Awake Craniotomy for the Treatment of a Cortical Pseudoaneurysm in a Pregnant Patient.

Neurosurgical pathologies presenting during pregnancy are uncommon. If present, the situation creates a unique diagnostic, observational, and therapeutic challenge as both lives are placed at potential risk. Surgical procedures during pregnancy are approached carefully as physiological stressors associated with surgery and anesthesia may cause fetal or maternal compromise. We present the only known case of a pseudoaneurysm treated with an awake craniotomy, allowing us to abate the risks associated with general anesthesia in pregnancy. A female suffered a superficially penetrating gunshot wound to the head for which she underwent a craniotomy with complete neurological recovery. She had complaints of intermittent headaches, dizziness, and tingling of her hands five months thereafter. The cerebral angiogram demonstrated an 8 mm pseudoaneurysm under her craniotomy site. A surgical repair of this aneurysm was undertaken in the 23rd week of pregnancy via an awake craniotomy with regional scalp block. The aneurysm was resected without complication, and the patient tolerated the procedure without neurological deficit during or subsequent to the operation. Cerebrovascular pathology in pregnant patients remains a difficult situation that poses challenges associated with the pathology itself as well as the anesthetic implications inherent with operative management. The neurosurgical literature demonstrates that surgical management of cerebrovascular pathology is well-tolerated in pregnancy, and our case further demonstrates the capability of utilizing an awake craniotomy for the treatment of this type of lesion without causing a residual deficit.

Anatomical Variations of the Transverse-Sigmoid Sinus Junction: Implications for Endovascular Treatment of Idiopathic Intracranial Hypertension.

Venous sinus pathology can result in multiple pathological diseases, including idiopathic intracranial hypertension (IIH). There remains a paucity of information on anatomical luminal variations of the major venous sinuses which may contribute to the etiology of certain disease states. Thirty-six transverse and sigmoid sinuses were removed following dissection of 19 unfixed cadaveric heads. Sinuses were opened longitudinally to study luminal variations. A semiquantitative classification system was developed to assess septations and blind pouches. Seventy-nine percent of cadavers had a luminal anatomical variation. Forty-four percent and 42% of sinuses dissected had occurrence of a septations or blind pouches, respectively. Thirty percent of septations and 25% of pouches were classified as large. Incidence of anatomical variations was not statistically significant between cadaver gender or sinus laterality. Luminal variations are present in the transverse and sigmoid sinuses at rates higher than expected. This study is the first to report the presence of blind pouches in the luminal wall of transverse and sigmoid sinuses. These variations can have clinical importance to the endovascular surgeon and may also contribute to the pathophysiological etiology of venous sinus diseases. Anat Rec, 299:1037-1042, 2016. © 2016 Wiley Periodicals, Inc.

Anchor technique: Use of stent retrievers as an anchor to advance thrombectomy catheters in internal carotid artery occlusions.

In three recent cases of acute complete internal artery occlusions, we used stent retriever deployed through the mechanical aspiration/distal access catheters to achieve recanalization. In all cases the stent retriever was used as an anchor and supplemented mechanical thrombectomy. This report describes the technical details of the procedure and presents an alternative plan of action in difficult cases when standard thrombectomy techniques do not work.

Balloon-augmented Onyx embolization of cerebral arteriovenous malformations using a dual-lumen balloon: a multicenter experience.

INTRODUCTION: Conventional Onyx embolization of cerebral arteriovenous malformations (AVMs) requires lengthy procedure and fluoroscopy times to form an adequate 'proximal plug' which allows forward nidal penetration while preventing reflux and non-targeted embolization. We review our experience with balloon-augmented Onyx embolization of cerebral AVMs using a dual-lumen balloon catheter technique designed to minimize these challenges. METHODS: Retrospectively acquired data for all balloon-augmented cerebral AVM embolizations performed between 2011 and 2014 were obtained from four tertiary care centers. For each procedure, at least one Scepter C balloon catheter was advanced into the AVM arterial pedicle of interest and Onyx embolization was performed through the inner lumen after balloon inflation via the outer lumen. RESULTS: Twenty patients underwent embolization with the balloon-augmented technique over 24 discreet treatment episodes. There were 37 total arterial pedicles embolized with the balloon-augmented technique, a mean of 1.9 per patient (range 1-5). The treated AVMs were heterogeneous in their location and size (mean 3.3±1.6 cm). Mean fluoroscopy time for each procedure was 48±26 min (28 min per embolized pedicle). Two Scepter C balloon catheter-related complications (8.3% of embolization sessions, 5.4% of pedicles embolized) were observed: an intraprocedural rupture of a feeding pedicle and fracture and retention of a catheter fragment. CONCLUSIONS: This multicenter experience represents the largest reported series of balloon-augmented Onyx embolization of cerebral AVMs. The technique appears safe and effective in the treatment of AVMs, allowing more efficient and controlled injection of Onyx with a decreased risk of reflux and decreased fluoroscopy times.

Developing practice recommendations for endovascular revascularization for acute ischemic stroke.

Guidelines have been established for the management of acute ischemic stroke; however, specific recommendations for endovascular revascularization therapy are lacking. Burgeoning investigation of endovascular revascularization therapies for acute ischemic stroke, rapid device development, and a diverse training background of the providers performing the procedures underscore the need for practice recommendations. This review provides a concise summary of the Society of Vascular and Interventional Neurology endovascular acute ischemic stroke roundtable meeting. This document was developed to review current clinical efficacy of pharmacologic and mechanical revascularization therapy, selection criteria, periprocedure management, and endovascular time metrics and to highlight current practice patterns. It therefore provides an outline for the future development of multisociety guidelines and recommendations to improve patient selection, procedural management, and organizational strategies for revascularization therapies in acute ischemic stroke.

Management of the great mimicker: Meckel cave tumors.

BACKGROUND: Meckel cave tumors are often asymptomatic and have a sufficiently characteristic magnetic resonance imaging/computed tomography signature that allows treatment/surveillance decisions to be made without biopsy confirmation. Radiographic diagnosis requires the surgeon to be fully aware of the plethora of unusual Meckel cave lesions that mimic benign tumors when they are malignant, inflammatory, or infectious and in need of a completely different and often timely intervention. When such a diagnosis is considered, it behooves the surgeon and benefits the patient to have a percutaneous biopsy technique available. OBJECTIVE: To use our recent experience with a patient with idiopathic inflammatory sensory neuropathy and another with Meckel cave lymphoma to review the management of tumors of the Meckel cave. METHODS: The technique of percutaneous biopsy of Meckel cave tumors through the foramen ovale with biopsy needles is detailed. CONCLUSION: Obtaining tissue biopsy percutaneously prevents patients with Meckel cave tumors best treated with nonsurgical management from undergoing open surgical resection with its concomitant morbidity.

Decompression of Chiari malformation with and without duraplasty: morbidity versus recurrence.

OBJECT: The optimal surgical management of Chiari malformation (CM) is evolving. Evidence continues to accrue that supports decompression without duraplasty as an effective treatment to achieve symptomatic relief and anatomical decompression. The risks and benefits of this less invasive operation need to be weighed against decompression with duraplasty. METHODS: The authors performed a retrospective review of all CM decompressions from 2003 to 2007. All operations were performed by a single surgeon at a single institution. Data were analyzed for outcome, postoperative morbidity, and recurrence. RESULTS: Of 121 unique patients, 56 underwent posterior fossa decompressions without duraplasty (PFD) and 64 patients underwent posterior fossa decompressions with duraplasty (PFDD). Of the 56 PFD patients, 7 (12.5%) needed a subsequent PFDD for symptomatic recurrence. Of the 64 patients who underwent a PFDD, 2 (3.1%) needed a repeated PFDD for symptomatic recurrence. Patients treated with PFDD had an average operative time of 201 minutes in contrast to 127 minutes for those who underwent PFD (p = 0.0001). Patients treated with PFDD had average hospital stays of 4.0 days, whereas that for patients treated with PFD was 2.7 days (p = 0.0001). While in the hospital, patients treated with PFDD used low-grade narcotics, intravenous narcotics, muscle relaxants, and antiemetic medications at statistically significant differing rates. CONCLUSIONS: While PFD was associated with a higher rate of recurrent symptoms requiring repeated decompression, this may be justified by the significantly lower morbidity rate. Clearer delineation of the trade-off between morbidity and recurrence may be used to help patients and their families make decisions regarding care.

The legacy of Johann Friedrich Meckel the Elder (1724-1774): a 4-generation dynasty of anatomists.

Few families have had an impact on medicine to equal that of the Meckel family. Johann Friedrich Meckel the Elder is of special interest to the neurosciences, given that his dissertation on the fifth cranial nerve included the first description of the arachnoid space investing the trigeminal nerve into the middle fossa. He was interested in neuroanatomy, along with botany and pathology of the inguinal hernia and the lymphatic system. His mentors included the eminent Albrecht von Haller (1708-1777) and August Buddaeus (1695-1753), and he extended his own influence on the work of Giovanni Morgagni and Alexander Monro II. He spent the latter part of his life in Berlin as professor of anatomy, botany, and obstetrics. His son, Philipp Friedrich Theodor Meckel (1755-1803), was one of the founders of the current collection of anatomic specimens at the University of Halle and provided important groundwork for the practice of obstetrics. Meckel the Elder's grandson, Johann Friedrich Meckel the Younger (1781-1833), was a more prolific investigator and founder of the science of teratology. Many anatomic structures, such as Meckel's diverticulum, bear his name, and he vastly expanded the university's anatomic collection. August Albrecht Meckel (1789-1829), Meckel the Younger's brother, practiced legal medicine and investigated avian anatomy but died prematurely from tuberculosis. August's son, Johann Heinrich Meckel (1821-1856), took the instructor's position in pathologic anatomy at the University of Berlin that his great-grandfather had held at the Charité. After his untimely death from pulmonary disease, his position was filled by Rudolf Virchow. The history of this family is discussed in detail.

Dural relationships of Meckel cave and lateral wall of the cavernous sinus.

OBJECT: The purpose of this study was to elucidate the anatomy of the trigeminal nerve (cranial nerve [CN] V), Meckel cave (MC), and lateral wall of the cavernous sinus (CS). METHODS: Ten fresh cadaver heads (20 sides) and 2 middle fossa embalmed specimens were removed, decalcified, sectioned, stained, and studied microscopically. RESULTS: In the MC, the posterior fossa meningeal dura extended into the middle fossa surrounding CN V. The average medial length of the MC was 16.7 mm and the lateral length was 13.5 mm. The dural roof of MC was thicker than its floor and was covered by a paw-shaped fibrous tissue extending from the tentorium to the ganglion (in 100% of specimens). Between the dural sleeve of the MC and venous space of the CS, a separate fibrous wall could be identified in 45% (9 of 20) extending between the tentorium and the floor of the CS. The mean length of CN V in the MC proximal to the posterior margin of the Gasserian ganglion was 11.8 mm. The mean length of CN V1 was 19.4 mm; V2, 12.3 mm; and V3, 7.4 mm distal to the anterior margin of the ganglion. The periosteal dura followed the bone of the middle fossa and was continuous with the extracranial periosteum. The lateral dural wall of the CS consisted of a medial (membranous) and a lateral wall. The latter was separated into a thin outer layer and a thicker fibrous inner layer that became thinner as it extended posterolaterally. CONCLUSIONS: The MC is an extension of the posterior fossa dura with intricate relationships with the surrounding dural layers.

Submuscular transposition of the ulnar nerve for the treatment of cubital tunnel syndrome.

THE ULNAR NERVE is compressed at the cubical notch in patients with cubital tunnel syndrome. To definitively alleviate this compression, the nerve can be transposed under the pronator teres and flexor carpi ulnaris muscles. This procedure is also known as medianization of the ulnar nerve because it then courses parallel to the median nerve. In the current article the procedure is described in a step-by-step fashion.