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.

Ischemic stroke in a young adult with a known epileptogenic arteriovenous malformation: illustrative case.

BACKGROUND: Brain arteriovenous malformations (AVMs) usually manifest as hemorrhages or seizures. They rarely present with ischemic symptoms, especially in young patients. We present a case of an epileptogenic AVM that led to cerebral infarction due to paradoxical embolic occlusion of the middle cerebral artery (MCA) involving the main feeder of the lesion. OBSERVATIONS: A 35-year-old male had been suffering from AVM-associated epilepsy for 10 years and was scheduled for surgery. He suddenly developed right-sided hemiconvulsions followed by hemiparalysis and impaired consciousness. Computed tomography revealed no intracerebral hemorrhage, and symptoms were initially thought to indicate epilepsy and Todd's palsy. Because of his prolonged symptoms, he underwent magnetic resonance imaging, which revealed a large cerebral infarction due to occlusion of the MCA involving the main feeder of the AVM. The patient underwent AVM resection, and the partially thrombosed nidus was completely removed. Histopathological investigation revealed a fresh thrombus in totally occluded nonarteriosclerotic feeders. He had no atrial fibrillation; however, subsequent transesophageal echocardiography revealed a patent foramen ovale, suggesting a paradoxical embolism. LESSONS: This case serves as a reminder that AVMs can present with considerable variability. Acute cerebral infarction should be considered a possible mechanism of seizures, even in patients with epileptogenic AVM.

Clinical Characteristics of Ruptured Intracranial Aneurysm in Patients with Multiple Intracranial Aneurysms.

OBJECTIVE: It is difficult to correctly identify the ruptured aneurysm in patients with multiple intracranial aneurysms. Here, we investigated the clinical characteristics of ruptured intracranial aneurysms in such patients. METHODS: We retrospectively analyzed 361 patients who underwent microsurgical clipping of ruptured intracranial aneurysms at our institution from 2012 to 2018. Patients' age, sex, Fisher group, World Federation of Neurosurgical Societies grade, size (neck width, depth, maximum diameter), location, and shape of intracranial aneurysm, and hemorrhage pattern on admission were reviewed. RESULTS: In total, 266 patients (74%) had single intracranial aneurysms and 95 (26%) had multiple intracranial aneurysms. Eighty-nine of the 95 multiple intracranial aneurysms (94%) had irregular shape (P < 0.01). The median aspect ratios of ruptured and unruptured intracranial aneurysms were 2.2 ± 1.1 and 1.0 ± 0.4, respectively (P < 0.01). Twelve of 95 patients (13%) had ruptured intracranial aneurysms that were smaller than unruptured intracranial aneurysms. Among the 12 patients, the aspect ratios of ruptured intracranial aneurysms were greater than those of unruptured intracranial aneurysms (P < 0.01). Regarding morphologic characteristics, aspect ratio, maximum size, and irregular shape could be the useful predictive factors, but the greatest aspect ratio among patients with multiple aneurysms was the most predictive of an intracranial aneurysm rupture, after adjustment for aneurysmal size (adjusted odds ratio 217.82; 95% confidence interval 56.41-841.08). CONCLUSIONS: The results of this study indicate that the aspect ratio is the most predictive factor of a ruptured intracranial aneurysm in patients with multiple intracranial aneurysms.

Trans-cell Approach through Closed-cell Stent for Middle Meningeal Artery Embolization in Recurrent Chronic Subdural Hematoma.

We report a case of recurrent chronic subdural hematoma (CSDH) treated using the trans-cell approach through a closed-cell stent for middle meningeal artery embolization (MMAE). A 77-year-old man with acute ischemic stroke due to anterior circulation tandem occlusion was treated with intracranial thrombectomy and carotid artery stenting using a closed-cell stent 5 years ago. He experienced head trauma after a fall, which then developed into a CSDH. Burr hole surgery was performed twice, followed by MMAE considering the high possibility of recurrence due to antiplatelet therapy and brain atrophy after ischemic stroke. A distal access catheter was inserted into the external carotid artery through the closed-cell stent, and a microcatheter was navigated in the middle meningeal artery. The anterior and posterior convexity branches were embolized with 16.7% N-butyl cyanoacrylate. The postoperative course was favorable, and CT at 3-month follow-up showed a decrease in the hematoma. Even after the placement of the closed-cell stent, endovascular treatment of the external carotid artery is possible and can be a therapeutic option using the trans-cell approach.