Balloon migration into a giant carotid aneurysm after parent artery occlusion using detachable balloons.

SUMMARY: We treated a 70-year-old man with a giant paraophthalmic region aneurysm of the right internal carotid artery using the parent artery occlusion technique with three detachable balloons. Initially, the patient did well, but migration of the distal balloon into the aneurysm was detected seven months later. This report suggests that initial parent artery occlusion using balloons will not always induce permanent thrombosis of a large aneurysm, because the occlusion and thrombosis is strictly dependant on the position of the balloons that are used, and adjunct use of coils may be indicated.

Repeat intra-arterial papaverine for recurrent cerebral vasospasm after subarachnoid haemorrhage.

We assessed the prevalence of recurrent vasospasm following failure of intra-arterial papaverine and the efficacy of repeat intra-arterial infusions of papaverine for control of recurrent vasospasm. Of 24 patients treated with intra-arterial papaverine for vasospasm following aneurysm surgery, 12 did not improve clinically after the initial treatment; 9 received second or third infusions on consecutive days; 6 received only a second infusion; and 3 received a third. Superselective infusion into the intracranial arteries was performed in all nine cases. Despite angiographic improvement after the initial or second infusions, all nine patients showed varying degrees of recurrent vasospasm at the time of the second or third treatment. Within 24 h of a second infusion, three of the six patients had significant clinical improvement, and one of these showed marked improvement soon after a third infusion. Our preliminary results suggest that repeat papaverine infusion may be a way of controlling recurrent or recalcitrant vasospasm.

Primary solitary amyloidosis of the spine: a case report and review of the literature.

BACKGROUND: Amyloidosis is a term that encompasses a group of disorders that have as their common feature the intercellular deposition of the amyloid protein by several different pathogenetic mechanisms. Primary solitary amyloidosis, or amyloidoma, is a rare subset of amyloidosis in which the amyloid deposition is focal and not secondary to a systemic process or plasma cell dyscrasia. We present the second reported case of a cervical spine amyloidoma and discuss its presentation and management. METHODS: This 58-year-old man presented with a 1-year history of intermittent chest pain that would radiate into both legs precipitated by valsalva maneuvers. A magnetic resonance imaging (MRI) of the cervical spine revealed a homogenously enhancing lesion focally involving the C-7 vertebral level with significant spinal cord compression. He underwent combined anterior and posterior decompressive procedures with instrumentation for spinal stabilization. Histopathology revealed amyloid deposits and a systemic work-up was negative for amyloidosis. RESULTS: The patients is free of any tumor recurrence at 24 months and has a stable spine construct. CONCLUSIONS: Primary solitary amyloidosis is a rare subtype of amyloidosis which, unlike other forms of amyloidosis, has an excellent prognosis with local resection. Diagnosis requires special stains and therefore a degree of suspicion for the disease. Management of vertebral amyloidoma involves aggressive local resection of the tumor when feasible and stabilization of the spine as mandated by the degree of tumor involvement. Complete evaluation for the diagnosis of systemic amyloidosis is essential for the management and prognostication of each case.

Dural tail adjacent to acoustic neuroma: MR features.

There have been several reports describing the presence of a dural tail on enhanced MR as being specific for or suggestive of meningioma. It has also been stated that it is a specific diagnostic sign in distinguishing meningioma from acoustic neuroma. We report a case of a dural tail in an acoustic neuroma.

Cervical spondylotic myelopathy: treatment with posterior decompression and Luque rectangle bone fusion.

Cervical spondylotic myelopathy appears to result from a combination of factors. The two major components are 1) compressive forces resulting from narrowing of the spinal canal, and 2) dynamic forces owing to mobility of the cervical spine. There is substantial evidence to suggest that the repetitive trauma to the spinal cord that is sustained with movement in a spondylotic canal may be a major cause of progressive myelopathy. Utilization of extensive anterior procedures that remove the diseased ventral features as well as eliminate the dynamic forces owing to the accompanying fusion have grown in popularity. Cervical laminectomy enlarges the spinal canal, but does not reduce the dynamic forces affecting the spinal cord, and may actually increase cervical mobility, leading to a perpetuation of the myelopathy. The authors propose the combination of posterior decompression and Luque rectangle bone fusion to deal with both the compressive and the dynamic factors that lead to cervical spondylotic myelopathy. Ten patients who had advanced myelopathy underwent the combined procedures. Nine of the 10 experienced significant neurological improvement, and the 10th has had no progression. The combination of posterior decompression and Luque rectangle bone fusion may offer a simple, safe, and effective alternative treatment for cervical spondylotic myelopathy.

Subarachnoid hemorrhage due to intracranial aneurysm: current management.

Intracranial aneurysms cause in excess of 28,000 subarachnoid hemorrhages per year in North America. The combined mortality and morbidity from aneurysmal subarachnoid hemorrhage exceeds 40%, and therefore yields a remarkably high toll of human and economic loss. As a lesion that is treatable, even curable at particular stages, management decisions are critical. In spite of significant advances in surgical technique, the mortality rate remains high. Erroneous diagnosis in good-grade patients significantly contributes to the lack of improvement in current statistics. Diagnosis and subsequent contemporary management is discussed.

Symptomatic pineal cyst: case report.

Pineal cysts are being described with increasing frequency since the advent of magnetic resonance imaging. Although pineal cysts are incidental findings in as many as 4% of magnetic resonance imaging studies, symptomatic pineal cysts are quite rare. We present a case of pineal cyst causing aqueductal obstruction with symptomatic hydrocephalus and resultant headache and syncope, which was treated by surgical resection. A review of the relevant literature and discussion follow.

Vicryl (polyglactin 910) mesh as a dural substitute in the presence of pia arachnoid injury.

Previously presented data showed that Vicryl mesh was a potentially effective dural grafting material. It is easily handled, relatively inexpensive, absorbed over time, and elicits a minimal inflammatory response. The present experimental project was conducted to investigate the effectiveness of a tightly woven version of the material as a watertight seal and to evaluate its performance in the presence of pia arachnoid injury. The mesh formed a seal promptly and adhesion formation was slight. Tightly woven Vicryl mesh appears to have a significant potential as an absorbable dural substitute.

Restoration of hearing after removal of cerebellopontine angle meningioma: diagnostic and therapeutic implications.

A case of cerebellopontine angle meningioma with restoration of hearing from a profoundly deaf state is presented. Meningiomas of the posterior fossa commonly present with decreased or absent hearing and can appear deceptively similar to acoustic neurinomas on radiographic and audiometric testing. Because total restoration of hearing can occur with meningioma, even with significant preoperative deficit, utilization of the translabyrinthine approach is less desirable if any preoperative question as to the diagnosis exists. Any hearing-impaired patient with a cerebellopontine angle mass that is not conclusively thought to represent acoustic neurinoma should be approached by the suboccipital technique to maximize the opportunity for restoration of hearing.

Postoperative radiographic appearance of intracranial hemostatic gelatin sponge.

Hemostatic gelatin sponges were placed in hemispheric defects created in four dogs which were then periodically scanned by computed tomography to determine the postoperative appearance of the sponges. The hemostatic sponges appeared as low attenuation regions for 7-10 days. The attenuation value of these Gelfoam cavities was intermediate between fat and air. Subsequently, clinical cases were selected in which the location of gelatin sponges were known to demonstrate the appearance of the material in patients. In addition to enhancing the accuracy of computed tomographic interpretation, we have found that the gelatin sponge can be useful as a transient computed tomography marker for localization of surgical activity.

Vicryl (polyglactin 910) mesh as a dural substitute.

Many substances have been used as dural substitutes. Although the various materials are effective in a variety of settings, a material that is absorbed over time, elicits minimal inflammatory reaction, is relatively inexpensive, and is easily manipulated would be beneficial. An experimental project was conducted involving closure of dural defects in dogs with a Vicryl (polyglactin 910) mesh graft. Macroscopic and histological examination performed at various times after placement revealed resorption of the graft material, little cerebromembranous adhesion formation, and complete lack of injury to subjacent cortical zones. A substantial neomembrane forms over the zone of the mesh graft. The authors suggest that Vicryl mesh has significant potential as an absorbable, minimally reactive dural substitute.

Blunt trauma to the carotid artery with transient deficit and early repair.

Blunt trauma to the carotid artery is an uncommon but easily overlooked source of neurological deficit. The prompt diagnosis and angiographic definition of carotid-artery injuries can allow early operative intervention in these potentially devastating lesions. We describe a case report of blunt trauma with transient deficit in a patient who underwent direct repair via Dacron-patch angioplasty.