Penetrating Vertebral Artery Injuries: A Literature Review and Proposed Treatment Algorithm.

BACKGROUND: Penetrating vertebral artery injuries (VAIs) are rare but devastating trauma for which the approach to treatment varies greatly. The literature on treatment modalities is limited to case reports, case series, and 1 review, with the majority of cases being treated surgically. However, with the advent of digital subtraction angiography, treatment has shifted toward less invasive endovascular modalities that allows one to assess the flow and risks of sacrificing the vertebral artery (VA). METHODS: In accordance with Preferred Reporting Items for Systematic reviews and Meta-Analyses, a systematic review of VAI was performed. Two case reports were also detailed. Using a multidisciplinary team, a decision algorithm was proposed for approaching penetrating VAIs. RESULTS: We identified 169 patients. Of the penetrating VAI, the majority were occlusions, most commonly managed conservatively. Other injuries including pseudoaneurysm, dissection, transection, and arterial-venous fistula were treated predominantly endovascularly and occasionally with the surgical exploration/ligation. Most endovascular treatments included embolization without significant stroke or complication from VA sacrifice. However, there are incidences in which VA sacrifice should be avoided and these scenarios can be better delineated with digital subtraction angiography to assess flow and anatomy. CONCLUSIONS: This systematic review not only details the updated treatment options but also provides a decision algorithm for the treatment of penetrating VAI. It highlights the shifting treatment options of penetrating VAI to endovascular therapy, as well as details VAI variants that may suggest stenting over embolization.

Nonaneurysmal Subarachnoid Hemorrhage in Scuba Diving.

BACKGROUND: Decompression illness often presents with a wide variety of vague neurologic symptoms. Animal models have suggested that intracranial hemorrhages may result from nitrogen bubble ischemic insults. However, there is a paucity of cases and no known case reported to date of non-aneurysmal subarachnoid hemorrhage after rapid ascension from diving. CASE DESCRIPTION: A 60-year-old man presented with headache, nausea, emesis, and confusion 2 days after ascending rapidly from scuba diving. Given the severity and his symptoms unremitting despite oxygen at home, a computed tomography scan of the head was obtained revealing a prepontine and right sylvian fissure subarachnoid hemorrhage with ventriculomegaly. No underlying vascular abnormality was discovered. The patient was discharged from the hospital posthemorrhage day 7, neurologically intact. CONCLUSIONS: In patients presenting with persistent headache, nausea, emesis and/or other neurologic symptoms after diving, health care providers should consider intracranial hemorrhage in their work up.

Anterior Petrosectomy: Consecutive Series of 46 Patients with Attention to Approach-Related Complications.

Objective Anterior petrosectomy(AP) was popularized in the 1980s and 1990s as micro-neurosurgery proliferated. Original reports concentrated on the anatomy of the approach and small case series. Recently, with the advent of additional endonasal approaches to the petrous apex, the morbidity of AP remains unclear. This report details approach-related morbidity around and under the temporal lobe. Methods A total of 46 consecutive patients identified from our surgical database were reviewed retrospectively. Results Of the 46 patients, 61% were women. Median age of the patients was 50 years (mean: 48 ± 2 years). Median follow-up of this cohort was 66 months. Most procedures dealt with intradural pathology (n = 40 [87%]). Approach-related morbidity consisted of only two patients (4%) with new postoperative seizures. There were only two significant postoperative hemorrhages (4%). Cerebrospinal fluid leakage occurred in two patients (4%) requiring reoperation. Conclusion Approach-related complications such as seizures and hematoma were infrequent in this series, < 4%. This report describes a contemporary group of patients treated with open AP and should serve as a comparison for approach-related morbidity of endoscopic approaches. Given the pathologies treated with this approach, the morbidity appears acceptable.

Anterior inferior petrosectomy: defining the role of endonasal endoscopic techniques for petrous apex approaches.

OBJECT: Historically, surgery to the petrous apex has been addressed via craniotomy and open microscopic anterior petrosectomy (OAP). However, with the popularization of endoscopic approaches, the petrous apex can further be approached endonasally by way of an endoscopic endonasal anterior petrosectomy (EAP). Endonasal anterior petrosectomy is a relatively new procedure and has not been compared anatomically with OAP. The authors hypothesized that the EAP and OAP techniques approach different portions of the petrous apex and therefore may have different applications. METHODS: Four cadaveric heads were used. An OAP was performed on one side and an EAP was performed on the contralateral side; the limits of bony resection were defined. The extent of bony resection was then evaluated using predissection and postdissection thin-slice CT scans. The comparative resection was then reconstructed using 3D modeling on Brainlab workstations. RESULTS: The average resection volumes for EAP and OAP were 0.297 cm(3) and 0.649 cm(3), respectively, representing a comparative percentage of 46% (EAP/OAP). An EAP and OAP achieved resection of 29% and 64% of the total petrous apex volume, respectively. Indeed, EAP addressed the inferior portion of the petrous apex located adjacent to the petroclival suture more completely than OAP, where 45% of the bone overlying the petroclival suture (petroclival angle to the jugular foramen) was resected with the EAP, while 0% was resected with the OAP. CONCLUSIONS: In anatomically normal cadavers, OAP achieved nearly a 50% larger volumetric resection than EAP. Furthermore, while OAP appears to completely address the superior portion of the petrous apex, EAP appears to have a niche in approaches to lesions in the inferior petrous apex. Given these results, the authors propose that OAP be redefined as the "superior anterior petrosectomy," while EAP be referred to as the "inferior anterior petrosectomy," which more clearly defines the role of each approach in anterior petrosectomy.