Um cirurgião sob o olhar de Deus

Objetivo A síndrome de Terson (ST), também conhecida como hemorragia vítrea, é relatada em pacientes com hemorragia subaracnóide causada por um aneurisma rompido. Este estudo tem como objetivo avaliar a presença de hemorragia ocular nesses pacientes, buscando identificar aqueles que poderiam se beneficiar do tratamento específico para a recuperação do déficit visual. Métodos Estudo prospectivo de 53 pacientes com hemorragia subaracnóide espontânea (SSAH) por aneurisma rompido. Os pacientes foram avaliados quanto à hemorragia vítrea por fundoscopia indireta com 6 a 12 meses de seguimento. Resultados A idade dos pacientes variou de 17 a 79 anos (média de 45,9 ± 11,7); 39 pacientes eram do sexo feminino (73%) e 14 do sexo masculino (27%). Seis pacientes (11%) apresentaram ST e 83,3% apresentaram perda transitória de consciência durante a ictus. Conclusões Uma avaliação oftalmológica deve ser realizada rotineiramente em pacientes com hemorragia subaracnóide, especialmente naqueles com pior grau neurológico. Além disso, o prognóstico foi ruim em pacientes com ST.

Superficial-Temporal-Artery-To-Middle-Cerebral-Artery Bypass in Cerebrovascular Occlusive Disease and Hemodynamic-Related Ischemia: Illustrative Case and Literature Review

Stroke is the third most common cause of death worldwide. About 10% to 15% of strokes related to the territory of the carotid artery are associated with its complete occlusion. There is an important subgroup of patients with cerebrovascular occlusive diseases who might benefit from an external-carotid-to-internal-carotid bypass. In the present study, we report a case of a 53-year-old male patient with stenosis of the M2 branch of themiddle cerebral artery (MCA), with a history of 20 episodes of transient ischemic accidents (TIA)s, in whom an anastomosis of the M4 branch of the superficial temporal artery-MCA was performed. The patient was discharged in three days, and in the two years of follow-up, they were no more TIAs.We also conducted a review of the literature on cerebrovascular occlusive disease and extracranial-intracranial bypass surgery. New methods to evaluate cerebral hemodynamics made it possible to classify a new subgroup of patients with symptomatic cerebrovascular disease and documented cerebrovascular compromise in whom the drug therapy fails, who can benefit from the extracranial-intracranial bypass. Our case report illustrates the advantages of revascularization in these selected patients.

Jugular Foramen's Paraganglioma in a Patient with Von Hippel-Lindau Disease: Case Report

Glomus jugular tumors, also known as paragangliomas (PGLs), are rare and related to several clinical syndromes described. These are located in the carotid body, the jugular glomus, the tympanic glomus and the vagal glomus. The symptoms are directly related to the site of involvement and infiltration. These lesions have slow growth, are generally benign and hypervascularized, have a peak incidence between the age of 30 to 50 years old; however, when associated with hereditary syndromes, they tend to occur a decade earlier. Several familial hereditary syndromes are associated with PGLs, including Von Hippel- Lindau disease (VHL) in< 10% of the cases. The diagnosis and staging of PGLs are based on imaging and functional exams (bone window computed tomography [CT] with a "ground moth" pattern and magnetic resonance imaging (MRI) with a "salt and pepper" pattern). The cerebral angiography is a prerequisite in patients with extremely vascularized lesions, whose preoperative embolization is necessary. The histopathological finding of cell clusters called "Zellballen" is a characteristic of PGLs. Regarding the jugular foramen, the combination of two or three surgical approaches may be necessary: (1) lateral group, approaches through themastoid; (2) posterior group, through the retrosigmoid access and its variants; and (3) anterior group, centered on the tympanic and petrous bone. In the present paper, we report a case of PGL of the jugular foramen operated on a young female patientwho underwent a surgery with a diagnosis ofVonHippel-Lindau Disease (VHL) at the Neurosurgery Service of the Hospital Heliópolis, São Paulo, state of São Paulo, Brazil in 2018, by the lateral and posterior combined route.

Spontaneous Convexity Subarachnoid Hemorrhage Caused by Internal Carotid Occlusion: Radiological Features

A 79-year-old patient was admitted to the emergency room with transitory monoparesis in the left hand and dysphasia. The brain computed tomography (CT) and magnetic resonance imaging (MRI) showed a spontaneous right convexity subarachnoid hemorrhage (cSAH). Digital subtraction angiography (DSA) confirmed an asymptomatic occlusion of the right internal carotid artery (ICA) . Cases related to stenosis have already been described, but there is no similar report of a case related to occlusion, even though the pathophysiology of both entities is similar. Atraumatic SAH has been associated with intracranial and extracranial artery stenosis.

The Role of Neurophysiological Monitoring during Complex Aneurysm Surgery: Report of Two Cases and Review of the Literature

The surgical treatment of intracranial aneurysms is a routine operation in the neurosurgeon practice. Complex aneurysms are those with morphological irregularities, usually large or giant; thrombosed, partially thrombosed or calcified; with aberrant fundus/neck ratio and near eloquent neurological structures. These cases demand special skills by the surgical team. The present article is a report of two cases of complex aneurysms successfully treated, with a discussion on the role of neurophysiological monitoring. In these two cases of supra- and infratentorial complex giant aneurysms, intraoperative monitoring was extremely relevant. Thus, we believe that treating complex and giant aneurysms carries several pitfalls, and the use of multimodal intraoperative monitoring is mandatory to mitigate risks and deliver the best result to the patient.

Angiographic Findings in Refractory Delayed Cerebral Ischemia

Background Delayed cerebral ischemia (DCI) follows a refractory course in a subgroup of patients with aneurysmal subarachnoid hemorrhage (SAH), leading to diffuse ischemic injury. The role of angiographic vasospasm (AV) is unknown. Our goal is to study the angiographic alterations and the clinical profile of refractory DCI patients. Methods Retrospective study of patients with SAH who presented with DCI treated with medical and endovascular therapy, with a refractory evolution, defined asmultiple ischemic infarction and brain death. Results Out of a cohort of 336 patients, 7 (2%) developed refractory DCI. The median age of the patients was 48 (38­60) years old. Five patients had ruptured anterior communicating artery (ACoA) aneurysms. Four patients were treated with coil embolization, and three with microsurgical clipping. Angiographic vasospasm was classified as severe in 5 cases. Compromise of bilateral circulation was detected in six patients. Distal circulation vasospasm occurred in five cases. Slow circulatory transit times were observed in three patients. Conclusion Angiographic findings such as bilateral circulatory compromise and distal vasospasm were frequent alterations. Further studies are required to establish the association of these findings with the clinical outcomes.

Research progress in ultrasound use for the diagnosis and treatment of cerebrovascular diseases

Cerebrovascular diseases pose a serious threat to human survival and quality of life and represent a major cause of human death and disability. Recently, the incidence of cerebrovascular diseases has increased yearly. Rapid and accurate diagnosis and evaluation of cerebrovascular diseases are of great importance to reduce the incidence, morbidity and mortality of cerebrovascular diseases. With the rapid development of medical ultrasound, the clinical relationship between ultrasound imaging technology and the diagnosis and treatment of cerebrovascular diseases has become increasingly close. Ultrasound techniques such as transcranial acoustic angiography, doppler energy imaging, three-dimensional craniocerebral imaging and ultrasound thrombolysis are novel and valuable techniques in the study of cerebrovascular diseases. In this review, we introduce some of the new ultrasound techniques from both published studies and ongoing trials that have been confirmed to be convenient and effective methods. However, additional evidence from future studies will be required before some of these techniques can be widely applied or recommended as alternatives.

Accidente cerebrovascular bulbar lateral con trayecto extracraneal de la arteria cerebelosa póstero-inferior / Lateral medullary stroke with extracranial course of the postero- inferior cerebellar artery

Presentamos dos casos de accidente cerebrovascular en sujetos con trayecto extracraneal de la arteria cerebeloso póstero-inferior. Caso 1: varón de 21 años, quien presentó ataxia y dismetría derecha luego de un traumatismo cervical en un partido de rugby. Caso 2: mujer de 56 años, quien inició con vértigo y hemiparesia izquierda luego de esfuerzo físico intenso. En ambos casos, los estudios angiográficos mostraron un trayecto extracraneal de la arteria cerebelosa póstero-inferior. Este vaso raramente se origina por debajo del foramen magno, en relación cercana con las primeras tres vértebras cervicales y la articulación atlanto-axial. En este nivel, está expuesta a daño mecánico causante de disección, como por ejemplo trauma directo, manipulación cervical abrupta o extensión cefálica prolongada. Por lo tanto, en pacientes con accidente cerebrovascular de región lateral de bulbo y trayecto extracraneal de la arteria cerebelosa póstero-inferior se debería considerar esta asociación.

We present two cases of lateral medullary stroke in subjects with extracranial trajectory of the postero-inferior cerebellar artery. Case 1: a 21-year-old male who presented ataxia and right dysmetria after cervical trauma in a rugby match. Case 2: 56-year-old woman, who started with vertigo and left hemiparesis after intense physical effort. In both cases, the angiographic studies showed an extracranial trajectory of the posterior inferior cerebellar artery. This vessel rarely originates below the foramen magnum, in close relationship with the first three cervical vertebrae and the atlanto-axial joint. At this level, it is exposed to mechanical damage causing dissection, such as direct trauma, abrupt cervical manipulation or prolonged cephalic extension. Therefore, this association should be considered in patients with stroke of the lateral region of the bulb and extracranial trajectory of the posterior-inferior cerebellar artery.

Importancia del diagnóstico histopatológico en el tratamiento de las lesiones del tronco cerebral en adultos / Relevance of histopathological diagnosis in the treatment of brainstem lesions in adults

Los tumores del tronco cerebral son infrecuentes en la población adulta. Las controversias surgen cuando se considera la necesidad de confirmar el diagnóstico histopatológico en esta área elocuente del cerebro, balanceando los beneficios de obtener un diagnóstico certero y las desventajas de los procedimientos invasivos. Existen escasas publicaciones acerca de su tratamiento quirúrgico en adultos, todas series pequeñas analizadas retrospectivamente. Presentamos nuestra experiencia con el propósito de contribuir al proceso de toma de decisiones. Diez de 13 pacientes fueron intervenidos. Las lesiones se clasificaron en focales (n:7), infiltrativa difusa (n:1), tectal (1) y exofítica (1). El estado neurológico según la escala Karnofsky Performance Status fue ≥ 70 en 6 casos y < 70 en 7. Las muestras fueron obtenidas mediante abordaje microquirúrgico directo o por biopsia estereotáctica. Los hallazgos histopatológicos fueron confirmados en todos los casos: astrocitoma pilocítico (n:1), glioma de bajo grado (n:1), glioblastoma (n:1), hemangioblastoma celular (n:1), subependimoma (n:1), disgerminoma (n:1), y lesiones pseudotumorales (n:4, 3 cavernomas, 1 pseudotumor inflamatorio). La amplia variedad de hallazgos patológicos en esta localización en adultos exige una precisa definición histopatológica, que no solo determina la terapéutica adecuada sino que también previene las consecuencias potencialmente catastróficoas de los tratamientos empíricos.

Brainstem tumors are uncommon beyond childhood. Controversies arise regarding the need of histological diagnosis in this eloquent area of the brain, weighting the benefits of a reliable diagnosis against the disadvantages of invasive procedures. There are scant publications about the surgical management of brainstem tumors in adults, all of them involving small retrospective cohorts. We are reporting our experience with the aim of contributing to the decision making process. Out of a series of 13 patients, 10 were approached surgically. According to Guillamo´s classification the lesions were: focal (n:7), diffuse infiltrative (n:1), tectal (n:1), and exophytic (n:1). According to the Karnofsky Performance Status scale, the neurological status was ≥ 70 in 6 cases and < 70 in 7. Histopathology was confirmed in all 10 treated cases and the samples were obtained by a direct microsurgical approach or by stereotactic biopsy. Histopathological findings were: pilocytic astrocytoma (n:1), low grade glioma (n:1), glioblastoma (n:1), cellular haemangioblastoma (n:1), subependimoma (n:1), pseudotumoral lesions (n:4; 3 cavernomas, 1 inflammatory pseudotumor), and disgerminoma (n:1). As a broad variety of pathologies could be found in this brain localization, an accurate histopathological definition can not only determine the adequate therapy, but also avoid the disastrous consequences of empiric treatments.

Tratamiento neuroquirúrgico de la isquemia cerebral / Neurosurgical treatment of cerebral ischemia

Introducción: El manejo actual de la isquemia cerebral aguda (IA) contempla el uso de r-tPA y terapia endovascular, mientrasque en la isquemia cerebral crónica (IC) la mejor terapia aún no está definida. La revascularización cerebral microquirúrgicaha sido descrita como tratamiento alternativo para pacientes con IA y contraindicación para r-tPA o terapia endovascular, asícomo para pacientes con IC en quienes la terapia médica ha fracasado. Objetivo: Comunicar la experiencia inicial en cirugíade revascularización cerebral, con énfasis en la utilidad de la embolectomía microquirúrgica y del bypass cerebral comoterapia de rescate en IA, así como del bypass cerebral en IC. Pacientes y Método: Serie prospectiva de 5 pacientes conisquemia cerebral tratados con cirugía de revascularización cerebral en el período 2013 a 2016. Se describe la técnica y resultadosquirúrgicos, así como el estado funcional a los 3, 6 y 12 meses de seguimiento según modified Rankin Scale (mRS)...

Background: Tissue Plasminogen Activator (t-PA) and mechanical thrombectomy are today the best treatment approachfor acute ischemic stroke (AIS). However, the best management for chronic cerebral ischemia (CCI) is still debated. Microsurgicalrevascularization has been described as alternative treatment for patients with AIS and contraindication for t-PA orendovascular therapy, and for patients with CCI and failure of maximal medical therapy. Aim: To describe the effectiveness ofmicrosurgical embolectomy and cerebral bypass as salvage therapy in AIS, as well as cerebral bypass in CCI. Methods: Fivepatients were treated by cerebral revascularization between 2013 and 2016. Surgical and functional results were analyzed.Neurological outcomes were assessed by modified Rankin Scale (mRS) at 3, 6 & 12 months...

Cavernomatosis múltiple y aneurisma cerebral trombosado: una asociación inusual / Cavernous haemangioma multiple and brain aneurysm thrombosed: an unusual association

Los cavernomas son malformaciones angiográficamente ocultas, pueden ser únicos o múltiples y esporádica o familiar.Suelen asociarse a otras malformaciones vasculares como las anomalías de drenaje venoso, sin embargo no es habitual su asociación con aneurismas cerebrales. Los aneurismas son malformaciones evidenciables en angiografía, sin embargo cuando se encuentran trombosados puede dificultarse su diagnostico, observándose en algunos casos como lesiones pseudotumorales. Nuestro objetivo es exponer una rara asociación entre cavernomatosis múltiple y aneurisma cerebral trombosado en un paciente pediátrico. Presentamos una paciente de 2 años de edad con diagnóstico de cavernomatosis múltiple y aneurisma cerebral trombosado. Se realiza una revisión de la literatura de ambas entidades y su rara asociación, medianteuna búsqueda exhaustiva en la base de datos de PUBMED Y COCHRANE utilizando las siguientes palabras claves: Cavernous angioma. Familial cavernomatosis. Hemorrhagic stroke. Multiple cavernomatosis. Cerebral aneurysm. Thrombosed aneurysm. Se discute la epidemiologia, diagnóstico y manejo quirúrgico de la cavernomatosis múltiple y sus asociaciones, preconizando fundamentalmente la evaluación pre quirúrgica de estos pacientes. No encontramos ningún caso de asociación entre cavernomatosis múltiple y aneurismas en nuestra revisión bibliográfica. Dado que se pueden presentar como lesiones pseudotumorales, la tomografía computada, resonancia magnética y la angiografía cerebral son métodos fundamentales para llegar a un diagnostico prequirúrgico certero. La indicación quirúrgica debe ser evaluada individualmente en cada paciente, y se debe realizar un seguimiento clínico-imagenologico.

Cavernomas are angiographically occult malformations may be single or multiple and sporadic or familial. Usually associated with other vascular malformations such as venous drainage anomalies, however it is not common its association with brain aneurysms. Aneurysms are into evidence malformations in angiography, however when they meet their diagnosis can be difficult thrombosed observed in some cases as pseudotumoral injuries. Our goal is to present a rare association between multiple cavernous haemangioma and thrombosed cerebral aneurysm in a pediatric patient. We present a patient 2 years old diagnosed with multiple cavernous haemangioma and thrombosed cerebral aneurysm. A review of the literature of both entities and its rare association is done through an exhaustive search in the database PUBMED and COCHRANE using the following keywords: Cavernous angioma. Familial cavernous haemangioma. Hemorrhagic stroke. Multiple cavernous haemangioma. Brain aneurysm. Thrombosed aneurysm. The epidemiology, diagnosis and surgical management of multiple cavernous haemangioma and their associations is discussedessentially advocating the presurgical evaluation of these patients. No case of association between multiple cavernous haemangioma and aneurysms in our literature review. Because can be presented as pseudotumoral lesions, computed tomography, magnetic resonance imaging and cerebral angiography are fundamental methods to reach an certain diagnosis preoperatively. The surgical indication should be evaluated individually for each patient, and should be performed a clinical-imaging follow-up.

Risk Factors for the Rupture of Bifurcation Intracranial Aneurysms Using CT Angiography

PURPOSE: To investigate the clinical and morphological characteristics in relation to risk of bifurcation intracranial aneurysm rupture. MATERIALS AND METHODS: Data from 202 consecutive patients with 219 bifurcation aneurysms (129 ruptured and 90 unruptured) managed at the authors' facility between August 2011 and July 2014 were retrospectively reviewed. Based on their clinical records and CT angiographic findings, the ability of risk factors to predict aneurysm rupture was assessed using statistical methods. RESULTS: Age, hypertension, diabetes mellitus, and cerebral atherosclerosis were negatively correlated with aneurysm rupture. Aneurysms located in the middle cerebral artery, daughter artery ratio, lateral angle ratio (LA ratio), and neck width were negatively correlated with rupture. Aneurysms located in the anterior communicating artery, irregularity, with daughter sac, depth, width, maximum size, aspect ratio (AR), depth-to-width ratio, and bottleneck factor were significantly and positively correlated with rupture. Binary logistic regression model revealed that irregular shape [odds ratio (OR) 6.598] and AR (OR 3.507) strongly increased the risk of bifurcation aneurysm rupture, while age (OR 0.434), cerebral atherosclerosis (OR 0.125), neck width (OR 0.771), and LA ratio (OR 0.267) were negatively correlated with rupture (p<0.05). Receiver operating characteristic analysis revealed the threshold values of AR and LA ratio to be 1.18 and 1.50, respectively. CONCLUSION: Age (≥60 yr), cerebral atherosclerosis, and aneurysms with a larger neck width and larger LA ratio are protective factors against bifurcation aneurysm rupture. An aneurysm with an irregular shape and an increased AR reflect the greater likelihood of a rupture.

Application of indocyanine green video angiography in surgical treatment of intracranial aneurysms / Aplicação da angiografia intraoperatória com indocianina verde no tratamento cirúrgico de aneurismas cerebrais

Indocyanine green (ICG) video angiography has been used for several medical indications in the last decades. It allows a real time evaluation of vascular structures during the surgery. This study describes the surgical results of a senior vascular neurosurgeon. We retrospectively searched our database for all aneurysm cases treated with the aid of intraoperative ICG from 2009 to 2014. A total of 61 aneurysms in 56 patients were surgically clipped using intraoperative ICG. Clip reposition after ICG happened in 2 patients (3.2%). Generally, highly variable clip adjustment rates of 2%–38% following ICG have been reported since the introduction of this imaging technique. The application of ICG in vascular neurosurgery is still an emerging challenge. It is an adjunctive strategy which facilitates aneurismal evaluation and treatment in experienced hands. Nevertheless, a qualified vascular neurosurgeon is still the most important component of a high quality work.

A angiografia intraoperatória com indocianina verde (ICG) já foi aplicada em diversas situações clínicas por vários anos. O ICG permite avaliação em tempo real de estruturas vasculares durante a cirurgia. Este artigo descreve os resultados cirúrgicos do autor sênior. Avaliamos retrospectivamente os casos de aneurismas intracranianos operados de 2009 a 2014. Um total de 61 aneurismas em 56 pacientes foram operados com ICG. O reposicionamento do clip ocorreu em 2 casos (3.2%). Geralmente, taxas variáveis de reposicionamento do clip têm sido descritas (2%–38%). A aplicação de ICG na neurocirurgia vascular ainda é um desafio crescente. É um artifício que auxilia na avaliação e tratamento de aneurismas intracranianos em mãos experientes. No entanto, um neurocirurgião vascular continua sendo o principal componente de um resultado cirúrgico de alto nível.

Multidetector computed tomography angiography in clinically suspected hyperacute ischemic stroke in the anterior circulation: an etiological workup in a cohort of Brazilian patients / Angiotomografia computadorizada multidetectores na avaliação da suspeita clínica de acidente vascular encefálico isquêmico hiperagudo da circulação anterior: determinação etiológica precoce em um grupo de pacientes brasileiros

Objective The potential of computed tomography angiography (CTA) was assessed for early determination of stroke subtypes in a Brazilian cohort of patients with stroke. Method From July 2011 to July 2013, we selected patients with suspected hyperacute stroke (< 6 hours). Intracranial and cervical arteries were scrutinized on CTA and their imaging features were correlated with concurrent subtype of stroke. Results Stroke was documented in 50/106 selected patients (47.2%) based on both clinical grounds and imaging follow-up (stroke group), with statistically significant arterial stenosis and vulnerable plaques on CTA. Intracranial large artery disease was demonstrated in 34% of patients in the stroke group. Partial territorial infarct prevailed (86%) while artery-to-artery embolization was the most common stroke mechanism (52%). Conclusion Multidetector CTA was useful for the etiologic work-up of hyperacute ischemic stroke and facilitated the knowledge about the topographic pattern of brain infarct in accordance with its causative mechanism. .

Objetivo Avaliar o potencial da angiotomografia computadorizada multidetectores (ATCM) na determinação etiológica precoce do acidente vascular encefálico (AVE) e correlacionar o mecanismo causal com o padrão de infarto. Método De Julho de 2011 a Julho de 2013, foram selecionados os pacientes com suspeita clínica de AVE hiperagudo. Os achados da ATCM dos vasos intracranianos e cervicais foram correlacionados com a etiologia final do evento. Resultados AVE foi confirmado em 50/106 pacientes (47,2%). Estes apresentaram alterações angiográficas estatisticamente mais relevantes. Aterosclerose dos grandes vasos intracranianos esteve presente em 34% destes pacientes. O padrão radiológico topográfico de infarto mais comum foi o infarto territorial parcial (86%). A embolização arterio-arterial foi o mecanismo mais prevalente (52%). Conclusão A utilização da ATCM traz benefícios na detecção etiológica precoce dos pacientes com suspeita de AVE hiperagudo, além de possibilitar o entendimento do padrão radiológico topográfico de acordo com o mecanismo causal do evento isquêmico. .

Is previous experience in laparoscopic necessary to perform robotic radical prostatectomy? A comparative study with robotic and the classic open procedure in patients with prostate cancer

PURPOSE: To assess comparative results of robot-assisted radical laparoscopic prostatectomy (RARP) performed by surgeons without any experience in laparoscopic prostatectomy and the open procedure performed by surgeons with large experience. METHODS: We analyzed 84 patients (50 subjected to robotic surgery) from June 2012 to September 2013. Data were prospectively collected in a customized database. Two surgeons carried out all the RARP cases. These two surgeons and six more performed the open cases. The perioperative outcomes between the two groups were analyzed with a minimum followup of 12 months. RESULTS: The corporal mass index (BMI) was higher in the open group (p=0.001). There was more operatve time, less hospitalization and blood loss, better trifecta and pentafecta and earlier continence (p=0.045) in the robotic group (p=0.001). There was no difference in positive surgical margins but with greater extraprostatic extension in the open group (p=0.002). CONCLUSIONS: Robot-assisted radical prostatectomy is a safe procedure even in the hands of surgeons with no previous experience. Besides this, better operative outcomes can be reached with this modern approach. .

Microcatheter Looping to Facilitate Aneurysm Selection in Coil Embolization of Paraclinoid Aneurysms

OBJECTIVE: Described herein is a microcatheter looping technique to facilitate aneurysm selection in paraclinoid aneurysms, which remains to be technically challenging due to the inherent complexity of regional anatomy. MATERIALS AND METHODS: This retrospective study was approved by our Institutional Review Board, and informed consent was waived. Microcatheter looping method was employed in 59 patients with paraclinoid aneurysms between January 2012 and December 2013. In the described technique, construction of a microcatheter loop, which is steam-shaped or pre-shaped, based on the direction of aneurysms, is mandatory. The looped tip of microcatheter was advanced into distal internal carotid artery and positioned atop the target aneurysm. By steering the loop (via inner microguidewire) into the dome of aneurysm and easing tension on the microcatheter, the aneurysm was selected. Clinical and morphologic outcomes were assessed with emphasis on technical aspects of the treatment. RESULTS: Through this looping technique, a total of 59 paraclinoid aneurysms were successfully treated. After aneurysm selection as described, single microcatheter technique (n = 25) was most commonly used to facilitate coiling, followed by balloon protection (n = 21), stent protection (n = 7), multiple microcatheters (n = 3), and stent/balloon combination (n = 3). Satisfactory aneurysmal occlusion was achieved through coil embolization in 44 lesions (74.6%). During follow-up of 53 patients (mean interval, 10.9 +/- 5.9 months), only one instance (1.9%) of major recanalization was observed. There were no complications related to microcatheter looping. CONCLUSION: This microcatheter looping method facilitates safe and effective positioning of microcatheter into domes of paraclinoid aneurysms during coil embolization when other traditional microcatheter selection methods otherwise fail.

Incidence and Risk Factors for Rebleeding during Cerebral Angiography for Ruptured Intracranial Aneurysms

PURPOSE: The purpose was to evaluate the incidence and risk factors for rebleeding during cerebral angiography in ruptured intracranial aneurysms. MATERIALS AND METHODS: Among 1896 patients with ruptured intracranial aneurysms between September 2006 and December 2013, a total of 11 patients who experienced rebleeding of the ruptured aneurysms during digital subtraction angiography (DSA) were recruited in this study. RESULTS: There were 184 patients (9.7%) who had suffered rebleeding prior to the securing procedure. Among them, 11 patients experienced rebleeding during DSA and other 173 patients at a time other than DSA. Eight (72.7%) of the 11 patients experienced rebleeding during three-dimensional rotational angiography (3DRA). The incidence of rebleeding during DSA was 0.6% in patients with ruptured intracranial aneurysms. Multivariate logistic regression analysis showed that aneurysm location in anterior circulation [odds ratio=14.286; 95% confidence interval (CI), 1.877 to 250.0; p=0.048] and higher aspect ratio (odds ratio=3.040; 95% CI, 1.896 to 10.309; p=0.041) remained independent risk factors for rebleeding during DSA. CONCLUSION: Ruptured aneurysms located in anterior circulation with a high aspect ratio might have the risk of rebleeding during DSA, especially during 3DRA.

Incidence and Risk Factors for Rebleeding during Cerebral Angiography for Ruptured Intracranial Aneurysms

PURPOSE: The purpose was to evaluate the incidence and risk factors for rebleeding during cerebral angiography in ruptured intracranial aneurysms. MATERIALS AND METHODS: Among 1896 patients with ruptured intracranial aneurysms between September 2006 and December 2013, a total of 11 patients who experienced rebleeding of the ruptured aneurysms during digital subtraction angiography (DSA) were recruited in this study. RESULTS: There were 184 patients (9.7%) who had suffered rebleeding prior to the securing procedure. Among them, 11 patients experienced rebleeding during DSA and other 173 patients at a time other than DSA. Eight (72.7%) of the 11 patients experienced rebleeding during three-dimensional rotational angiography (3DRA). The incidence of rebleeding during DSA was 0.6% in patients with ruptured intracranial aneurysms. Multivariate logistic regression analysis showed that aneurysm location in anterior circulation [odds ratio=14.286; 95% confidence interval (CI), 1.877 to 250.0; p=0.048] and higher aspect ratio (odds ratio=3.040; 95% CI, 1.896 to 10.309; p=0.041) remained independent risk factors for rebleeding during DSA. CONCLUSION: Ruptured aneurysms located in anterior circulation with a high aspect ratio might have the risk of rebleeding during DSA, especially during 3DRA.

Imaging-Based Management of Acute Ischemic Stroke Patients: Current Neuroradiological Perspectives

Advances in imaging-based management of acute ischemic stroke now provide crucial information such as infarct core, ischemic penumbra/degree of collaterals, vessel occlusion, and thrombus that helps in the selection of the best candidates for reperfusion therapy. It also predicts thrombolytic efficacy and benefit or potential hazards from therapy. Thus, radiologists should be familiar with various imaging studies for patients with acute ischemic stroke and the applicability to clinical trials. This helps radiologists to obtain optimal rapid imaging as well as its accurate interpretation. This review is focused on imaging studies for acute ischemic stroke, including their roles in recent clinical trials and some guidelines to optimal interpretation.

A giant carotid aneurysm with intrasellar extension: a rare cause of panhypopituitarism

No abstract available.