Exploring Spinal Subarachnoid Hemorrhage: A Neurosurgical Case Series.

Spinal subarachnoid hemorrhage (SSAH) is a rare condition that can cause spinal cord or nerve root compression and permanent neurologic damage. The reported etiologies include trauma, vascular malformations or aneurysms, coagulopathies, neoplasms, autoimmune disease, and spontaneous hemorrhage. If there is evidence of neurologic deterioration, it is commonly managed as a surgical emergency, but cases of conservative management have also been reported. In this case series, we present three patients who suffered from SSAH. The first was a spontaneous cervical SSAH that occurred following cardiac catheterization, the second was a spontaneous thoracolumbar SSAH in a patient with a known history of coagulopathy, and the third was a thoracolumbar SSAH that was caused by a dural arteriovenous fistula (dAVF). All three patients exhibited neurologic deficits and thus underwent emergent decompression and hematoma evacuation. The patient with the dAVF also required open ligation of the fistula. Following surgical intervention, all three patients regained at least partial neurologic function, but one patient developed symptomatic arachnoid cysts that required further intervention. The presented case series highlights the importance and time-sensitivity of surgical decompression in patients experiencing neurologic deficits from SSAH. These cases underscore the urgency of timely neurosurgical intervention to mitigate neurologic impairment and add insights to the existing literature on this rare condition.

PulseRider Treated Aneurysm with Significant Artifact on Postoperative Magnetic Resonance Angiography: A Case Report and Literature Review.

The PulseRider is a neuroendovascular adjunct for wide-necked intracranial aneurysms. The decreased metal burden of the PulseRider theoretically reduces artifact on radiologic imaging. However, we report here on a case of a patient who underwent PulseRider-assisted stent-coiling of a basilar tip aneurysm. He returned 19 months later for intermittent diplopia and darkening of vision but was neurologically intact on exam. Both contrast-enhanced and time-of-flight magnetic resonance angiography (MRA) demonstrated absence of signal in the basilar artery in the proximal anchors of the PulseRider. Given his lack of reproducible symptoms and high functional status, it is presumed that the imaging reflected artifact and not thrombosis/stenosis. Although the PulseRider is a useful treatment option for wide-necked intracranial aneurysms, the clinician should be aware that even contrast-enhanced MRA can produce artifact that resembles thrombosis/stenosis. Non-angiogram radiologic imaging modalities may be appropriate for evaluation for residual aneurysm but not patency of the parent artery.

Basilar tip aneurysm Wingspan stent-assisted coil embosurgery via P1 to P1 approach.

Wide neck basilar tip aneurysms are challenging to secure with coil embosurgery despite balloon remodeling and stent-assisted coiling. In patients with favorable posterior circle of Willis anatomy, the traditional antegrade placement of two stents that span the basilar apex to both proximal posterior cerebral arteries (P1s) can be avoided by implanting a single stent across the P1s and basilar apex via a retrograde posterior communicating artery approach. This case report details the first use of the high radial force Wingspan stent placed in this fashion during basilar aneurysm coiling repair.

Off-Label Application of Pipeline Embolization Device for Intracranial Aneurysms.

PURPOSE: The Pipeline embolization device (PED) is approved in the USA for treating giant and large aneurysms arising from the petrous to superior hypophyseal segments of the internal carotid artery in patients older than 21 years of age. This study investigates off-label PED results in a large cohort. MATERIALS AND METHODS: Retrospective, single-center review of all patients who had off-label PED surgery. RESULTS: Sixty-two aneurysms (48 patients) underwent off-label PED treatment from 2012- 2017. There were 44 females and four males (age 21 to 75 years; mean/median, 54.3/55.0 years). The most common presenting symptom was headache (47/62, 75.8%). All aneurysms were in the anterior circulation. Aneurysm size ranged from 1.4 to 25.0 mm (mean/median, 7.6/6.9 mm). Fifty-two aneurysms had post-operative imaging with total/near-complete occlusion of 84.6% (44/52). Aneurysm-based operative near-term complication rate was 9.7% while there were no permanent complications. For aneurysms and headache, 86.7% improved/resolved after embo-surgery, and were four times more likely to have a better clinical outcome (resolved or improved symptoms) after surgery (odds ratio [OR], 4.333; P=0.0325). Left-sided aneurysms had a higher occlusion rate (OR, 20; P=0.0073). Hypertension (OR, 4.2; P=0.0332) and smoking (OR, 7; P=0.0155) were more prone towards aneurysm occlusion. Patients without a family history were 14 times more likely to have favorable imaging outcome (P=0.0405). There is no difference of occlusion rates between untreated and previously treated aneurysms (P=0.6894). Overall, occlusion rate decreased by 14% with an increase of aneurysm size by 1 mm (P=0.0283). CONCLUSION: For anterior circulation aneurysms, the off-label application of PED is as effective and safe as reported for on-label intracranial aneurysms.

Successful Endovascular Bailout Strategy for Retained Accunet Embolic Protection Device During Vertebral Artery Stenting.

Introduction: Vertebral artery stenosis can lead to posterior circulation TIAs and stroke. Stenting is often performed to treat symptomatic vertebral artery stenosis. As with carotid stenting, embolic protection devices (EPD) are increasingly used when stenting a vertebral artery stenosis. In general, EPDs may rarely become detached or retained in the circulation during stent revascularization. We discuss a 77-year-old male with a history of cerebral atherosclerosis and prior left occipital lobe and right insular infarcts who presented with increasing left sided weakness and was found to have severe stenosis of the proximal left vertebral artery. We report the only known case and successful endovascular bailout for an irretrievable EPD occurring during vertebral artery stenting. Methods: Systematic reviews of the medical literature were performed using PubMed and multiple combinations of keywords to search for irretrievable EPDs in either the carotid or vertebral arteries. The bibliographies of the results were used to identify additional publications until this process was exhausted. Results: No prior reports were found for retained or detached vertebral artery EPD. A total of six cases were found where an EPD was lost in the carotid circulation. In three of the cases, a carotid arteriotomy was required to retrieve the EPD. In two other cases, diagnostic catheters were used to retrieve the EPD. In our case, an EverFlex Biliary Stent was used to flatten the irretrievable EPD into the vertebral artery wall while preserving robust vertebral artery perfusion. 21-month clinical and 16-month imaging follow-up demonstrated durable vertebral artery patency and no ischemic symptoms. Conclusion: Successful bailout strategy for a retained vertebral artery EPD during stenting may be achieved with a self-expanding stent. The resultant revascularization remained durable and without clinical sequelae.

Retromedullary Hemangioblastoma Mimicking a Posterior Inferior Cerebellar Artery Aneurysm: Case Report and Literature Review.

BACKGROUND: Hemangioblastomas (HBMs) are benign vascular neoplasms that most commonly arise within the cerebellum. Although other vascular lesions should be considered in the differential diagnosis, HBMs rarely resemble aneurysms on neuroimaging and only 1 case of a cerebellar HBM mimicking a posterior fossa aneurysm has been reported. Here we describe a retromedullary HBM that masqueraded as a distal posterior inferior cerebellar artery (PICA) medullary branch aneurysm. CASE DESCRIPTION: A 63-year-old asymptomatic male was incidentally diagnosed with an unruptured 3-mm left PICA aneurysm via computed tomography angiography during a workup for carotid stenosis. Two years later, the presumed aneurysm enlarged to 6.5 mm and prompted elective treatment. Endovascular treatment was unsuccessful, and the patient was immediately transitioned to a craniotomy for aneurysm clipping. After microsurgical dissection, the lesion was visualized on the posterior medullary surface with several small arterial feeders extending from the brainstem into the aneurysm dome, but no major parent vessel was observed. Because a clip could not be safely applied to these small vessels, they were instead coagulated and the lesion was completely resected. Final pathology revealed hemangioblastoma (World Health Organization grade I). CONCLUSIONS: To our knowledge, this is the second case of HBM mimicking a PICA aneurysm. Given the rarity of PICA medullary branch aneurysms and their highly symptomatic nature, other etiologies, especially HBM, should be strongly considered when an apparent distal PICA aneurysm is diagnosed in an asymptomatic patient. If the lesion is unamenable to endovascular treatment, there should be high suspicion for HBM and subsequent craniotomy should be pursued.

Improving Forward Infusion Pressure during Brain Tumor Embolization with the Double Catheter and Coil Technique.

Endovascular embolization or embosurgery of brain tumors can be used to reduce neoplasm vascularity prior to surgical resection. Two challenges with embosurgery relate to insufficient perfusion pressure into the tumor and inadvertent escape of infused agents into parenchymal branches of the adjacent brain. This report describes a multi-catheter and coil technique to improve tumor perfusion and prevent reflux into normal branches.

Neuroform-EZ Stent Modification for Facilitated Delivery during Intracranial Aneurysm Embosurgery.

The Neuroform EZ Stent System is a fourth generation intracranial aneurysm stent that utilizes an integrated navigation guidewire. While designed to facilitate stent delivery, the guidewire can rarely impede proper positioning of the stent. In this technical case report, severing the guidewire from the stent delivery system with surgical scissors was required for successful stent implantation.

Bilateral mirror posterior inferior cerebellar artery aneurysms: diagnostic caveat on catheter angiography.

Only three definitive cases of bilateral mirror proximal posterior inferior cerebellar artery (PICA) aneurysms have ever been reported. A fourth example is presented where each PICA aneurysm remained angiographically occult on contralateral vertebral artery angiography despite retrograde filling of the parent vessel PICA. Implications for clinical practice are discussed.

Results of epistaxis embosurgery using detachable platinum fibered coils.

BACKGROUND: Safety and efficacy outcomes are lacking for embosurgery of the distal internal maxillary artery (IMax) using detachable platinum fibered coils (DPFCs) in patients with uncontrollable epistaxis. METHODS: A retrospective analysis was conducted on patients treated October 2006 through May 2009 with a diagnosis of uncontrollable or recurrent epistaxis managed by DPFC. Inclusion criteria included patients with epistaxis complicating open or endoscopic nasal surgery, or patients with the following covariant risk factors: aspirin, clopidogrel, warfarin, ibuprofen or hypertension. Patients were excluded if particulates, liquid glue or non-permanent embolics were used as adjuvants. Medical record review and follow-up for 1 month were performed on all patients to determine treatment results and complications. RESULTS: A cohort of 20 patients meeting enrollment criteria was comprised of 13 men and 7 women with a mean age of 63 years (range 35-85 years). Epistaxis etiologies included recent nasal surgery (N=2) while all patients (N=20) had one or more covariant epistaxis risk factors. 17 patients underwent bilateral IMax embolization. Three patients had unilateral IMax embosurgery in which two patients had a remote history of contralateral IMax open ligation for previous epistaxis. 95% of the cohort remained free of recurrent nose bleeding requiring medical or surgical intervention. 95% of the patients had no complications while one patient (5%) had transient unilateral facial pain. There was no procedure-related death, blindness or stroke. One patient died during follow-up from unrelated causes. CONCLUSION: DPFC embosurgery is effective and safe in managing uncontrollable epistaxis.

Use of a wire extender during neuroprotected vertebral artery angioplasty and stenting.

BACKGROUND: The off-label use of an extender wire during vertebral artery stenting and angioplasty with or with neuroprotection has not been previously reported. MATERIAL AND METHODS: Retrospective, single-patient, technical report. RESULTS: After monorail balloon angioplasty was performed on a proximal left vertebral artery stenosis, the 190 cm long Accunet neuroprotection filter device was not long enough for delivery of an over-the-wire stent. After mating a 145 cm long, 0.014 inch extension wire to the filter device, a balloon-mounted Liberté stent was implanted with good angiographic and clinical results. CONCLUSION: The off-label use of an extender wire permits successful over-the-wire stenting on a monorail neuroprotection device for vertebral artery endosurgery.

Fenestration of the posterior inferior cerebellar artery.

Fenestration of the posterior inferior cerebellar artery (PICA) is exceedingly rare. Only one known example - a right PICA fenestration, has been documented in the peer-reviewed literature. A left-sided PICA fenestration is presented in this unique case illustration.

Double origin of the posterior inferior cerebellar artery: association with intracranial aneurysm on catheter angiography.

OBJECTIVE: Double origin of the posterior inferior cerebellar artery (PICA) is a congenital anomaly in which the PICA forms from two separate vessels arising from the vertebral artery. The prevalence of double origin of the PICA on catheter angiography is unknown because only four case reports have been published. Because some congenital intracranial vascular oddities are associated with an elevated incidence of aneurysm formation, we sought to determine the association between intracranial aneurysm and double origin of the PICA and to measure the prevalence of double origin of the PICA on catheter angiography. MATERIALS AND METHODS: A retrospective review was done over a 27-month period to identify patients with double origin of the PICA. Patients were excluded if both PICAs were not adequately visualized on catheter angiography. The cohort was then divided into two groups consisting of patients with and those without intracranial aneurysm. RESULTS: A total of 207 patients (101 males, 106 females) met the inclusion criteria. One or more cerebral aneurysms were found in 35.3% and double origin of the PICA in 1.45% of the patients. Double origin of the PICA was present in 4.1% of the patients with an aneurysm, and none of the patients without an aneurysm had double origin of the PICA (p = 0.043). A majority of the seven known cases of double origin of the PICA described by angiography in the peer-reviewed literature have associated intracranial aneurysm disease. CONCLUSION: Our data show that double origin of the PICA is seen in 4.1% of patients with intracranial aneurysm and on 1.45% of catheter angiograms. Double origin of the PICA has an increased association with intracranial aneurysmal disease and may represent a risk factor for subsequent development of intracranial aneurysm.

Stent-angioplasty for internal-to-external carotid artery anastomotic stenosis: a case report.

Endosurgical stenting and angioplasty using filter neuroprotection can be safely performed with a durable result for the repair of a cervical internal-to-external carotid artery anastomotic stenosis.

T1-weighted imaging of the brain at 3 tesla using a 2-dimensional spoiled gradient echo technique.

RATIONALE AND OBJECTIVES: The objective of this study was to evaluate a 2-dimensional spoiled gradient echo (GRE) imaging approach using a very short in-phase TE for routine T1-weighted imaging of the brain at 3 T. MATERIALS AND METHODS: Patient examinations were compared from a 3 T magnetic resonance (MR) unit located immediately adjacent to a similarly equipped 1.5 T unit. Pre- and postcontrast T1-weighted images were evaluated and compared at 1.5 versus 3 T with a 2-dimensional (2-D) spin echo sequence used at 1.5 T and a 2-D GRE sequence at 3 T. The 2 MR systems used are from the same vendor, use similar 8-channel coils, and use identical gradients. The T1-weighted GRE sequence, used at 3 T, relies on a short TE (2.4 ms) to limit flow-related and susceptibility artifacts. Region-of-interest analysis was performed on 16 different sagittal patient examinations at both field strengths (32 total) and similarly on 10 different pre- and postcontrast axial examinations (40 total). Four blinded neuroradiologists also evaluated these studies. RESULTS: Using an off-midline sagittal slice depicting the caudate nucleus (signal-to-noise ratio [SNR] 163 +/- 28 vs. 70 +/- 7, 3 T vs. 1.5 T) and corona radiata (SNR 214 +/- 35 vs. 82 +/- 10), 3 T markedly outperformed 1.5 T in both SNR and contrast-to-noise ratio (CNR) (51 +/- 14 vs. 12 +/- 5). On axial imaging, despite a reduction in slice thickness (5 to 3 mm) and scan time (5 to 1 minute), there was no significant difference pre- or postcontrast in SNR and CNR comparing 3 and 1.5 T. On blinded film review, 3 T performed slightly better on sagittal scans than 1.5 T in regard to motion artifacts (reduced), gray-white matter differentiation, and overall image quality. On axial scans, 3 T performed markedly better in all 3 categories both pre- and postcontrast. In regard to overall image quality, 3 T was preferred 9:2 precontrast and 4:1 postcontrast. CONCLUSIONS: High-quality, thin-section (3-mm) T1-weighted imaging can be readily performed at 3 T using a short TE 2-D GRE technique. This approach offers superior SNR and CNR with reduced motion artifacts and scan time as compared with imaging at 1.5 T and is advocated for routine brain imaging at 3 T. It is robust (used in over 1500 patients to date) and does not experience significant specific absorption ratio limitations, poor tissue contrast, or accentuated motion artifacts like encountered with spin echo T1-weighted imaging at 3 T.

N-butylcyanoacrylate embolization of a middle meningeal artery aneurysm in a patient with neurofibromatosis type 2.

Aneurysms of the middle meningeal artery are rare, with no documented association with neurofibromatosis type 2 (NF2). Middle meningeal artery aneurysm embolization with N-butylcyanoacrylate has not been described, and altogether, few accounts exist regarding the endovascular management of these unusual aneurysms. In this case report of a patient with NF2, an unruptured middle meningeal artery aneurysm was prophylactically embolized in a previously unreported fashion by using N-butylcyanoacrylate acrylic glue.

Outcomes for overlapping stents in the extracranial carotid artery.

Various diseases of the carotid artery are treatable by stenting. However, few reports of overlapping carotid stents exist. As a result, the indications, long-term outcomes, and potential complications of this technique remain largely unknown. We therefore present and examine a series of 11 patients treated by this unique stenting method. A retrospective single-institution review was performed for patients in whom overlapping carotid stents were placed. Only patients with imaging follow-up beyond 3 months were included. Of 38 patients who had extracranial carotid artery stents placed, 11 patients fulfilled the inclusion criteria for both overlapping stents and imaging follow-up greater than 3 months (range, 0.4-3 years; mean, 1.3 years). Clinical follow-up ranged between 0.4 and 3.6 years (mean, 2.1 years). Carotid pathology within this cohort included atheromatous stenosis (n = 3), recurrent stenosis following carotid endarterectomy (n = 2) or stenting (n = 1), postirradiation angiitis (n = 1), carotid artery kink created by initial stent placement (n = 2), and both traumatic (n = 1) and neoplastic (n = 1) carotid blowout syndrome. No permanent stroke or stenting-related death occurred. Focal stenosis or intimal hyperplasia resulting in 35% or less luminal narrowing developed in three patients (27%) after tandem stenting. Overlapping stents provide a durable treatment for a variety of extracranial carotid pathologies. Clinically and hemodynamically significant (> 50%) poststenting stenosis or intimal hyperplasia did not occur in this series.

Double origin of the posterior inferior cerebellar artery.

Double origin of the posterior inferior cerebellar artery (PICA) has rarely been demonstrated by angiography in the peer-reviewed literature. Of the three previous reports, this PICA variant arose from the left vertebral artery. We report a right-sided, double-origin PICA.