Direct, High-flow Bypass for a Pediatric Giant, Fusiform Aneurysm of the Inferior Division of M2: Case Report and Review of Literature.

In this case report, we describe the first reported case of treating a 7-year-old male patient who has a giant, fusiform aneurysm confined to the inferior M2 segment by means of a saphenous vein graft. Given the lack of good endovascular management options for this particular scenario, craniotomy was recommended and an end-to-side ECA-ICA anastomosis was carried out with technical details of the surgery outlined in the manuscript. The patient did not sustain any major postoperative complications. The graft remained patent upon completion of the surgery and at the time of last follow-up, 9 months post-surgery. This case serves as an illustrative example of the need for high-flow bypass for a select few patients even as endovascular technology continues to improve.

The spectrum of management practices in nontraumatic subarachnoid hemorrhage: A survey of high-volume centers in the United States.

BACKGROUND: There is a considerable variety of management practices for nontraumatic subarachnoid hemorrhage (ntSAH) across high-volume centers in the United States. We sought to design a survey which would highlight areas of controversy in the modern management of ntSAH and identify specific areas of interest fo further study. METHODS: A questionnaire on management practices in ntSAH was formulated using a popular web-based survey tool (SurveyMonkey(™), Palo Alto, CA) and sent to endovascular neurointerventionists and cerebrovascular surgeons who manage a high volume of these patients annually. Two-hundred questionnaires were delivered electronically, and after a period of 2 months, the questionnaire was resent to nonresponders. RESULTS: Seventy-three physicians responded, representing a cross-section of academic and other high-volume centers of excellence from around the country. On average, the responding interventionists in this survey each manage approximately 100 patients with ntSAH annually. Over 57% reported using steroids to treat this patient population. Approximately 18% of the respondents use intrathecal thrombolytics in ntSAH. Over 90% of responding physicians administer nimodipine to all patients with ntSAH. Over 40% selectively administer antiepileptic drugs to patients with ntSAH. Several additional questions were posed regarding the methods of detecting and treating vasospasm, as well as the indications for CSF diversion in patients with ntSAH further demonstrating the great diversity in management. CONCLUSION: This survey illustrates the astonishing variety of treatment practices for patients with ntSAH and underscores the need for further study.

A survey of ventriculostomy and intracranial pressure monitor placement practices.

BACKGROUND: Over the past 3 decades, the incidence of ICP monitoring has consistently increased and the indications for placement have expanded. Although ventriculostomy and ICP monitor placement are among the most commonly performed neurosurgical procedures, few studies have examined the current practice patterns of these procedures. METHODS: A 10-question survey was sent to 3100 practicing neurosurgeons and a similar 11-question survey to 720 neurosurgery residents. Basic demographic information and estimated rates of proper ventriculostomy placement were sought. RESULTS: Nine hundred thirty-four practicing neurosurgeons and 100 neurosurgery residents responded to our survey. Respondents estimated a mean of 1.4 passes per ventriculostomy procedure for practicing neurosurgeons, 1.4 for senior residents, and 2.4 for junior residents. Estimated rate of successful cannulation of the ipsilateral ventricle ranged from 72% to 84% for these groups. CONCLUSIONS: This survey gives a sketch of the current state of practice and the attitudes of practitioners toward the placement procedure. Both residents and practicing neurosurgeons admit to frequently using multiple passes and frequent catheter placement outside the ipsilateral frontal horn. Despite these imperfections, survey respondents were reluctant to embrace technology that could improve placement accuracy if it increased procedure time. Intracranial pressure monitor placement is an ideal topic for prospective study. The prevalence of the procedure would allow the morbidity associated with various monitors and emerging technologies to be quickly and accurately established. Results of such study could be applied to the tens of thousands of patients undergoing these procedures annually.

Cyclic Cushing syndrome: definitions and treatment implications.

Endogenous Cushing syndrome (CS) results from hypercortisolemia caused by excess adrenocorticotropic hormone production in a pituitary adenoma or ectopic tumor, or by an adrenal tumor that directly produces excess cortisol. The diagnosis can usually be ascertained with a reasonable degree of certainty based on clinical and laboratory findings of hypercortisolism. There are patients, however, in whom the production of excess cortisol exhibits a cyclic or intermittent pattern, and, as a result, the clinical symptoms may be quite complex and varied. In these patients the hypothalamic-pituitary-adrenal axis may be normal between cycles, and dexamethasone suppression testing may produce a paradoxical response. In the present article, the authors provide a definition of cyclic Cushing syndrome, review the causes and its potential pathophysiological mechanisms, and discuss the treatment options based on a review of the available literature.

Rotational vertebral artery insufficiency resulting from cervical spondylosis: case report and review of the literature.

BACKGROUND: Four cases of vertebrobasilar insufficiency secondary to osteophyte formation at C5-C6 have been reported in the literature. In this article, we report the fifth such case and discuss the utility of dynamic computed tomographic angiography (CTA) in the management of this disorder. CASE DESCRIPTION: A 55-year-old right-handed man presented for evaluation after syncopal episodes associated with right-head turning. Workup revealed cervical spondylosis with stenosis. The C5-C6 level was significantly affected. Dynamic angiography revealed obstruction of vertebral artery flow with right-head turning secondary to an osteophyte at the foramen transversarium at C5-C6. This patient underwent a C5-C6 anterior cervical discectomy and fusion. He also underwent unroofing of the vertebral artery and drilling of the osteophyte at the foramen transversarium. Postoperative CTAs reveal reconstitution of flow in the vertebral artery with head turning. CONCLUSION: The utility of dynamic 3-dimensional CTA in the management of this disorder avoids the risk of invasive studies.