Internal maxillary artery (IMax) - middle cerebral artery bypass in a patient with bilateral atherosclerotic carotid occlusion: A technical case report.

Since the first description of the possible utilization of the internal maxillary artery for bypass surgery, there are some reports of its use in aneurysm cases; however, there is no information about the possible advantages of this type of bypass for cerebral ischemic disease. We present a 77-year-old man with a history of diabetes, hypertension, systemic atherosclerosis, and two acute myocardial infarctions with left hemiparesis. Imaging studies reported total occlusion of the right internal carotid artery and 75% occlusion on the left side, with an old opercular infarction and repeated transient ischemic attacks in the right middle cerebral artery territory despite medical treatment. After a consensus, we decided to perform a bypass from the internal maxillary artery to the M2 segment of the middle cerebral artery using a radial artery graft. After performing the proximal anastomosis, the calculated graft's free flow was 216 ml/min. Subsequently, after completing the bypass, the patency was confirmed with fluorescein videoangiography and intraoperative Doppler. Postoperatively, imaging studies showed improvement in the perfusion values and the hemiparesis from 3/5 to 4+/5. The patient was discharged one week after the operation, with a modified Rankin scale of 1, without added deficits. The use of revascularization techniques in steno-occlusive disease indicates a select group of patients that may benefit from this procedure. In addition, internal maxillary artery bypass has provided a safe option for large areas of ischemia that cannot be supplied with a superficial temporal artery - middle cerebral artery bypass.

Risk Factors Associated With Neurological and Extra-Neurological Complications and Mortality in Patients With Stroke.

Introduction Understanding when and how systemic complications can occur after an acute stroke is crucial. It is important to identify patients who are at higher risk for these complications. Early and effective treatment based on this knowledge can significantly improve patient outcomes. The objective of this study was to identify the risk factors associated with neurological and extra-neurological complications and mortality in stroke patients treated at a secondary care hospital. Methods Of a total of 170 patients diagnosed with hemorrhagic/ischemic stroke and transient cerebral ischemia at a secondary care hospital in Mexico, the records of 125 were reviewed and of these, 86 were included in the study. The study group comprised 86 adult patients (> 18 years of age) diagnosed with ischemic or hemorrhagic stroke or transient cerebral ischemia. Their demographics, clinical characteristics, in-hospital complications, and mortality were retrospectively analyzed.  Results Of the 86 patients examined, 34.9% experienced complications, regardless of the type of stroke. The most significant factor associated with mortality and complications during hospitalization in patients with stroke was previous diseases. Other factors that were linked to higher mortality were pre-existing medical conditions. The most common neurological complication among patients with stroke during hospitalization was intracranial hypertension (3.5%). As for extra-neurological complications, pressure ulcers and nosocomial pneumonia had an occurrence rate of 4.7%. Conclusions The main neurological complication during hospitalization of patients with stroke was intracranial hypertension, while the extra neurological complications were pressure ulcers and nosocomial pneumonia.

Spontaneous Intracranial Hemorrhage Associated With an Intracranial Meningioma.

Spontaneous intracranial hemorrhage associated with an intracranial meningioma is rare, with a reported incidence of below 2.4% of all meningiomas. Such cases are described with a cause subdural with intratumoral hemorrhage, which is a challenge for patients and healthcare professionals because it can occur spontaneously without other pathological antecedents. We describe the case of a 55-year-old woman with subdural hemorrhage over the frontoparietal region of the right hemisphere associated with a meningioma, generating a mass effect and shifting the third ventricle and lateral ventricle. Therefore, urgent surgical treatment was decided. A tumor lesion was found with apoplexy, soft consistency, and violaceous color with abundant vascularity in the lesion's center, suggesting a probable angiomatous meningioma. The histopathological evaluation confirmed meningothelial hemorrhagic meningioma grade I, according to the World Health Organization grading. This article discusses the causes, risk factors, diagnosis, and surgical treatment for hemorrhage associated with intracranial meningioma.

Microsurgical Treatment of a Giant Intracavernous Carotid Artery Aneurysm in a Pediatric Patient: Case Report and Literature Review.

Intracranial aneurysms in children account for 4%-5% of all cases, with 20% being considered giant (>25 mm). The main sites of occurrence are the internal carotid artery (ICA) and the middle cerebral artery (MCA). Rupture and secondary subarachnoid hemorrhage occur in approximately 55%-72.5% of cases, with a 10%-23% mortality rate. We report the case of a previously healthy nine-year-old girl who developed sudden, severe right retroocular pain and a holocranial headache as a mode of onset. Besides, the patient presented with double vision, and her relatives sought medical attention. Paresis of the right III, IV, and VI cranial nerves was found at physical examination. An MRI and digital subtraction angiography showed the presence of a giant aneurysm in the cavernous portion of the ICA with a mass effect. The patient was treated surgically through a high-flow bypass using a radial artery graft and trapping of the aneurysm. She had an uneventful postoperative course and was discharged three days after the operation to continue follow-up at the outpatient clinic. The therapeutic options were: a) an endovascular approach using flow diverters or stenting and coiling; or b) surgical treatment with proximal closure of the ICA if the patient had good collateral circulation or trapping the aneurysm combined with a high-flow bypass if the collateral circulation was not good or absent. After discussion, we decided on the surgical option. Even when the surgery was successful in this case, there is no consensus about the best way to treat it; the selection should be based on the center´s experience when confronting this rare entity.

Ruptured aneurysm associated with a twig-like middle cerebral artery: An illustrative case report.

Background: Anomalies of the middle cerebral artery (MCA) are rare; among the different types of anomalies, the aplastic or twig-like (Ap/T) MCA is extremely rare and has been reported under various names, including aplastic, unfused, or rete type anomaly. The occurrence of a brain aneurysm associated with this anatomic variant is an even rare event, and probably their development and rupture are related to hemodynamic stress of the tinny wall of vessels forming the network. Case Description: We present a 43-year-old male patient with an explosive and persistent right orbitofrontal headache. A computed tomography showed a right frontobasal hematoma with intraventricular disruption. Magnetic resonance angiography showed a right MCA aneurysm and what seems to be a MCA trunk stenosis. Cerebral digital subtraction angiography demonstrated a plexiform arterial network and one aneurysm arising from the network. The patient was successfully treated by surgical clipping to evacuate the hematoma and to prevent further intracranial hemorrhages. Conclusion: The Ap/T-MCA may be associated with hemodynamic stress with a significant effect through the tinny wall of the vessels causing hemorrhage or leading to the formation and rupture of cerebral aneurysms. Based on a correct diagnosis of the anomaly, treatment can be completed successfully through different standard methods.

Family members' perceptions of inpatient palliative care consult services: a qualitative study.

BACKGROUND: Family members are commonly involved in end-of-life decision making and typically involved in inpatient palliative care consultations. Although much research has documented patient outcomes following inpatient palliative care consultation, little is known about family member perceptions of the consultation. AIM: The purpose of this study was to determine how inpatient palliative care consultations impacted family members' understanding of the patient's condition, knowledge of available care options, and decision-making ability. DESIGN: An exploratory, qualitative study was conducted employing individual interviews among family members of seriously ill patients, recruited purposively. Interviews were conducted in person, at the hospital, or via telephone, using a semistructured protocol. SETTING/PARTICIPANTS: Family members of seriously ill patients were recruited from a nonprofit, community hospital. RESULTS: Interviews were conducted among 23 family members. Four themes were identified and included: perceived qualities of the inpatient palliative care consultation, family readiness, impact on decision-making process, and focus on comfort and quality of life. While most comments reflected positive aspects of the inpatient palliative care consult, such as improved pain control and communication, and increased access to medical professionals and time to discuss patient conditions, some themes reflected a lack of adequate preparation for the inpatient palliative care consultation and readiness for discussing prognosis. CONCLUSION: Family members report discussion with the inpatient palliative care team results in improved communication and knowledge, which contributes to decision-making ability. However, palliative care consultation may be improved by developing stronger protocols for introducing palliative care and by including the attending physician in the process to preclude conflicting, inconsistent information and recommendations.