Interhemispheric approach with callosal resection for distal anterior cerebral artery aneurysms. Technical note.

Distal anterior cerebral artery aneurysms are commonly found near the genu of the corpus callosum. While these aneurysms may be surgically obliterated through a variety of approaches, exposure via the interhemispheric fissure is used by many surgeons. Early identification of the afferent artery may be difficult with this approach, however, particularly if the aneurysm lies just beneath the genu of the corpus callosum. The authors have modified the interhemispheric approach to distal anterior cerebral artery aneurysms by electively exposing the feeding artery through a small anterior callosotomy. While this maneuver is not necessary for all distal anterior cerebral artery aneurysms, it can greatly enhance exposure in the region just below the genu of the corpus callosum. Experience with this technique in five patients is reported. In all cases, the limited anterior callosotomy enhanced surgical exposure. No morbidity could be attributed to the callosotomy in any patient. It is concluded that, when the interhemispheric approach is used, anterior callosotomy improves exposure of the region just below the genu of the corpus callosum and may be a useful maneuver when treating distal anterior cerebral artery aneurysms.

Cerebral vasoconstriction as a complication of carotid endarterectomy. Case report.

The case is presented of an elderly man with an acute confusional state occurring soon after he had undergone a right carotid endarterectomy. Angiography demonstrated segmental areas of cerebral vasoconstriction and an electroencephalogram revealed periodic lateralized epileptiform discharges, both involving the right hemisphere. Cerebral hyperperfusion has been implicated in the genesis of several transient neurological syndromes following carotid endarterectomy. This case suggests that cerebral vasoconstriction may also be associated with impairment of cerebrovascular autoregulation observed after this procedure.

Traumatic atlanto-occipital dislocation. Case report.

Traumatic atlanto-occipital dislocation is a serious injury that is usually fatal. The number of patients surviving this injury, however, appears to be increasing, and most of these survivors are children. This may reflect an improvement in emergency transport services. Seventeen previously reported cases of patients surviving atlanto-occipital dislocation for more than 48 hours are reviewed and an additional case is presented. Many of these patients had an excellent neurological outcome. The radiographic criteria necessary for the diagnosis of atlanto-occipital dislocation are discussed. Cervical computerized tomography may confirm the diagnosis when necessary. It is suggested that there are three types of atlanto-occipital dislocation; utilizing this new classification, a rationale for treatment is described. Fusion is favored for long-term stability.

Kinetics of horseradish peroxidase migration through cerebral cortex.

This study provides a semiquantitative description of the migration of the extracellular space marker, horseradish peroxidase (HRP), through the cerebral cortex. Following a continuous subarachnoid infusion of HRP, this marker was fixed rapidly within the cortical extracellular space (ECS) by intravascular aldehyde perfusion fixation. Microscopic measurements of the maximum depth of penetration of HRP into the cortex perpendicular to the pial surface were taken from coronal whole brain sections of rabbits that had been exposed to HRP for varying periods of time. The depth of penetration plotted as a function of time of exposure to HRP produced a 'diffusion profile'. The failure of experimental points to conform to an ideal diffusion curve indicates that simple diffusion alone is an inadequate explanation of the rate of movement of large molecular solutes from the subarachnoid space through the cerebral cortical ECS. The complex pattern of migration velocity of HRP through cortex may be due to alterations of flux of this solute which result from variations in the volume of ECS in different cortical laminae and to the presence of bulk flow of extracellular fluid in the deeper cortical regions.

Surgical anatomy of the proximal anterior cerebral artery.

The authors present this study of proximal anterior cerebral arteries in the normal human to provide a clearer basis for strategy in aneurysm surgery. They describe patterns of origin of branches, their subarachnoid course, and parenchymal distribution. Branches that originate from the anterior cerebral artery at the internal carotid bifurcation perfuse the genu and contiguous posterior limb of the internal capsule and the rostral thalamus. Proximal 4-mm branches supply the anterior limb of the internal capsule, the neighboring hypothalamus, anteroventral putamen, and pallidum. The remaining anterior cerebral artery proximal to the communicating artery sends branches to the optic chiasm, the adjacent hypothalamus, and the anterior commissure. Heubner's artery arises directly opposite the anterior communicating artery to supply much of the striatum and internal capsule rostral to the anterior commissure. The anterior communicating artery branches supply the fornix, corpus callosum, septal region, and anterior cingulum. The parenchymal distribution of these end arteries may be surmised from the site of origin named vessels. With this anatomical information one can avoid interruption of blood supply to vital structures when dealing with the anterior cerebral artery and its branches.