Surgical management and alternative strategies for neighboring intracranial aneurysms.

AIM: Neighboring aneurysms are misidentified or named as a single multi-lobulated aneurysm, despite the demonstration of angiographic cleavage, because of the close proximity and different size. During surgery, neighboring intracranial aneurysms represent an interesting subset of aneurysms that may pose unique management challenges. Meticulous preoperative radiological planning is necessary to properly appreciate the local anatomy. Intraoperative microsurgical dissection of these aneurysm complexes may be difficult if a plane cannot be created between the neighboring lesions with dissection of the aneurysm necks and preservation of blood flow becoming a challenging situation. METHODS: A retrospective review over a 10-year period, of all patients with intracranial aneurysms treated by our service was performed to identify those patients with neighboring aneurysms. RESULTS: We encountered 73 instances of neighboring aneurysms (MCA-22, PCOMMA/AChA-20, ACOMMA-15, paraclinoid-5, upper basilar-4, pericallosal-3, ICA bifurcation-2, VB junction-2). Most patients were managed with either microsurgery for both aneurysms or coiling for both. Seven patients with severe SAH underwent coiling of the presumed ruptured (much larger) aneurysm with subsequent microsurgery for the neighboring aneurysm which was not considered amenable to endovascular therapy. In the setting of neighboring lesions, microsurgery was sometimes deemed significantly more difficult than usual, particularly when the aneurysm domes were adherent precluding optimal visualization of the local vascular anatomy. Temporary vascular occlusion was often helpful to allow for proper inspection and identification of all perforating vessels initially hidden by the adherent sacs. CONCLUSION: Neighboring intracranial aneurysms represent an interesting subset of aneurysms that may pose unique management challenges. Careful evaluation of preoperative angiography is necessary to properly appreciate the local anatomy in these cases. Microsurgical dissection of these aneurysm complexes may be difficult if a plane cannot be created between the neighboring lesions. Because neighboring aneurysms tend to obscure the local anatomy, intraoperative angiography and innovative surgical strategies were useful in our experience.

Non-infected carotid artery pseudoaneurysm 29 years after endarterectomy, endovascular management with covered stent.

Pseudoaneurysm formation is a rare complication following carotid endarterectomy (CEA). Arterial pseudoaneurysms lack all three layers of the arterial wall that include the intima, media and adventitia. Pseudoaneurysms are most commonly seen after injuries to the artery in the form of blunt trauma and puncture, and are less common after surgeries such as carotid endarterectomy. These lesions present most frequently as enlarging, pulsatile, expandable masses associated with swelling and pain. Management of this complication is challenging. Traditionally, open surgical repair has been the preferred treatment. Recently, endovascular techniques using stent graft implantation alone or combined graft and coil embolization have offered a less invasive approach for the management of this lesion. Pseudoaneurysm development has been described within hours to several years after initial arterial injury, normally presenting within 5 years. To our knowledge, this is the first case report of pseudoaneurysm formation in a patient presenting 29 years after a carotid endarterectomy; during that time the patient remained completely asymptomatic until 2 months prior to his admission. The patient is an 84-year-old male with a history of stroke which prompted a left carotid endarterectomy in 1981. Twenty-nine years post procedure it was noted that the patient had a lump that was progressively enlarging on the left side of his neck, zone 1. It was pulsatile on examination. MRI/A imaging suggested a left carotid bulb aneurysm. The consulting vascular surgeon felt the patient would not be a good surgical candidate and so stenting was considered. Carotid and cerebral angiogram demonstrated a large 6 cm left carotid pseudoaneurysm off the carotid bulb. The diagnostic procedure was followed by a successful placement of an 8 x 10 cm Viabahn covered stent from the left common carotid artery to the left internal carotid artery. Following the procedure, the carotid artery was patent and there was minimal to no further residual filling of the pseudoaneurysm. Poststenting, the patient remained at his neurological baseline. This case demonstrates that pseudoaneurysm formation can occur as a long term complication after carotid endarterectomy. It may present as a rapidly expandable, pulsatile, vascular lesion in the absence of clinical and sub-clinical infection. Placement of an endovascular stent graft may be a safe and effective option for treatment of infected and non-infected carotid pseudoaneurysm.

Intracranial aneurysm formation in siblings with pseudoxanthoma elasticum: case report.

Although intracranial aneurysms have been associated with many hereditary collagen disorders, the incidence of brain aneurysms in pseudoxanthoma elasticum (PXE) appears to be exceedingly low and uncertain. We describing a rare case of a sisters with PXE who both developed intracranial aneurysms. This report supports the previously questioned hypothetical association between PXE and intracranial aneurysms.

Breath sulfides and pulmonary function in cystic fibrosis.

We have determined the concentrations of carbonyl sulfide (OCS), dimethylsulfide, and carbon disulfide (CS(2)) in the breath of a group of cystic fibrosis (CF) patients and one of healthy controls. At the detection sensitivity in these experiments, room air always contained measurable quantities of these three gases. For each subject the inhaled room concentrations were subtracted from the time-coincident concentrations in exhaled breath air. The most significant differences between the CF and control cohorts in these breath-minus-room values were found for OCS. The control group demonstrated a net uptake of 250 +/- 20 parts-per-trillion-by-volume (pptv), whereas the CF cohort had a net uptake of 110 +/- 60 pptv (P = 0.00003). Three CF patients exhaled more OCS than they inhaled from the room. The OCS concentrations in the CF cohort were strongly correlated with pulmonary function. The dimethylsulfide concentrations in breath were greatly enhanced over ambient, but no significant difference was observed between the CF and healthy control groups. The net (breath minus room) CS(2) concentrations for individuals ranged between +180 and -100 pptv. They were slightly greater in the CF cohort (+26 +/- 38 pptv) vs. the control group (-17 +/- 15 pptv; P = 0.04). Lung disease in CF is accompanied by the subsistence of chronic bacterial infections. Sulfides are known to be produced by bacteria in various systems and were therefore the special target for this investigation. Our results suggest that breath sulfide content deserves attention as a noninvasive marker of respiratory colonization.

Continuous and pulsed ultrasound do not increase heat shock protein 72 content.

Therapeutic ultrasound (US) is a common treatment used in the rehabilitation of injured muscle. To determine whether therapeutic US could increase the content of heat shock protein (HSP) 72 in skeletal muscle, male Sprague-Dawley rats were anesthetized and the muscles from one hind limb treated with 15 min of US at 1 MHz using either: 1. continuous US at 1.0 W/cm(2), 2. pulsed US at 2.0 W/cm(2) at 50% duty cycle, or 3. pulsed US at 1.0 W/cm(2) at 20% duty cycle. All treatments were applied using a transducer (1.6-cm diameter) on an area of the rat hind limb twice the size of the sound head. At 24 h following treatment, the plantaris, soleus, white and red gastrocnemius muscles were removed and assessed for HSP 72 content by Western blotting. No significant increases in HSP 72 content were detected in any of the muscles examined following any US treatment. These results suggest muscle HSP content is not elevated following a typical therapeutic dose of either continuous or pulsed US in the rat.

Fitness, acute exercise, and anabolic and catabolic mediators in cystic fibrosis.

Exercise can stimulate catabolic inflammatory cytokines even in healthy children. For patients with cystic fibrosis (CF), this may be problematic because CF is characterized by increased inflammation and suppressed growth. We examined fitness and the response to brief exercise of interleukin-6 (IL-6), tumor necrosis factor-alpha (TNF-alpha), insulinlike growth factor-I (IGF-I), and IGF binding protein-1 (IGFBP-1) in 14 subjects with CF (10.5 +/- 0.8 yr of age), 9 of whom were treated with ibuprofen, and 14 healthy control subjects (11.6 +/- 0.5 yr of age, NS). Subjects performed brief intermittent, constant work rate protocol (scaled to each individual's exercise capacity) with blood and urine sampling. Peak V O(2) was correlated with IGF-I (r = 0.68, p < 0.01) in control subjects but not in subjects with CF. In subjects with CF, baseline IL-6 was 79% greater (p < 0.05) and IGF-I was 47% lower than in control subjects (p < 0.05). Post hoc analysis revealed a progressive increase in the IL-6 response to exercise, with the lowest increase observed in control subjects (11.8 +/- 4.6 pg/L/kJ), higher increases in patients with CF treated with ibuprofen (23.4 +/- 7.7 pg/L/kJ), and highest in subjects with CF not receiving ibuprofen (29.2 +/- 7.5 pg/L/kJ). Qualitatively similar results were observed for TNF-alpha. Exercise also significantly increased IGFBP-1 in both control subjects and subjects with CF. Brief exercise can increase even chronically elevated inflammatory mediators in CF, and this response may be attenuated by ibuprofen.

Plastic bronchitis and the role of bronchoscopy in the acute chest syndrome of sickle cell disease.

STUDY OBJECTIVES: To review the prevalence, clinical features, and role of bronchoscopy in patients with plastic bronchitis during the acute chest syndrome (ACS) of sickle cell disease (SCD). DESIGN: Eight-year review of clinical experience. SETTING: Tertiary referral children's hospital. PATIENTS: Twenty-six pediatric inpatients with 29 ACS episodes requiring diagnostic bronchoscopy. RESULTS: Of the pediatric inpatients with ACS who underwent bronchoscopy, plastic bronchitis was diagnosed in 21 of 29 episodes (72%). There was no difference in clinical features between the patients with and without plastic bronchitis. Bronchoscopy was an essential diagnostic tool, but its therapeutic benefits were doubtful. CONCLUSIONS: This is the first report of the prevalence of plastic bronchitis in patients with ACS of SCD. In our patient population, this condition was found to be common. The role of diagnostic bronchoscopy is essential. A large series, multicenter study is required to determine whether bronchoscopy and BAL are therapeutically beneficial when added to currently practiced supportive care.

Pediatric fiberoptic bronchoscopy with a laryngeal mask airway.

BACKGROUND AND OBJECTIVES: Bedside flexible fiberoptic bronchoscopy (FFB) with sedation has been recognized as a diagnostic modality in children. In certain circumstances, general anesthesia with endotracheal intubation is advocated. This study evaluates the usefulness of the laryngeal mask airway (LMA) as an alternative to endotracheal intubation during pediatric FFB. DESIGN, SETTING, AND PATIENTS: Between July 1995 and June 2000, we studied 92 children (51 girls; age range, 1 through 15 years) in the operating theater of a major tertiary children's hospital. The LMA was used in children with atelectasis, diffuse infiltrates, and those who required BAL under general anesthesia. The size of the LMA was chosen to accommodate a bronchoscope appropriate for the child's weight and age. RESULTS: Procedures were well tolerated, no complications were observed, and oxygen saturation exceeded 95% in all patients. Major findings included mucoid impaction and purulent bronchial secretions, and BAL was successfully accomplished in all individuals. CONCLUSIONS: Diagnostic BAL or extraction of mucous plugs should be accomplished with optimal control of the airway under general anesthesia. The use of the LMA during FFB is safe, provides excellent patient comfort, and should be utilized as an alternative to endotracheal intubation.

Multiple intracranial aneurysms as delayed complications of an atrial myxoma: case report.

OBJECTIVE AND IMPORTANCE: Atrial myxomas are rare cardiac tumors that may cause neurological complications; however, delayed neurological events after total tumor resection are rare. In this report, we present a patient who developed transient cerebral ischemic attacks and was found to have multiple intracranial aneurysms 5 years after successful resection of her atrial myxoma. At the time of myxoma resection, there were no neurological symptoms; at the time of presentation with transient ischemic attacks, there was no evidence of atrial recurrence. CLINICAL PRESENTATION: A 32-year-old woman presented with five episodes of right arm and face paresthesia, each lasting 15 to 20 minutes, 5 years after successful resection of her atrial myxoma. Clopidogrel bisulfate therapy was initiated, with resolution of her symptoms. Angiography revealed multiple, peripherally located, fusiform cerebral aneurysms. INTERVENTION: A left frontal craniotomy for resection and biopsy of one of the aneurysms was performed, to establish the diagnosis. Pathological analysis of the biopsied aneurysm provided evidence of direct atrial myxoma invasion and occlusion of the cerebral blood vessel. CONCLUSION: Neurological symptoms may accompany or lead to the diagnosis of atrial myxoma. Rarely, as in this case, myxomatous aneurysms may develop years after definitive treatment of the primary tumor. Patients who have undergone successful resection of a left atrial myxoma may be at risk for delayed cerebral ischemia associated with aneurysm development, and this phenomenon must be considered for patients with neurological symptoms who present even years after myxoma removal. The natural history, pathophysiological features, and treatment dilemma of these aneurysms are discussed.

Ruptured intracranial aneurysms. A review of diagnosis and management.

Despite decades of aggressive efforts to improve the outcome from ruptured intracranial aneurysms, subarachnoid hemorrhage (SAH) still carries high morbidity and mortality rates. Aneurysmal subarachnoid hemorrhage continues to be a frightening and poorly understood condition, contributing to delays in diagnosis and compromising patient care. Prompt diagnosis followed by aggressive treatment represents the best available method to improve patient outcome. Optimal results depend on rapid medical stabilization of the patient, early aneurysm repair to prevent rebleeding, and prevention of the recognized complications of subarachnoid hemorrhage. This review summarizes recommendations for managing the patient with a ruptured intracranial aneurysm.

Prospective evaluation of syndesmotic ankle sprains without diastasis.

Sixty consecutive collegiate athletes with "high" ankle symptoms were prospectively evaluated over a 3-year period in an effort to better define this debilitating ankle injury. All athletes included in this study had tenderness over the distal anterior tibiofibular ligament, tenderness proximally along the interosseous membrane, and functional disability. No study subject had a fracture or frank tibia-fibula diastasis. The severity of the sprain was quantified using the interosseous "tenderness length." A standard rehabilitation protocol was followed by all patients. Athletes returned to competition when they could perform all functional testing without difficulty. Time to return to full competitive activity averaged 13.4 days. The number of days missed from competition was statistically related to the interosseous tenderness length (P = 0.0001) and to positive results on the squeeze test (P = 0.03). Fifty-three of the 60 injured athletes were evaluated at least 6 months after injury. Patients rated their outcomes as good or excellent. Six of the patients experienced occasional ankle pain and stiffness, four patients reported recurrent ankle sprains, and one patient had heterotopic ossification formation.

Outcomes after aneurysm rupture during endovascular coil embolization.

OBJECTIVE: Intracranial aneurysm rupture during placement of Guglielmi detachable coils has been reported, but the management and consequences of this event have not been extensively described. We present our experience with this feared complication and report possible neuroradiological and neurosurgical interventions to improve outcomes. METHODS: We retrospectively reviewed the records for 701 patients with 734 intracranial aneurysms that were treated with endovascular coiling, during a 6-year period, in the metropolitan Minneapolis-St. Paul (Minnesota) area. This analysis revealed 10 cases of perforation during coiling. The management and outcomes were recorded, and the pertinent literature was reviewed. RESULTS: All 10 cases involved previously ruptured aneurysms. This complication occurred sporadically and was not observed in the first 100 cases. Perforation occurred during microcatheterization of the aneurysm in two cases and during coil deposition in eight cases. Seven of the perforated aneurysms were located in the anterior circulation and three in the posterior circulation. Six of the 10 patients made good or fair recoveries; all three patients with posterior circulation lesions died immediately after rehemorrhage. Elevated intracranial pressure (ICP) was noted for all five patients with intraventricular catheters in place. Bilateral pupil dilation and profound hemodynamic changes were noted for eight patients. Coiling was rapidly completed, and total or nearly total occlusion was achieved in all cases. Emergency ventriculostomy was performed to rapidly reduce increased ICP for two patients, both of whom made good recoveries. Hemodynamic and angiographic factors after perforation, such as prolonged systemic hypertension, persistent dye extravasation after deployment of the first Guglielmi detachable coil, and persistent prolongation of contrast dye transit time (suggesting ongoing ICP elevation), were correlated with poor outcomes. CONCLUSION: Previously ruptured aneurysms seem to be more susceptible to endovascular treatment-related perforation than are unruptured lesions. Worse prognoses are associated with iatrogenic rupture during coiling of posterior circulation lesions, compared with those in the anterior circulation. When perforation is recognized, the definitive treatment seems to be reversal of anticoagulation therapy and completion of Guglielmi detachable coil embolization. Immediate neurosurgical intervention is limited in these cases and focuses on decreasing ICP via emergency ventriculostomy. However, these measures may be life-saving, and neurosurgical assistance must be readily available during treatment of these cases.

Delayed cerebrovascular complications of intrathecal colloidal gold.

OBJECTIVE: Therapy with intrathecal colloidal gold has been used in the past as an adjunct in the treatment of childhood neoplasms, including medulloblastoma and leukemia. We describe the long-term follow-up period of a series of patients treated with intrathecal colloidal gold and emphasize the high incidence of delayed cerebrovascular complications and their management. METHODS: Between 1967 and 1970, 14 children with posterior fossa medulloblastoma underwent treatment at the University of Minnesota. Treatment consisted of surgical resection, external beam radiotherapy, and intrathecal colloidal gold. All patients underwent long-term follow-up periods. RESULTS: Of the 14 original patients, 6 died within 2 years of treatment; all experienced persistent or recurrent disease. The eight surviving patients developed significant neurovascular complications 5 to 20 years after treatment. Three patients died as a result of aneurysmal subarachnoid hemorrhage, and five developed ischemic symptoms from severe vasculopathy that resembled moyamoya disease. CONCLUSION: Although therapy with colloidal gold resulted in long-term survival in a number of cases of childhood medulloblastoma, our experience suggests that the severe cerebrovascular side effects fail to justify its use. The unique complications associated with colloidal gold therapy, as well as the management of these complications, are presented. We recommend routine screening of any long-term survivors to exclude the presence of an intracranial aneurysm and to document the possibility of moyamoya syndrome.

Pseudomyasthenia resulting from a posterior carotid artery wall aneurysm: a novel presentation: case report.

OBJECTIVE AND IMPORTANCE: Painful oculomotor palsy can result from enlargement or rupture of intracranial aneurysms. The IIIrd cranial nerve dysfunction in this setting, whether partial or complete, is usually fixed or progressive and is sometimes reversible with surgery. We report an unusual oculomotor manifestation of a posterior carotid artery wall aneurysm, which mimicked ocular myasthenia gravis. CLINICAL PRESENTATION: A 47-year-old woman developed painless, intermittent, partial IIIrd cranial nerve palsy. She presented with isolated episodic left-sided ptosis, which initially suggested a metabolic or neuromuscular disorder. However, digital subtraction angiography revealed a left posterior carotid artery wall aneurysm, just proximal to the origin of the posterior communicating artery. INTERVENTION: The aneurysm was successfully clipped via a pterional craniotomy. During surgery, the aneurysm was observed to be compressing the oculomotor nerve. The patient's symptoms resolved after the operation. CONCLUSION: The variability of incomplete IIIrd cranial nerve deficits can present a diagnostic challenge, and the approach for patients with isolated IIIrd cranial nerve palsies remains controversial. Although intracranial aneurysms compressing the oculomotor nerve classically produce fixed or progressive IIIrd cranial nerve palsies with pupillary involvement, anatomic variations may result in atypical presentations. With the exception of patients who present with pupil-sparing but otherwise complete IIIrd cranial nerve palsy, clinicians should always consider an intracranial aneurysm when confronted with even subtle dysfunction of the oculomotor nerve.

Long-term survival with metastatic cancer to the brain.

Metastatic cancer to the brain has a poor prognosis. The focus of this work was to determine the incidence of long-term (> or = 2y) survival for patients with brain metastases from different primary cancers and to identify prognostic variables associated with prolonged survival. A retrospective review of 740 patients with brain metastases treated over a 20 y period identified 51 that survived 2 or more years from the time of diagnosis of the brain metastasis. Prognostic variables that were examined included age, sex, histology, tumor number and location, and treatment. In the 51 patients, 35 (69%) had single lesions and 16 (31%) had multiple tumors. For all tumor types (740 patients), the actuarial survival rate was 8.1% at 2 y, 4.8% at 3 y, and 2.4% at 5 y. At 2 y, patients with ovarian carcinoma had the highest survival rate (23.9%) and patients with small cell lung cancer (SCLC) had the lowest survival rate (1.7%). At 5y, survival rates were 7.8% for ovarian carcinoma, 2.9% for non-SCLC, 2.3% for melanoma and renal cell carcinoma, 1.3% for breast carcinoma and there were no survivors with SCLC, gastrointestinal, bladder, unknown primary, or prostate cancer. Age, sex, histology, location for single tumors, systemic chemotherapy, and stereotactic radiosurgery did not significantly influence survival. The presence of a single lesion (P = 0.001, chi-square test), surgical resection (P= 0.001), and WBRT (P = 0.009) were favorable prognostic variables for extended survival. Multiple bilateral metastases was a poor prognostic indicator (P= 0.001). Multivariate analysis showed younger age (P< 0.05), single metastasis (P < 0.0001), surgical resection (P < 0.0001), whole brain radiation therapy (P < 0.0001), and chemotherapy (P = 0.0288) were associated with prolonged survival. 29 patients (57%) died of systemic disease progression, 9 (18%) died of central nervous system progression, and the cause of death was unknown in 3 (6%). Patients with a single non-SCLC, breast, melanoma, renal cell, and ovarian carcinoma brain metastasis have the best chance for long-term survival if treated with surgical resection and WBRT.

Muscle size and cardiorespiratory response to exercise in cystic fibrosis.

The mechanism responsible for diminished exercise performance in cystic fibrosis (CF) is not clear. We hypothesized that reduced muscle size, rather than an intrinsic muscle defect, was the primary factor in such diminished exercise performance. Twenty-two subjects with CF (14 females and eight males, aged 6.5 to 17.7 yr, with FEV(1) of 46% to 111% predicted) participated in a study of this hypothesis, and were compared with healthy children tested in the same laboratory. Muscle size was estimated from midthigh muscle cross-sectional area (CSA) obtained by magnetic resonance imaging, and fitness was determined by progressive cycle ergometer exercise testing with breath-by-breath measurements of gas exchange. Peak oxygen consumption (V O(2)) was reduced in CF subjects (956 +/- 81 [mean +/- SEM] ml/min, as compared with 1,473 +/- 54 ml/min in controls; p < 0.00001). Surprisingly, CF subjects had a lower peak V O(2) per CSA (mean for CF subjects 70 +/- 3% predicted, p < 0.0001) than did controls, whereas muscle CSA in CF subjects was not significantly smaller than in controls. The scaling parameters of peak V O(2) and muscle CSA did not differ significantly between healthy controls (0.80 +/- 0.16) and CF subjects (1.03 +/- 0.12). Indexes of aerobic function that are less effort-dependent than peak V O(2) were also lower in the CF subjects (e.g., the slope of V O(2) versus work rate [WR] (DeltaV O(2)/DeltaWR) was 68 +/- 2% predicted; p < 0.005). The study data did not support the initial hypothesis, and suggest a muscle-related abnormality in oxygen metabolism in patients with CF.

Carotid stenting and "extarterectomy" in the management of head and neck cancer involving the internal carotid artery: technical case report.

OBJECTIVE AND IMPORTANCE: Head and neck cancer that invades the internal carotid artery (ICA) represents a significant management challenge. We describe a novel technique that allows for aggressive tumor removal without disrupting blood flow through the affected ICA. CLINICAL PRESENTATION: A 62-year-old man was referred to our institution for management of a neck malignancy involving the ICA. Cerebral angiography suggested that there was good collateral flow from the opposite hemisphere, but the patient reported visual loss in the ipsilateral eye during balloon test occlusion of the ICA. INTERVENTION: A self-expanding stent was deployed in the ICA; it spanned the entire length of the artery involved by tumor. One month later, the patient underwent tumor resection. During surgery, a long ICA arteriotomy was performed directly down to the mesh of the stent. A neoendothelium had formed within the stent, which prevented arterial bleeding. The carotid wall was dissected from the stent without difficulty and removed en bloc with the surrounding tumor. The exposed stent was wrapped circumferentially with a synthetic patch material. The patient tolerated the procedure well, and postoperative angiography demonstrated normal filling of the ICA. CONCLUSION: We describe a novel approach to a patient with head and neck cancer involving the cervical ICA. Preliminary stenting, which allows time for endothelialization before surgery, may permit aggressive tumor resection without interrupting flow through the ICA. This technique obviates the need for complicated carotid reconstruction procedures and avoids the risk of delayed ischemia from carotid sacrifice.