, Clough Shelton, and William T. Couldwell

OBJECTIVE

The middle fossa approach is an effective option for the treatment of small (Koos grade I and II) vestibular schwannomas (VSs) when the goal is hearing preservation. The authors evaluated the rates of hearing preservation and examined the factors associated with improved hearing outcomes after the middle fossa approach for VSs.

METHODS

In this retrospective, single-center cohort study evaluating the clinical outcomes after resection of small VSs using the middle fossa approach, consecutive adult patients (> 18 years) who underwent surgery between January 2000 and December 2021 were included. Clinical and imaging characteristics were analyzed, including baseline hearing status, duration of surgery, anesthetic parameters, and imaging characteristics of the surgically treated tumors.

RESULTS

Among the 131 included patients, 102 had valid and discoverable pre- and postoperative audiology assessments. The mean follow-up was 26 months (range 1–180 months). There were 85 patients with serviceable hearing preoperatively, defined as American Academy of Otolaryngology–Head and Neck Surgery (AAO-HNS) class A or B, of whom 78% retained class A or B hearing at the last follow-up. Binary logistic regression demonstrated that preoperative hearing AAO-HNS class (OR 0.19, 95% CI 0.05–0.77; p = 0.02), overlap between fundus and cochlea (OR 0.32, 95% CI 0.11–0.96; p = 0.04), and duration of anesthesia (OR 0.98, 95% CI 0.97–0.99; p = 0.03) were independent predictors of hearing outcomes. Additionally, 75% of patients with high diffusion-weighted imaging signal in the tumor (p = 0.009) and 67% of patients with the tumor originating at the modiolus of the cochlea (p = 0.004) had poor hearing outcomes.

CONCLUSIONS

The hearing preservation rates after microsurgical resection of small VSs using the middle fossa approach are high, with 78% of patients maintaining AAO-HNS class A or B hearing. Poor hearing status at baseline, longer duration of anesthesia, and large overlap between the fundus of the internal auditory canal and the cochlea were independently associated with unfavorable hearing outcomes. Imaging characteristics can be used to stratify patients’ risk of hearing loss.

Free access

nlm-article

Cover Neurosurgical Focus

Safety and efficacy of the Pipeline Flex embolization device with Shield Technology for the acute treatment of ruptured internal carotid artery pseudoaneurysms: a multi-institution case series

Michael T. Bounajem, Evan Joyce, Jonathan P. Scoville, Joshua Seinfeld, Jessa Hoffman, Jonathan A. Grossberg, Vanesha Waiters, Andrew C. White, John Nerva, Jan-Karl Burkhardt, Daniel A. Tonetti, Kareem El Naamani, M. Reid Gooch, Pascal Jabbour, Stavropoula Tjoumakaris, Santiago Ortega Gutierrez, Michael R. Levitt, Michael Lang, William J. Ares, Sohum Desai, Justin R. Mascitelli, Craig J. Kilburg, Karol P. Budohoski, William T. Couldwell, Bradley A. Gross, and Ramesh Grandhi

OBJECTIVE

Ruptured blister, dissecting, and iatrogenic pseudoaneurysms are rare pathologies that pose significant challenges from a treatment standpoint. Endovascular treatment via flow diversion represents an increasingly popular option; however, drawbacks include the requirement for dual antiplatelet therapy and the potential for thromboembolic complications, particularly acute complications in the ruptured setting. The Pipeline Flex embolization device with Shield Technology (PED-Shield) offers reduced material thrombogenicity, which may aid in the treatment of ruptured internal carotid artery pseudoaneurysms.

METHODS

The authors conducted a multi-institution, retrospective case series to determine the safety and efficacy of PED-Shield for the treatment of ruptured blister, dissecting, and iatrogenic pseudoaneurysms of the internal carotid artery. Clinical, radiographic, treatment, and outcomes data were collected.

RESULTS

Thirty-three patients were included in the final analysis. Seventeen underwent placement of a single device, and 16 underwent placement of two devices. No thromboembolic complications occurred. Four patients were maintained on aspirin alone, and all others were treated with long-term dual antiplatelet therapy. Among patients with 3-month follow-up, 93.8% had a modified Rankin Scale score of 0–2. Complete occlusion at follow-up was observed in 82.6% of patients.

CONCLUSIONS

PED-Shield represents a new option for the treatment of ruptured blister, dissecting, and iatrogenic pseudoaneurysms of the internal carotid artery. The reduced material thrombogenicity appeared to improve the safety of the PED-Shield device, as this series demonstrated no thromboembolic complications even among patients treated with only single antiplatelet therapy. The efficacy of PED-Shield reported in this series, particularly with placement of two devices, demonstrates its potential as a first-line treatment option for these pathologies.