Endovascular Management of Complex Fenestration-Associated Aneurysms: A Single-Institution Retrospective Study and Review of Existing Techniques.

BACKGROUND: Aneurysms associated with fenestrations of intracranial arteries are exceptionally rare findings. Management strategies for these aneurysms are not well-defined, especially regarding endovascular treatment. We sought to investigate the strategies and feasibility of endovascular treatment approaches for various fenestration-associated intracranial aneurysms. METHODS: We performed a retrospective chart review of 2000 aneurysms treated endovascularly, identifying 8 aneurysms located at arterial fenestrations. The technical details and procedural outcomes were reviewed to identify common management approaches, technical nuances, and treatment outcomes. RESULTS: There were 3 (37.5%) aneurysms associated with fenestrations of the basilar artery or vertebrobasilar junction. All 3 were successfully treated with a previously undescribed coil-assisted flow-diversion technique, resulting in complete obliteration. Three (37.5%) aneurysms were associated with fenestrations of the anterior communicating artery. Of those, 2 were successfully treated with stent-assisted coil embolization and 1 with coil embolization alone. One (12.5%) aneurysm was associated with a fenestration of the paraclinoid internal carotid artery and 1 (12.5%) aneurysm found was at the takeoff of the posterior inferior cerebellar artery at a fenestration of the vertebral artery. Both were successfully treated with coil-assisted flow diversion. There were no permanent procedural complications. Major considerations for endovascular management of these aneurysms were the dominance of fenestration trunks, aneurysms arising from the fenestration apex or a fenestration limb, amenability to flow diversion, and anticipation of vascular remodeling. CONCLUSIONS: Fenestration-associated aneurysms are very rare. We have identified common factors to help guide decision-making for endovascular approaches and demonstrate successful aneurysm treatment using these methods.

Surgical limitations in convexity meningiomas en-plaque: Is radical resection necessary?

Meningiomas-en-plaque (MEP) comprise 2.5% of all meningiomas. While they typically arise in the sphenoid wing, convexity MEP are comparatively rare and are often confused with meningeal sarcoidosis, osteoma, tuberculoma, or fibrous dysplasia, with very little information published in the literature. We conducted a literature review on PubMed of English-only articles using a keyword search. All studies that described reports of convexity MEP were reviewed for patient demographics, presenting symptoms, radiological reports, surgical management, recurrence rates, histopathological presentation, post-operative complications, and follow-up. This resulted in 12 papers comprising 22 cases of convexity MEP. Seventeen (77%) of the 22 patients were female with an average age of 53.2years. Intitial presenting symptoms included headache in 12/20 (60%), hemiparesis in 5/20 (25%), and visual symptoms in 1/20 (5%). Of the 14 patients who underwent surgical resection, only four were reported as gross total resection. Twelve reports had associated pathology reports, with all 12 tumors graded as World Health Organization Grade I. Convexity MEP, while rare, present a challenge with regard to correct diagnosis and subsequent resection. The easier accessibility of these meningiomas predicts higher surgical success rates and incidence of total resection, though care must be taken to ensure gross total removal of tumor, dural attachments, and any overlying hyperostotic bone. Though hyperostosis is frequently observed with this variant of meningioma, it is neither exclusive nor wholly indicative of MEP. Due to its rarity in both clinical practice and the literature, further studies are warranted to identify modern imaging means to correctly diagnose this condition.

Sinus thrombectomy for purulent cerebral venous sinus thrombosis utilizing a novel combination of the Trevo stent retriever and the Penumbra ACE aspiration catheter: the stent anchor with mobile aspiration technique.

Intracranial complications of sinusitis are rare but life threatening. We present a case of a 17-year-old woman with sinusitis who deteriorated over the course of 12 days from subdural empyema and global purulent cerebral venous sinus thrombosis. The patient was managed with surgery and mechanical thrombectomy utilizing a novel 'stent anchor with mobile aspiration technique', in which a Trevo stent retriever (Stryker) was anchored in the superior sagittal sinus (SSS) while a 5 MAX ACE reperfusion catheter (Penumbra) was passed back and forth from the SSS to the sigmoid sinus with resultant dramatic improvement in venous outflow. The patient was extubated on postoperative day 3 and was discharged with minimal lower extremity weakness on postoperative day 11. This is the first report using the Trevo stent retriever for sinus thrombosis. It is important to keep these rare complications in mind when evaluating patients with oral and facial infections.

Association of a Distal Intradural-Extracranial Posterior Inferior Cerebellar Artery Aneurysm With Chiari Type I Malformation: Case Report.

BACKGROUND AND IMPORTANCE: Distal extracranial posterior inferior cerebellar artery (PICA) aneurysms are very rare lesions and have not been previously reported in association with a Chiari type I malformation (CMI). CLINICAL PRESENTATION: A 56-year-old woman with a distal, low-lying, intradural-extracranial PICA aneurysm presented with a subarachnoid hemorrhage and was treated with coil embolization. The patient presented again 1 month later with symptoms of a CMI and was found to have tonsillar herniation and a large syrinx that appeared to be exacerbated by the coil mass. The patient was re-treated with a suboccipital craniectomy, C1-2 laminectomy, aneurysm trapping and excision, end-to-end PICA anastomosis, and expansile duraplasty. CONCLUSION: Although just a single case, important teaching points regarding the angiographic appearance of a CMI and treatment options for distal PICA aneurysms that are situated below the foramen magnum can be learned. A low-lying caudal PICA loop should trigger a workup for a CMI. Caution should be taken when using coil embolization for aneurysms in the high cervical spinal canal. Bypass with aneurysm trapping and excision may be a superior treatment option in these cases because the posterior fossa and high cervical canal can be concomitantly decompressed. To our knowledge, this is the only case reported of a distal intradural-extracranial PICA aneurysm associated with a CMI.

Sinus thrombectomy for purulent cerebral venous sinus thrombosis utilizing a novel combination of the Trevo stent retriever and the Penumbra ACE aspiration catheter: the stent anchor with mobile aspiration technique.

Intracranial complications of sinusitis are rare but life threatening. We present a case of a 17-year-old woman with sinusitis who deteriorated over the course of 12 days from subdural empyema and global purulent cerebral venous sinus thrombosis. The patient was managed with surgery and mechanical thrombectomy utilizing a novel 'stent anchor with mobile aspiration technique', in which a Trevo stent retriever (Stryker) was anchored in the superior sagittal sinus (SSS) while a 5 MAX ACE reperfusion catheter (Penumbra) was passed back and forth from the SSS to the sigmoid sinus with resultant dramatic improvement in venous outflow. The patient was extubated on postoperative day 3 and was discharged with minimal lower extremity weakness on postoperative day 11. This is the first report using the Trevo stent retriever for sinus thrombosis. It is important to keep these rare complications in mind when evaluating patients with oral and facial infections.

Rotational angiography for diagnosis and surgical planning in the management of spinal vascular lesions.

OBJECT: The management of spinal vascular malformations has undergone significant evolution with the advent of advanced endovascular and angiographic technology. Three-dimensional rotational spinal angiography is an advanced tool that allows the surgeon to gain a better appreciation of the anatomy of these spinal vascular lesions and their relation to surrounding structures. This article describes the use of rotational angiography and 3D reconstructions in the diagnosis and management of spinal vascular malformations. METHODS: The authors present representative cases involving surgical treatment planning for spinal vascular malformations with focus on the utility and technique of rotational spinal angiography. They report the use of rotational spinal angiography for a heterogeneous collection of vascular pathological conditions. RESULTS: Eight patients underwent rotational spinal angiography in addition to digital subtraction angiography (DSA) for the diagnosis and characterization of various spinal vascular lesions. Postprocessed images were used to characterize the lesion in relation to surrounding bone and to enhance the surgeon's ability to precisely localize and obliterate the abnormality. The reconstructions provided superior anatomical detail compared with traditional DSA. No associated complications from the rotational angiography were noted, and there was no statistically significant difference in the amount of radiation exposure to patients undergoing rotational angiography relative to traditional angiography. CONCLUSIONS: The use of rotational spinal angiography provides a rapid and powerful diagnostic tool, superior to conventional DSA in the diagnosis and preoperative planning of a variety of spinal vascular pathology. A more detailed understanding of the anatomy of such lesions provided by this technique may improve the safety of the surgical approach.