A technique for reconstruction of a giant extracranial internal carotid artery aneurysm: A technical note.

Background: Surgery is effective for extracranial internal carotid artery (EICA) aneurysms. However, the risk of cranial nerve injury associated with surgical repair, such as graft-assisted resection and extracranial-intracranial bypass techniques, is relatively high. Here, we report two cases of surgical treatment for EICA aneurysms and describe the surgical techniques and strategies to avoid cranial nerve injury. Methods: Two patients presented to our facility with an increasing cervical pulsatile mass and no neurological symptoms. Angiography showed a large aneurysm in the cervical internal carotid artery. Surgical treatment was performed to prevent rupture of the aneurysm. In both patients, the aneurysm was strongly attached to the vagus nerve. The aneurysm and vagus nerve were carefully dissected using a low-power bipolar (20 Malis; 3 watts), leaving connective tissue on the vagus nerve side. Results: The aneurysm was detached from the vagus nerve without injury. Based on intraoperative findings, one patient underwent clipping, and the other underwent aneurysmectomy and primary closure for aneurysm obliteration and angioplasty. Both patients were discharged without any cranial nerve dysfunction. Conclusion: The selection of a strategy based on intraoperative findings and low-power bipolar cutting is important for the treatment of extracranial carotid artery aneurysms to preserve cranial nerves.

Influence of Perioperative Three-Dimensional Computed Tomography (CT) Angiography and Surgical Clipping for Unruptured Cerebral Aneurysms on Renal Function in Patients with Chronic Kidney Disease.

BACKROUND: Surgical clipping is a valuable treatment option for unruptured intracranial aneurysms in patients with chronic kidney disease (CKD). However, the comprehensive impact of clipping and perioperative three-dimensional computed tomography angiography (3D-CTA) on renal function remains unclear. This study aimed to evaluate the effects of perioperative 3D-CTA and surgical clipping on renal function in patients with CKD. METHODS: We retrospectively analyzed 529 patients who underwent surgical clipping and perioperative 3D-CTA. An estimated glomerular filtration rate (eGFR) < 60 was defined as CKD. Patients were stratified according to their renal function (group 1: eGFR ≥60, group 2: 45 ≤ eGFR <60, group 3: 30 ≤ eGFR <45, group 4: eGFR <30 ml/min/1.73 m2), and eGFR was assessed preoperatively and 1 week and several months postoperatively. RESULTS: Of the 529 patients, 442 did not have CKD and 87 had CKD. Hypertension, hyperlipidemia, and hyperuricemia were significantly more common in those with CKD. After the surgery and perioperative series of 3D-CTA, renal function deterioration was not observed in any group, whether in the acute or chronic postoperative period. Notably, eGFR significantly increased in groups 2 (66.7 ± 10.1, P < 0.01) and 3 (48.9 ± 9.2, P = 0.02) 1 week postoperatively, despite the CKD. CONCLUSIONS: Surgical clipping of unruptured intracranial aneurysms and perioperative 3D-CTA with normal-dose contrast media did not impair renal function in patients with CKD. These results could be valuable in determining treatment strategies for those with CKD and intracranial aneurysms.

Cerebral Infarction Due to Post-traumatic Cerebral Vasospasm in a 12-Year-Old Female.

Cerebral infarction due to post-traumatic cerebral vasospasm is rare. Although some modalities are recommended to detect post-traumatic cerebral vasospasm, its diagnosis remains controversial and challenging. Therefore, in this report, we will use a case report to highlight challenges and to delineate the characteristics of post-traumatic cerebral vasospasm in pediatric patients, including the diagnostic and treatment options. A 12-year-old female was admitted to our hospital following a motor vehicle collision. Her consciousness was severely impaired. Initial computed tomography (CT) revealed an acute subdural hematoma along the tentorium, and a focal subarachnoid hemorrhage was observed in the Sylvian fissure. The patient underwent the insertion of an intracranial pressure sensor and received therapy for increased intracranial pressure (ICP) control under sedation. On the second day, CT angiography (CTA) revealed no signs of arterial abnormality. A patient who is comatose or under sedation has masked neurological symptoms. Thus, new neurological events could only be detected via an intracranial pressure sensor. Her ICP increased on the seventh day, and a CT scan showed a new cerebral infarction in the right middle cerebral artery (MCA) region. We performed decompressive craniectomy to reduce ICP. Postoperative CTA confirmed severe vasospasm in the right MCA. The severe cerebral vasospasm induced the cerebral infarction. Our review suggests that physicians in trauma departments should frequently perform vascular evaluations by CTA, magnetic resonance angiography (MRA), transcranial Doppler ultrasound, or digital subtraction angiography (DSA), especially within two weeks from onset, to detect post-traumatic cerebral vasospasm.

Another cause of treatable dementia: rapid cognitive improvement after carotid endarterectomy. Illustrative case.

BACKGROUND: Revascularization techniques in cervical internal carotid artery (ICA) stenosis are indicated to prevent the onset or recurrence of ischemic events in the setting of atherosclerotic carotid artery disease. Recent reports, case series, and comparative studies have suggested that revascularization techniques may also improve cognitive outcome in both symptomatic and asymptomatic patients, thus raising the question of whether another surgically treatable dementia has presented itself. OBSERVATIONS: A 70-year-old right-handed female with a history of hypertension, diabetes, and bilateral silent cerebral infarcts was evaluated for progressive cognitive impairment over a 1-year period, which was associated with a severe left cervical ICA stenosis. Carotid endarterectomy (CEA) was indicated as a revascularization technique, and the patient showed significant neurocognitive improvement as early as one month postoperatively, consistent with blood flow restoration to the left hemisphere on control imaging. LESSONS: This case serves as a reminder that CEA may improve the cognitive outcome of patients previously impaired by uncomplicated severe cervical ICA atherosclerotic disease, which can be another cause of treatable dementia. Further prospective studies may help to assess this potential benefit.

Clinical Features of Ruptured Very Small Intracranial Aneurysms (<3 mm) in Patients with Subarachnoid Hemorrhage.

OBJECTIVE: Although small unruptured aneurysms rarely rupture, many patients with subarachnoid hemorrhage (SAH) have ruptured small, especially very small intracranial aneurysms (VSIAs; <3 mm) in clinical practice. We aimed to clarify the proportion and clinical features of patients with SAH with ruptured VSIAs. METHODS: 609 patients with ruptured intracranial aneurysms diagnosed at our institution from January 2012 to December 2018 were retrospectively analyzed. We classified patients into 2 groups based on ruptured aneurysm size: VSIAs or non-VSIAs (≥3 mm). We analyzed age, sex, location of aneurysms, World Federation of Neurological Surgeons grade on admission, treatment modality, and outcome at discharge. RESULTS: Among 609 patients, 103 had ruptured VSIAs. The proportion of young patients (age <40 years) was greater in the VSIA group than the non-VSIA group (10.7% vs. 3.6%, P = 0.002). The proportions of VSIAs located in the middle cerebral and vertebrobasilar arteries were relatively low and high, respectively (P = 0.002, 0.005). Significantly more patients with VSIAs than those with non-VSIAs were classified under World Federation of Neurological Surgeons grade I-III (70.9% vs. 56.3%, P = 0.006). Coil embolization was preferred for VSIAs (68.0% vs. 32.0%, P = 0.006). Outcomes were more favorable in the VSIA group than in the non-VSIA group. CONCLUSIONS: Small unruptured aneurysms rarely rupture; however, many patients with SAH have ruptured VSIAs in clinical practice. We observed that VSIA rates among ruptured aneurysms were fairly high. Age, posterior circulation location, and preferable outcome may be important clinical characteristics of ruptured VSIAs.

Stent-assisted Coil Embolization Using a Transcirculation Technique for Superior Cerebellar Artery Aneurysm: A Report of Two Cases.

Stent-assisted coil embolization (SACE) is useful for treating wide-necked aneurysms. Most superior cerebellar artery (SCA) aneurysms have a wide neck, but there are few reports of SCA aneurysms treated with SACE. One reason is that the anatomical characteristic of SCA aneurysm is not suitable for standard SACE. It is often challenging to deliver a stent to SCA via the basilar artery in an anterograde manner. In contrast, it is not difficult to deliver a stent to SCA from the anterior circulation via the posterior communicating artery. This method, in which a catheter is navigated from the anterior to the posterior circulation, is called a transcirculation technique. We report two cases of SCA aneurysm successfully treated with SACE using transcirculation technique. This approach is helpful for wide-necked SCA aneurysms.

Thrombectomy for acute large vessel occlusion in posterior and anterior circulation: a single institutional retrospective observational study.

PURPOSE: Thrombectomy has been the gold standard therapy for anterior circulation occlusion; however, studies regarding thrombectomy in posterior circulation are lacking. In this study, we compared the efficiency of thrombectomy for acute large vessel occlusion between the posterior and anterior circulation at a single institution. METHODS: We retrospectively analyzed consecutive patients who underwent thrombectomy for acute large vessel occlusion at our institution between August 2014 and April 2021. Differences in the clinical background, time course, and treatment technique and outcomes were evaluated between anterior and posterior circulation occlusions. RESULTS: Overall, 353 patients (225 men and 128 women) were included: 314 patients had anterior circulation occlusion and 39 patients had posterior circulation occlusion. Between the patients with anterior and posterior circulation occlusions, the National Institutes of Health Stroke Scale (NIHSS) score (16 [12-21] vs. 29 [19-34], respectively, p < 0.001), door-to-puncture time (65 [45-99] vs. 99 [51-121] min, respectively, p = 0.018), and mortality (22 [7%] vs. 8 [20.5%] patients, respectively, p = 0.010) were significantly different; however, favorable outcome was not significantly different. CONCLUSION: Higher NIHSS score, delayed treatment, and higher mortality were observed in posterior circulation occlusion than in anterior circulation occlusion; successful reperfusion and favorable outcomes were similar between them. Similar favorable outcomes and reperfusion ratio to the anterior circulation might be achieved also in the posterior circulation; however, delayed treatment and the optimal first-pass strategy might need further improvement.

Preprocedural Prediction of Underlying Atherosclerotic Lesions in Cerebral Large-Vessel Occlusions: Clinical Backgrounds, Radiological Findings, and Treatment Outcomes.

AIMS: Mechanical thrombectomy using a standard device has been effective for acute cerebral large-vessel occlusions, particularly those due to cardiogenic embolism. However, evidence for those with underlying atherosclerotic lesions is lacking. In this study, we evaluated the predictive factors, treatment details, and outcomes of acute cerebral large-vessel occlusions with underlying atherosclerotic lesions in patients who underwent mechanical thrombectomy. METHODS: We retrospectively analyzed consecutive patients with acute large-vessel occlusions who underwent mechanical thrombectomy at our institution between August 2014 and May 2021. Predictive factors of underlying atherosclerotic lesions were evaluated using univariate and multivariate analyses. In addition, treatment details and outcomes were evaluated and compared with those of other etiologies. RESULTS: Among 322 included patients, 202 (62.7%) were males and 65 (20.2%) had underlying atherosclerotic lesions. Multivariate analysis identified dyslipidemia, lack of arterial fibrillation documented on admission, smoking, internal carotid artery lesions, and stenosis ≥ 25% in non-occluded large vessels as predictive factors of underlying atherosclerotic lesions. Regarding treatment for underlying atherosclerotic lesions, the need for percutaneous transluminal angioplasty, stent placement, medical therapy, and longer procedure time were observed, while successful reperfusion rates, favorable outcomes, and mortality rates showed no significant differences with those of other etiologies. CONCLUSION: Coexisting diseases and radiological findings were useful for predicting underlying atherosclerotic lesions. Further understanding these characteristics may lead to the early detection of underlying atherosclerotic lesions, optimal treatment strategies, and better outcomes.

Current treatment options and prognostic factors for ruptured distal anterior cerebral artery aneurysms.

BACKGROUND: Distal anterior cerebral artery (ACA) aneurysms are rare, representing 1-9% of all intracranial aneurysms. The best treatment strategy for these aneurysms continues to be debated. We clarified the clinical features and treatment outcomes of patients with ruptured distal ACA aneurysms according to the treatment options at our institute. METHODS: Thirty-seven consecutive patients (26 women; mean age, 65.2 years) with ruptured distal ACA aneurysms who underwent surgical clipping or coil embolization between 2012 and 2018 were included in the study. Clinical presentations, radiographic findings, and outcomes were retrospectively reviewed and compared between patients who underwent either surgical clipping or coil embolization. Risk factors associated with poor outcomes (modified Rankin Scale 4-6) were analyzed using multiple regression analysis. RESULTS: Nineteen patients (51.4%) had World Federation Neurological Surgeons (WFNS) Grade IV-V, 18 (48.7%) had frontal lobe hematomas, and 13 (35.1%) had multiple aneurysms. Surgical clipping and endovascular coiling were performed in 28 (75.7%) and nine (24.3%) patients, respectively. Aneurysms located at the A4-5 portions were mainly treated by surgical clipping (P = 0.04). There were no significant between-group differences in procedure-related morbidity and mortality; however, the complete occlusion rate was higher in the surgical group (P < 0.01). Overall, a favorable neurological outcome at discharge (mRS 0-3) was obtained in 23 patients (62.5%). Multiple regression analysis revealed that WFNS Grade IV-V and frontal lobe hematomas were risk factors for poor outcomes (mRS 4-6). CONCLUSION: Acceptable outcomes were obtained in 62.5% of cases, and there were no significant between-group differences in treatment results between clipping and coiling. A poor WFNS grade and intracerebral hematomas were risk factors for a poor prognosis.

Predictors of the Resolution of Cavernous Sinus Syndrome Caused by Large/Giant Cavernous Carotid Aneurysms After Parent Artery Occlusion with High-Flow Bypass.

OBJECTIVE: To evaluate the clinical results and factors related to the resolution of preoperative cranial neuropathy after internal carotid artery ligation with high-flow bypass in patients with symptomatic large or giant cavernous carotid aneurysms. METHODS: This study included 18 consecutive patients (15 women) with cranial neuropathy. All patients underwent therapeutic internal carotid artery ligation with high-flow bypass using a radial artery graft. Patient demographics, duration of symptoms, clinical outcomes, complications, and radiographic findings were retrospectively analyzed. The mean follow-up period was 31.0 months (range: 3-74 months). RESULTS: Patients' mean age was 66.6 years, and the mean aneurysm size was 23.7 mm. Six patients (33%) had partially thrombosed aneurysms. Preoperatively, 16 (89%) and 8 (44%) patients presented with ophthalmoplegia and facial pain, respectively. Bypass patency was confirmed in 15 patients (83%), and obliteration of the aneurysm was confirmed in all patients at the final follow-up. Preoperative ophthalmoplegia resolved in 10 patients (63%), and trigeminal pain resolved in all patients. Postoperative resolution of patients' ophthalmoplegia was significantly associated with age (P = 0.044), symptom duration before treatment (P = 0.042), and the degree of ophthalmoplegia (P = 0.046). The degree of postoperative residual ophthalmoplegia was positively correlated with the duration of ophthalmoplegia from onset to surgery (r = 0.619; P = 0.011). Preoperative trigeminal pain resolved regardless of the preoperative duration of this symptom in all patients. CONCLUSIONS: Early treatment is recommended when treating large or giant cavernous carotid aneurysms with cranial neuropathy. Complete resolution is possible in younger patients with partial neuropathy.

[Surgical Management of a Thromobotic Extracranial Carotid Artery Aneurysm:A Case Report].

Extracranial carotid artery aneurysms are relatively rare. We present a case involving a giant aneurysm arising from the extracranial carotid artery. The patient was a 79-year-old woman. She had a pulsating mass in the right side of her neck. However, she was neurologically intact. Contrast-enhanced CT scans of the neck showed an enhanced mass lesion with a thrombus in the right side of her neck. Angiography revealed a saccular aneurysm 3.4 cm in size near the bifurcation site of the right common carotid artery into the external carotid artery. She underwent an urgent resection of the aneurysm and a carotid artery reconstruction. Postoperatively, she recovered well and the total resection of the lesion was angiographically confirmed. Histopathological examination revealed that the wall of the aneurysm had undergone fibrosis and contained a few elastic fibers and microhemorrhages. The wall of the aneurysm was also infiltrated by inflammatory cells. The surgical strategy for and appropriate preoperative evaluation of this rare disease was discussed.

Disturbed Consciousness and Coma: Diagnosis and Management of Intracranial Hypotension Caused by a Spinal Cerebrospinal Fluid Leak.

OBJECTIVE: The diagnosis and treatment of intracranial hypotension associated with a spinal cerebrospinal fluid (CSF) leak, especially in comatose patients, have yet to be established. METHODS: Clinical manifestations, neuroimaging findings, and treatment outcomes in 11 patients (Glasgow Coma Scale score 10 ± 4) were described and compared with 36 patients with normal consciousness. RESULTS: Patients with disturbed consciousness were diagnosed at a significantly older age (55 ± 11 years; P < 0.001) than those without (42 ± 8.8 years). Neuroimaging findings in patients with disturbed consciousness were characterized by a smaller midbrain-pons angle (7.8 ± 10°; P < 0.001), brainstem swelling (122%; P = 0.002), and thicker subdural hematomas (16 ± 7.0 mm°; P < 0.001). Epidural blood patch (EBP) alone did not achieve sustained improvements in patients with disturbed consciousness but did in most patients without (94%; P = 0.001). Over the treatment course, 5 patients progressed to coma, which correlated with a high signal intensity on T2-weighted magnetic resonance imaging in the brainstem. Hematoma drainage before EBP caused neurologic deterioration in 2 patients. Simultaneous EBP after hematoma drainage achieved sustained improvements in 5 of 6 patients. Simultaneous microsurgical dural repair after hematoma drainage achieved more rapid improvements in 3 of 3 patients. CONCLUSIONS: Among patients with intracranial hypotension caused by a spinal CSF leak, disturbed consciousness may occur in elderly patients because of severe diencephalic-mesencephalic deformities. Simultaneous EBP after safe hematoma drainage is indicated for these patients. Alternatively, dural repair is indicated for patients for whom the spinal level of dural disease has been identified. Hematoma drainage before EBP is not recommended because it caused deterioration.

Ruptured intrameatal anterior inferior cerebellar artery aneurysm associated with obstructed internal auditory artery in a patient with sudden hearing loss and vertigo.

BACKGROUND: Intrameatal aneurysms arising from the meatal loop of the anterior inferior cerebellar artery (AICA) are extremely rare. CASE PRESENTATION: We report a 60-year-old man presenting with severe vertigo and sudden left hearing loss associated with subarachnoid hemorrhage caused by rupture of a saccular aneurysm arising from the meatal loop of the AICA, which was entirely buried in the meatus. Intraoperatively, we identified the occluded internal auditory artery arising from the meatal loop of the AICA, where the aneurysm originated, and performed neck clipping. CONCLUSION: These findings suggest that internal auditory artery occlusion is a potential cause of loss of auditory and vestibular functions.