Multidisciplinary approach to traumatic intracranial aneurysms secondary to shotgun and handgun wounds.

BACKGROUND: Traumatic intracranial aneurysms (TICAs) may develop following gunshot injuries to the head. Management of these lesions often combines various aspects of microneurosurgical and endovascular techniques to safely repair or obliterate vessel defects. METHODS: We reviewed our experience over the last 18 years and identified five cases of intracranial aneurysms following gunshot and handgun wounds that were treated surgically and/or endovascularly. RESULTS: All patients had successful obliteration of their lesions using a variety of therapeutic modalities aimed at preserving neurologic function while at the same time eliminating the aneurysm from the circulation. CONCLUSION: Both microneurosurgery and endovascular surgery have important roles to play in the management of TICAs. In some cases, both methods can be combined to eliminate lesions and maximize patient recovery in a safe, efficient, and effective fashion.

Posteroinferior cerebellar artery aneurysms: surgical results for 38 patients.

OBJECTIVE: Posteroinferior cerebellar artery aneurysms have an incidence of approximately 0.49%. Reports in the literature are sparse concerning outcomes in this patient population. We report our results for 38 consecutive patients who were treated during the last 6.5 years. METHODS: All patients (n = 38) with posteroinferior cerebellar artery aneurysms that were surgically treated at Zale-Lipshy University Hospital between January 1990 and May 1997 were retrospectively reviewed. Data were collected and analyzed relating to demographics, condition at presentation, lesion characteristics, associated medical problems, postsurgical complications, and outcome. RESULTS: Sixty-six percent of the patients (n = 25) experienced neurological sequelae, which included symptomatic vasospasm, hydrocephalus, dysarthria, paresis, diplopia, ataxia, and facial paralysis. Many, however, showed significant improvement during their hospitalization and during the course of the ensuing year. Seventy-four percent of the patients had a Glasgow Outcome Scale score of 1 or 2 at the time of discharge, 91% at 6 months after surgery, and 89% at 1 year after surgery. CONCLUSION: This review summarizes the presentations and outcomes of 38 consecutive surgical cases during a 6.5-year period and concludes that posteroinferior cerebellar artery aneurysms are not benign entities. The study does, however, also demonstrate that patients have significant recuperative potential after the treatment of these lesions.

Surgical treatment of cerebrospinal fluid fistulae involving lateral extension of the sphenoid sinus.

OBJECTIVE AND IMPORTANCE: Four cases of spontaneous cerebrospinal fluid rhinorrhea caused by communication between the subarachnoid space of the middle cranial fossa and a lateral extension of the sphenoid sinus are presented. The cause and management of this unique type of cranial base defect are discussed. CLINICAL PRESENTATION: During the past 10 years, four patients referred to our institution with atraumatic cerebrospinal fluid fistulae were observed to have temporal encephaloceles (encephalomeningoceles) traversing the floor of the middle cranial fossa. Three of the patients had previously undergone unsuccessful transnasal attempts to repair their fistulae by obliteration of the sphenoid sinus. The fourth patient presented before undergoing any treatment. No patient had associated hydrocephalus or tumor. Preoperative computed tomographic cisternograms revealed that all fistulae involved a lateral extension of the sphenoid sinus into the floor of the middle cranial fossa. INTERVENTION: After definitive localization, each patient was operated on transcranially through an anterior middle cranial fossa approach with extradural and/or intradural exploration. The associated temporal encephalocele was amputated or disconnected, and the dehiscent dura and middle cranial fossa floor defect were oversewn and packed with autogenous tissue, respectively. CONCLUSION: The surgical treatment of cerebrospinal fluid rhinorrhea secondary to middle fossa encephalocele associated with lateral extension of the sphenoidal sinus differs from the surgical strategy for more medial sphenoidal fistulae. Fistulae involving a lateral extension of the sphenoid sinus require a transcranial approach for direct visualization and obliteration of the defect, whereas fistulae involving the central portion of the sinus may be successfully obliterated transsphenoidally.

Detection of emboli after surgery for intracerebral aneurysms.

BACKGROUND: Neurological change after surgery for cerebral aneurysm caused by embolic events is commonly suspected, but direct detection of emboli has not been possible in the past. Transcranial Doppler ultrasound (TCD) is able to detect emboli, and large numbers of emboli detected in TCD studies have been associated with radiological changes and clinical deterioration. METHODS: During a 2-year period, 11 patients were observed to have emboli during routine TCD studies after aneurysm surgery. The computed tomographic (CT) scans of these patients were reviewed for low-density areas, suggesting ischemia. All patients studied during a 1-year interval (July 1995-July 1996) served as a control group and were reviewed for similar CT findings, and the two groups were compared using Fisher's exact test. RESULTS: Nine of the 11 patients (82%) observed to have emboli developed low-density areas on their CT scans, whereas 30 of the 123 (24%) patients without emboli developed low-density areas on their CT scans. The difference was significant (P < 0.001, Fisher's exact test). Credible sources for emboli were readily identified in each of the 11 patients. CONCLUSION: TCD allows detection of emboli after aneurysm surgery, and this detection is strongly associated with CT evidence of ischemia. Although detection of emboli was relatively rare in this study, rates of emboli occurrence may increase if systematic monitoring is used.