The presigmoid approach to anterolateral pontine cavernomas. Clinical article.

OBJECT: Anterolateral cavernomas of the pons have been surgically removed via a variety of approaches, commonly retrosigmoid or transventricular. The goal in this study was to evaluate the presigmoid approach as an alternative. METHODS: Clinical data were reviewed in 9 patients presenting with anterolateral pontine cavernomas between 1999 and 2007. RESULTS: All patients were treated via a presigmoid approach, which provided a nearly perpendicular trajectory to the anterolateral pons. The brainstem was entered through a "safe zone" between the trigeminal nerve and the facial/vestibulocochlear nerve complex. Complete resection was achieved in all cases. No patient experienced recurrent events during follow-up (1-24 months). The patients' modified Rankin Scale score improved within 1 year of surgery (1.7 ± 0.4) compared with baseline (2.6 ± 0.2; p < 0.05). Only one patient experienced a new deficit (decreased hearing), which was corrected with a hearing aid. CONCLUSIONS: The presigmoid approach is recommended for the resection of anterolateral pontine cavernomas. With this approach, the need for cerebellar retraction is nearly eliminated. The lateral "presigmoid" entry point creates a trajectory that allows complete resection of even deep lesions at this level, or anterior to the internal acoustic meatus.

The small "surgical aneurysm" at the basilar apex.

OBJECT: Because the risks are reduced, larger basilar apex aneurysms are usually treated endovascularly instead of with surgery. However, small basilar apex aneurysms are more common and an unfavorable shape may prevent definitive endovascular treatment. The goal of this study was to reevaluate the outcome of traditional surgery for small unruptured basilar apex aneurysms as an alternative to the currently more accepted endovascular treatment. METHODS: The authors reviewed clinical data obtained in 21 patients who underwent surgery between 2000 and 2007 for unruptured basilar apex aneurysms < 7 mm. RESULTS: The median age of the 21 patients was 52 years (range 29-74 years). All patients experienced a good outcome. Two patients harbored a small residual aneurysm (> 95% occlusion). Eight patients (38%) suffered a temporary third nerve paresis, which resolved in all cases. CONCLUSIONS: Surgical clip ligation remains an excellent treatment for small basilar apex aneurysms. The treatment is definitive and in experienced hands is associated with a low risk.

Stent/coil treatment of very large and giant unruptured ophthalmic and cavernous aneurysms.

BACKGROUND: Treatment of VLGUIA remains a challenge. To reduce mass effect and achieve complete occlusion, open surgery has been our favored treatment. However, endovascular therapy is preferred for lesions in the cavernous sinus or for older patients with complicating medical problems. The goal of this study is to investigate outcome of stent and/or coil treatment of VLGUIA. METHODS: Beginning in 2002, the neuroform stent has been available to the University of Texas Southwestern Medical Center in Dallas. Since then until 2006, 15 patients were treated for VLGUIA with stenting and/or coiling at this institution. These 15 patients were used for a retrospective analysis in this study. RESULTS: Median patient age was 65 years, median aneurysm size was 27 mm (20-37 mm), and median follow-up time was 22 months. Eight aneurysms were localized in the cavernous sinus and 7 at the ophthalmic segment of the internal carotid artery. Four aneurysms were completely occluded (100%); 3 aneurysms, nearly complete (90%-99%); and 8 aneurysms, partial (<90% occlusion). Twelve patients required retreatment. Final GOS was 1 (good recovery) in 11 patients, 2 (moderate disability) in 3 patients, and 3 (severely disabled) in 1 patient. No patient died or deteriorated. CONCLUSIONS: Stent/coil management of VLGUIA is constantly evolving. Current treatment results are promising, with very low morbidity/mortality. Disadvantage is the frequent persistence of residual aneurysm.

A1-A2 interposition grafting for surgical treatment of a giant "unclippable" A1 segment aneurysm.

BACKGROUND: Although various bypass options for the surgical treatment of middle cerebral artery aneurysms have been described, little has been reported about similar options for complex aneurysms of the anterior cerebral artery. CASE DESCRIPTION: We report the case of a 15-year-old adolescent girl, in whom a giant A1 segment aneurysm was successfully treated with aneurysm resection followed by saphenous vein interposition grafting. CONCLUSION: Recognizing the option for a bypass can be the key to success in the surgical management of complex intracranial aneurysms. A potential donor vessel of appropriate size (either arterial or venous) should be prospectively identified. Interposition grafting is technically feasible for proximal anterior cerebral artery aneurysms, although technically demanding.