Tips and Tricks in Microsurgical Treatment for Previously Embolized Aneurysms-Three-Dimensional Video.

One of the most popular treatment strategies for complex cerebral aneurysms with wide necks is stent-assisted coiling.1 Although it is a minimally invasive technique, it is associated with higher recurrence rates (approximately 20%) compared with surgical clipping.2 Recanalization is more common principally in ruptured aneurysms as well as in giant aneurysms, aneurysms located in the posterior circulation, aneurysms with a relatively wide neck morphology, and aneurysms followed for >1 year.2-6 Tirakotai et al. classified the indications for surgical treatment after coiling into 3 groups: 1) surgery of incompletely coiled aneurysms; 2) surgery for mass effects on neural structures; 3) surgery for vascular complications.7 Recanalization, if significant, often requires retreatment. Retreating with additional coils fails in perhaps 50% of cases.3 On the other hand, surgical clipping is complicated and difficult to perform. Recanalized aneurysms are categorized into 3 types: type I, coils are compressed; type II, coils are migrated; type III, coils are migrated, and multiple coils fill its neck or the parent artery. Direct clipping can be applied to types I and II, whereas trapping, wrapping, or auxiliary revascularization is required in type III.2 Coil extraction should not be attempted regularly because it is associated with high morbidity.8 In this three-dimensional video, we present the microsurgical treatment of a type I recanalized anterior communicating artery aneurysm, which in serial digital subtraction angiography control scans showed residual patency, progressive growth, and changes in its hemodynamic behavior (Video).

Awake Microsurgical Resection for a Precentral Gyrus Arteriovenous Malformation-Three-Dimensional Video and Anatomic Landmarks.

Arteriovenous malformations (AVMs) are complex, heterogeneous, and uncommon neurovascular disorders that frequently manifest in young adults. Parenchymal AVMs are thought to be congenital, but this has been recently questioned in the literature.1,2 AVMs can change over time and cause focal neurological signs or neurocognitive deficits.3 The clinical presentation of an AVM is variable and depends mainly on the occurrence of bleeding as well as its location, size, and ability to take flow from adjacent areas.4 AVMs can be treated by a single modality or a combination of different modalities. According to the Expert Consensus on the Management of Brain Arteriovenous Malformations, neurosurgery may be the best option for Spetzler-Martin grade 2 AVMs.5 However, the treatment of these lesions when located in eloquent areas, especially in the central lobe, is controversial. Awake craniotomy allows identification of eloquent gyrus and can potentially facilitate resection with functional preservation. An alternative is stereotactic radiosurgery, but a qualitative comparative analysis revealed higher obliteration rate with awake AVM excision compared with stereotactic radiosurgery.6 Awake craniotomy was the earliest surgical procedure known, and it has become fashionable again. It was used in the past for surgical management of intractable epilepsy, but its indications are increasing, and it is a widely recognized technique for resection of mass lesions involving the eloquent cortex and for deep brain stimulation.7 Its application for resection of vascular lesions, including AVMs, is still limited. In the Video, we present a case of a cerebral AVM of the precentral gyrus in which we achieved complete resection with awake microsurgical treatment without any neurological sequelae for the patient.

Microsurgical Treatment for a Cerebral Arteriovenous Malformation of the Central Sulcus.

Arteriovenous malformations (AVMs) are congenital neurovascular disorders frequently manifested in young adults. The clinical presentation is variable and depends on its location, size, and ability to steal flow from adjacent areas, but it depends mainly on the occurrence of bleeding.1 The treatment of these lesions when located in eloquent areas, especially around the central sulcus, is controversial. Surgical resection of an AVM in the central lobe may cause postoperative sensorimotor deficits because this anatomic region includes the precentral and postcentral gyri on the lateral surface and paracentral lobule on the medial surface.2 AVMs can be successfully treated by surgery, but this treatment may pose unacceptable risks to the patient if the AVM involves an eloquent cortex. We consider that surgical removal of many of these lesions is feasible when preoperative planning is performed,3 when it is based on deep anatomic knowledge, and particularly when using a refined microsurgical technique.1 In this 3-dimensional Video 1, we present a case of a cerebral AVM of the central sulcus in which we achieved complete resection with microsurgical treatment without any neurologic sequelae for the patient. The patient consented to publication of images.

Microsurgical Treatment for a Ruptured Posterior Inferior Cerebellar Artery Aneurysm: A 3-Dimensional Surgical Video and Anatomic Landmarks Review.

Aneurysms are the most frequent issue for the posterior inferior cerebellar artery (PICA). PICA aneurysms account for 1.4% to 4.5% of all intracranial aneurysms.1-3 Although the majority of PICA aneurysms arise from their junction with the vertebral artery, they can be found in any of 5 segments.4,5 Although PICA is more prone to form nonsaccular aneurysms than other intracranial arteries, ruptured aneurysms are usually saccular.6 Nearly all PICA aneurysms are located intracranially, above the foramen magnum. Extracranial PICA aneurysms are rare, with few reports in literature.7 Microsurgical clipping remains a good treatment alternative for these aneurysms. Higher risk of rerupture has even been reported with embolization of the distal PICA aneurysm with parent artery preservation.8 Here we present the case of a 64-year-old male patient who presented right after a thunderclap headache, followed by a temporary loss of consciousness and disorientation. He was diagnosed with a modified Fisher 4 and Hunt and Hess 2 subarachnoid hemorrhage and found to have a partially thrombosed left PICA saccular aneurysm of the caudal loop just below the foramen magnum. The lesion was approached via a midline suboccipital craniotomy with C1 laminectomy. Microsurgical clipping of the aneurysm was performed without any complications (Video 1). Postoperatively, the patient was discharged without neurologic deficits. We present the first surgical video of the necessary steps in order to perform a microsurgical clipping of an extracranially located caudal loop PICA aneurysm through a midline suboccipital craniotomy with C1 laminectomy.

Awake Microsurgical Resection for Optochiasmatic Cavernous Malformation.

Cavernous malformations (CM) affect approximately 0.5% of the population, with only a limited portion being located in the optic nerve and chiasma. The clinical presentation is determined by their locations. In the optochiasmatic CM, the acute visual disturbance is the most common presentation. Chronically, many show a progressive visual loss, chronic headache, and pituitary disturbances. The differential diagnosis includes optic glioma, arteriovenous malformations, aneurysm, craniopharyngioma, pituitary apoplexy, and inflammatory conditions. In Video 1, we present the case of a 39-year-old woman with a history of a hemorrhagic optochiasmatic cavernoma in 2016, who started using propranolol to reduce the lesion and symptoms of visual loss. Moreover, the first microsurgical resection of the cavernoma and evacuation of the hematoma were performed in the same year. Owing to evolvement from a partial to a total vision loss in the left eye and presentation of new symptoms in the right eye, the patient underwent microsurgical resection. The surgery was performed sequentially. An awake craniotomy was performed to monitor the chiasma and right optic nerve. The postoperative magnetic resonance imaging showed complete resection of the CM, and the patient fully recovered. The patient signed the institutional consent form, stating that he or she accepts the procedure and allows the use of his or her images and videos for any type of medical publications in conferences and/or scientific articles.

Microsurgical Treatment for Posthemorrhagic Cavernoma of Frontal Lobe Coexisting with Unruptured Ipsilateral Middle Cerebral Artery Aneurysm.

Cerebral cavernous malformations, also known as cavernomas, are vascular abnormalities of the brain that are clinically associated with a variety of neurologic symptoms that may include hemorrhagic strokes. They are the most common vascular abnormality, representing 10%-25% of all vascular malformations.1 Lesions associated with cavernomas include developmental venous anomalies, capillary telangiectasias, and other vascular malformations2 but not intracranial aneurysms. The latter association is extremely rare; in fact, there is only 1 case reported in the literature, in which the cavernoma was obscured by the presence of a cerebral hemorrhage and an unruptured aneurysm, which was presumed to be the primary cause of the bleeding, thereby misleading the surgeons to treat only the aneurysm.2 There are different alternatives for the management of different types of lesions.3-5 In this 3-dimensional operative video (Video 1), we present a case of a cavernoma associated with hemorrhage coexisting with an unruptured aneurysm in which we achieved complete resolution of both with microsurgical treatment through a pterional approach.6 The patient consented to publication of images.

Microsurgical Treatment of Ruptured Spetzler-Martin Grade 3 Right Hippocampal Arteriovenous Malformation: 3-Dimensional Operative Video.

We present a 14-yr-old male with a history of traumatic brain injury in March 2016, secondary to clonic tonic generalized seizures. CT scan showed hemorrhage at mesial temporal region in the body of right hippocampus, intraventricular hemorrhage at the level of lateral ventricles (right and left side) and fourth ventricle. After this the patient presented with pulsating right temporal headache of high intensity (VAS 10/10) that improved with common analgesics, dizziness, and clonic tonic generalized seizures despite taking Phenobarbital 100 mg/24 h. Neuropsychological assessment reveal major deficits regarding executive functions: working memory, verbal fluency, and planning abilities. Brain MRI and angiography showed AVM at the right level of hippocampus body. An intranidal aneurysm was also observed. Venous drainage was through the basal vein of Rosenthal. We planned for surgery and resection of the hippocampal AVM through the trans-T2 approach. Postoperatively, the patient was without medical complications. We present a 3-dimensional video of the microsurgical treatment for right hippocampal AVM performed through a trans-T2 approach. The patient signed the Institutional Consent Form, which allows the use of his/her images and videos for any type of medical publications in conferences and/or scientific articles.

Microsurgical Management of Trigeminal Schwannoma: Cohort Analysis and Systematic Review.

Background Trigeminal schwannomas are benign tumors with a predilection for women between 40 and 60 years of age and account for less than 0.5% of all intracranial tumors. Clinical presentation depends on size and location, and typical symptoms are ipsilateral hypesthesia, headache, and facial pain. Clinical features and imaging usually make the Diagnosis. Methods A retrospective cohort analysis of 14 patients treated at our institution between January 1999 and October 2016 was performed, with a critical and systematic review of data from the literature, focusing on articles published over the same period. Results Fourteen patients were included in our series comprised of mostly women with a mean age of 40 years. Lesion size ranged from 3 to 6.5 cm (mean 4.6 cm). Clinical status of patients was evaluated and also rated based on the Karnofsky Perfomance Scale with values greater than 90% found in all patients pre and postoperatively. Surgery was our treatment of choice, and gross total resection was achieved in 71% of patients. Associated morbidity was high at 57%, predominantly from cranial nerve palsy, and no deaths were encountered. Conclusions Microsurgery is a suitable treatment for large symptomatic trigeminal schwannomas, achieving good local control rates over the observation period at acceptable morbidity. Therefore, microsurgery appears to a suitable option. During the study period, a significant evolution in the availability of treatment methods occurred. Radiosurgery emerged as an alternative treatment for unresectable lesions. A comprehensive review of the available literature was performed, and results were compared according to treatment modality.

Awake Craniotomy for Removal of Left Insular Cavernous Malformation.

The insula plays a crucial role in speech planning due to its connections with cortical and subcortical areas. Surgical management of cavernous malformation (CM) of the insula consists of total resection of the lesion and the surrounding gliosis to avoid or reduce seizures. When located in the dominant hemisphere, an awake craniotomy with intraoperative mapping reduces the risk of functional damage. The insula is covered by the operculum and has a relationship with the middle cerebral artery and its branches that run along its lateral surface. Therefore high expertise is required to manage the exposure of the insula and its complex anatomy. This video demonstrates the surgical management of a large left insular CM. A 29-year-old female with multiple CM and 7 years of partial seizures and recent onset of short memory loss. Neuroimaging showed a large left insular and planum polare CM with important mass effect and hemorrhage signs. The patient consented to surgery, and an awake pretemporal craniotomy was carried out with continuous motor evoked potential monitoring. No language function was localized in the superior temporal gyrus; therefore corticectomy of the middle portion was performed to expand the operative corridor. The vessel manipulation during wide opening of the sylvian fissure increased the risk of postoperative vasospasm and blood drain into the surgical field. The CM was exposed and completely removed without functional damage. The patient recovered from surgery without complications, and no seizures occurred at 2 months' follow-up. Postoperative imaging showed complete removal of the CM.

Microsurgery for Upper Basilar Tip Aneurysm With Intraoperative Rupture: 3-Dimensional Operative Video.

In the last years, a shift from the microsurgical treatment to an endovascular therapy in patients with basilar apex aneurysm has been settled, part of this phenomenon is related to the significant tendency of vital perforators to be involved in the aneurysm dissection and clipping, which can implicate unfavorable outcomes. Nevertheless, microsurgical treatment remains the treatment that can provide the superior rates of stable and durable aneurysm occlusion, which is most important to young patients.In this video, we present the case of a 45-yr-old female patient who complained of a sudden and severe headache and presented with progressive lethargy during the following 3 d.At admission, computed tomography did not show abnormal findings. However, cerebrospinal fluid analysis showed erythrocytes and corroborated the clinical suspicion of spontaneous subarachnoid hemorrhage. The patient signed the Institutional Consent Form, which allows the use of his/her images and videos for any type of medical publications in conferences and/or scientific articles.Angiography and magnetic resonance imaging revealed a saccular basilar apex aneurysm. It showed a wide neck as well as a lobulated dome with upward and slightly left projection. The aneurysm did not involve angiographically visible thalamoperforator arteries, which allowed the microsurgical treatment by the fronto-orbitozygomatic approach. However, during the interpeduncular cistern dissection, an intraoperative rupture of the aneurysm occurred. This video exemplifies the steps required to manage an intraoperative rupture of a basilar apex aneurysm.