Vertebrobasilar dissecting aneurysms: microsurgical management in 42 patients.

OBJECTIVE: Vertebrobasilar dissecting (VBD) aneurysms are rare, and patients with these aneurysms often present with thromboembolic infarcts or subarachnoid hemorrhage (SAH). The morphological nature of VBD aneurysms often precludes conventional clip reconstruction or coil placement and encourages parent artery exclusion or endovascular stenting. Treatment considerations include aneurysm location along the vertebral artery (VA), the involvement of the posterior inferior cerebellar artery (PICA), and collateral blood flow. Outcomes after endovascular treatment have been well described in the neurosurgical literature, but microsurgical outcomes have not been detailed. Patient outcomes from a large, single-surgeon, consecutive series of microsurgically managed VBD aneurysms are presented, and 3 illustrative case examples are provided. METHODS: The medical records of patients with dissecting aneurysms affecting the intracranial VA (V4), basilar artery, and PICA that were treated microsurgically over a 19-year period were reviewed. Patient demographics, aneurysm characteristics, surgical procedures, and clinical outcomes (according to modified Rankin Scale [mRS] scores at last follow-up) were analyzed. RESULTS: Forty-two patients with 42 VBD aneurysms were identified. Twenty-six aneurysms (62%) involved the PICA, 14 (33%) were distinct from the PICA origin on the V4 segment of the VA, and 2 (5%) were located at the vertebrobasilar junction. Thirty-four patients (81%) presented with SAH with a mean Hunt and Hess grade of 3.2 at presentation. Six (14%) of the 42 patients had been previously treated using endovascular techniques. Nineteen aneurysms (45%) underwent clip wrapping, 17 (40%) were treated with bypass trapping, and 6 (14%) underwent parent artery sacrifice. The complete aneurysm obliteration rate was 95% (n = 40), and the surgical complication rate was 7% (n = 3). The 8 patients with unruptured VBD aneurysms were significantly more likely to be discharged home (n = 6, 75%) compared with 34 patients with ruptured aneurysms (n = 9, 27%; p = 0.01). Good outcomes (mRS score ≤ 2) were observed in 20 patients (48%). Eight patients (19%) died. CONCLUSIONS: These data demonstrate that patients with VBD aneurysms often present after a rupture in poor neurological condition, but favorable results can be achieved with open microsurgical repair in almost half of such cases. Microsurgery remains a viable treatment option, with the choice between bypass trapping and clip wrapping largely dictated by the specific location of the aneurysm and its relationship to the PICA.

The Neurosurgical Intraoperative Checklist for Surgery of the Craniocervical Junction and Spine.

Many sectors within healthcare have adapted checklists to improve quality control. Notwithstanding the reported successful implementation of surgical checklists in the operating theater, a dearth of literature addresses the specific challenges posed by complex surgery in the craniocervical junction and spine. The authors devised an intraoperative checklist to address the common errors and verify the completion of objectives unique to these surgeries. The data over six years is presented retrospectively; no historical control for comparison is available, as those omissions and surgical errors addressed by the checklist are not generally registered in any morbidity and mortality reports. Through six years and approximately 1200 surgeries, the checklist was implemented with 98% compliance. The checklist eliminated the occurrences of mundane surgical errors, minimized iatrogenic complications, and ensured completion of specific objectives. We discuss that preoperative checklists, now in general use in all hospitals, have not addressed the most common, intraoperative omissions. These technical omissions result in part from the complexity of spine surgery and directly impact the surgical outcome. The Neurosurgical Intraoperative Checklist is a practical, rapid, and comprehensive means to prevent common, avoidable errors and iatrogenic complications inherent to spine surgery.

Impact of reperfusion pump power on technical and clinical outcomes after direct aspiration thrombectomy (ADAPT).

INTRODUCTION: Higher aspiration forces using larger bore catheters in direct aspiration thrombectomy (ADAPT) have been associated with shorter procedure time and better outcomes in patients treated for acute ischemic stroke (AIS). However, the effect of using reperfusion pumps of higher aspiration power on outcomes of ADAPT has not been investigated. We evaluated the effect of using pumps with different aspiration powers on technical and clinical outcomes after ADAPT. METHODS: We reviewed a retrospective database of AIS cases between January 2018 and February 2019, while comparing technical and clinical outcomes between patients undergoing ADAPT using the MAX pump (28.5 inHg power) vs the ENGINE pump(29.2 inHg power). RESULTS: Among 194 patients (48% females, age 69±15 years) included in the study, 73 patients undergoing ADAPT using the ENGINE pump were age-, gender-, comorbidities-, and operator-matched to 118 patients treated using the MAX pump. The ENGINE group had shorter procedure time (20±17 vs 27±21 mins, p=0.017), lower number of aspiration attempts (2.2±1.6 vs 2.8±1.9, p=0.047), and similar rates of favorable 90 day modified Rankin Scale. Using multivariate linear regression, the use of the ENGINE reperfusion pump with higher vacuum power was independently and inversely correlated with procedure time (coefficient -2.23, p=0.027). While controlling for confounders, there was a trend toward an inverse correlation between use of the ENGINE pump and the number of attempts on linear regression (coefficient -1.04, p=0.09) and lower odds of PH2/intracranial (ICH) hemorrhages on logistic regression (OR 0.227, p=0.075). CONCLUSION: Our findings suggest that the use of the ENGINE reperfusion pump of higher aspiration power during ADAPT decreases procedure time, without increasing complications and post-procedural hemorrhage rates.

Technical and Clinical Outcomes After Thrombectomy for the Various Segments of the Middle Cerebral Artery.

BACKGROUND: After showing the success of mechanical thrombectomy (MT) in treating large-vessel occlusion stroke, the target population has been expanded to include patients with smaller and more distal vessels including the M2 segment of the middle cerebral artery. We compared the procedural and clinical outcomes of patients undergoing MT using direct aspiration (ADAPT [A Direct Aspiration at first Pass Technique]) between superior or inferior divisions of M2 and M1. METHODS: We retrospectively reviewed a database of patients undergoing MT between June 2013 and July 2018 at our center for clinical and procedural variables. Patients with isolated M1 or M2 occlusions were included. M2 occlusions were classified into superior and inferior divisions. Functional outcomes were collected at 90 days. RESULTS: A total of 205 patients with M1, 65 with M2 superior division (middle cerebral artery M2 superior segment [M2S]), and 57 with inferior division (middle cerebral artery M2 inferior segment [M2I]) stroke were included. M1 and M2S patients had comparable National Institutes of Health Stroke Scale score at presentation, but higher than M2I (P < 0.01). Compared with M1, M2 occlusions had longer procedure times and required more aspiration attempts (P < 0.05). M2S thrombectomy had a significantly lower rate of successful recanalization (P < 0.05). Rates of good outcome (modified Rankin Scale score 0-2) were 46% in M1, 34% in M2S, and 44% in M2I, and postprocedural hemorrhage rates were comparable between groups. On multivariate analysis, M2S occlusion was associated with longer procedure times, lower odds of good outcomes, and lower TICI recanalization scores (P < 0.05) compared with M1. CONCLUSIONS: ADAPT is safe and effective in M2 stroke. The procedural success and efficacy of ADAPT in M2 stroke are influenced by the anatomic division with less favorable clinical and technical outcomes in the M2S division.

Presentation and management of traumatic occipital spur fracture.

Occipital spur is an abnormal bony outgrowth of the external occipital protuberance (EOP). We describe an interesting and previously unreported case of fracture of an occipital spur following trauma. Our 20-year-old male patient was treated in the emergency department (ED) and discharged home without complication. Neurosurgical consultation was obtained but is not requisite for these injuries. Greater awareness of this unique presentation may help to expedite future emergency department treatment.