Journal of cerebrovascular and endovascular neurosurgery最新文献

Objective: Malignant middle cerebral artery infarction is associated with high mortality and severe disability despite decompressive craniectomy. The thalamus plays a central role in arousal and sensorimotor integration and may be vulnerable to early compression from cerebral mass effect. This study evaluates whether preoperative ipsilateral thalamic volume reduction predicts functional outcomes following decompressive craniectomy.

Methods: This retrospective cohort study included 41 adult patients with malignant middle cerebral artery infarction who underwent decompressive craniectomy between April 2017 and September 2022. Preoperative computed tomography scans were analysed for infarct volume, midline shift, herniation markers, and percentage ipsilateral thalamic volume reduction. Functional outcomes were assessed at discharge and 90 days using the Full Outline of UnResponsiveness score, National Institutes of Health Stroke Scale, modified Rankin Scale, Barthel Index, and Disability Rating Scale. Logistic regression and receiver operating characteristic analyses were performed.

Results: Mean ipsilateral thalamic volume reduction was 15.1%. Each 1% increase in thalamic volume loss independently increased the odds of poor functional outcome, defined as modified Rankin Scale scores of 5-6, at discharge and 90 days. Greater thalamic distortion was associated with higher National Institutes of Health Stroke Scale scores. Receiver operating characteristic analysis demonstrated good discrimination, with optimal thresholds of 14% at discharge and 19% at 90 days. Increased thalamic compression was associated with postoperative infections and longer hospital stays.

Conclusions: Preoperative ipsilateral thalamic volume reduction is a strong imaging biomarker for predicting outcomes after decompressive craniectomy in malignant middle cerebral artery infarction.

Internal Jugular Vein (IJV) compression is a common cause of cerebral venous hypertension symptoms such as headache and pulsatile tinnitus. Various causes are identified with cervical compression by the C1 transverse process being a rare one. Surgical styloidectomy and transverse process resection are commonly performed to relieve the pressure placed upon the IJV, however, minimally invasive treatments such as venous stenting are promising solutions. A 73-year-old patient presented to our outpatient clinic with peripheral vertigo, nystagmus, and gait instability. Computed tomography revealed stenosis of the left IJV caused by compression from the C1 transverse process. This rare anatomical variant was treated successfully with venous stenting, leading to significant symptomatic improvement. This case highlights the importance of considering extracranial venous stenosis as a differential diagnosis in patients with unexplained vertigo and demonstrates the utility of advanced endovascular techniques in managing such cases. This case illustrates that clinical presentation of venous hypertension could rarely be caused by extrinsic compression of jugular veins, either by vertebral transverse processes or styloid processes. Although generally treated surgically, we consider that minimally invasive endovascular venous stenting is a potentially effective treatment strategy. This is demonstrated by venous manometric pressure improvement and symptom resolution in the presented patient. This treatment approach deserves further research to demonstrate its clinical impact, recommendations, and long-term impact.

We report stentless reconstructive embolization of a high-flow vertebrovertebral arteriovenous fistula using a double-balloon jailing technique with microsnare-guided retrograde exchange. A 70-year-old woman had pulsatile tinnitus and a cervical bruit. Angiography demonstrated a V3-to-suboccipital cavernous sinus fistula with a single short tract, draining into vertebral venous plexuses and via the posterior condylar vein to the sigmoid sinus, without cortical reflux. Targeted embolization was planned by jailing an embolization microcatheter within the tract using arterial and venous balloon microcatheters. Direct transvenous navigation was prevented by septations and high shunt flow; therefore, an arterial microcatheter was advanced antegrade into the internal jugular vein, where it was captured with a microsnare introduced from the venous side, then drawn back as a coupled system to secure venous access. Subsequent inflation of both balloon microcatheters immobilized the embolization microcatheter and enabled dense coil packing. Angiography confirmed complete obliteration which persisted after balloon deflation. Tinnitus resolved immediately, and imaging showed durable occlusion with no recurrence at 5 years. This approach enables reconstructive obliteration of selected high-flow vertebrovertebral arteriovenous fistulas (VVAVFs) without stent implantation, potentially reducing antiplatelet exposure while preserving bailout options. Microsnare-guided retrograde exchange facilitates device delivery in cases of challenging transvenous navigation.

Objective: Chronic subdural hematoma (CSDH) commonly affects older adults and remains associated with recurrence despite surgical evacuation. Coagulation of middle meningeal artery (MMA) during burr-hole drainage may be useful where MMA embolization is unavailable, however reliable external landmarks for MMA localization are poorly defined. This study aimed to identify the MMA confluence point on 3D cranial CT scans of elderly Filipino patients and define its relationship to external cranial landmarks to support pre-operative planning.

Methods: A retrospective cross-sectional morphometric study was performed using plain cranial CT scans of patients aged ≥65 years from 2019 to 2023. Scans with intact calvarial anatomy and adequate visualization of MMA groove were included. Threedimensional reconstructions were generated, and bilateral distances from lateral canthus, external auditory canal, and canthomeatal line to MMA confluence point were measured. Analyses were performed by sex and laterality (p<0.05).

Results: A total of 221 patients were included (mean age 76 years; 63% female). The external auditory canal and lateral canthus showed low variability. Male patients had greater external auditory canal and canthomeatal line distances (p<0.05), while confluence measurements did not differ by sex. The confluence point was located farther from the canthomeatal line on the left (p=0.0125).

Conclusions: These findings provide a practical framework for MMA localization during pre-operative planning. In settings without MMA embolization, landmark-based localization offers a low-cost method to guide burr-hole placement and potential MMA coagulation, supporting resource-adapted strategy to reduce CSDH recurrence.

Objective: This study aims to analyze the angiographic features, demographic factors, and outcomes of endovascular treatment for ruptured intracranial aneurysms (IAs) in Central India.

Methods: This retrospective observational study was conducted in the Department of Interventional Radiology at a tertiary care hospital in Central India. It included 102 patients diagnosed with subarachnoid haemorrhage due to ruptured IAs between December 2021 and November 2024. Demographic data, comorbidities, angiographic features (size, location, morphology, and multiplicity), and clinical severity were analyzed. Patients underwent endovascular treatments such as unassisted coiling, stent-assisted coiling, and other techniques. Functional outcomes were evaluated using the Modified Rankin Scale (mRS).

Results: Females (62.8%) were more affected than males, with a peak incidence in the 51-60 years age group. Hypertension (44.1%) was the most common comorbidity. Most aneurysms (88.4%) were located in the anterior circulation, with the anterior communicating artery (27.7%) being the most common site. Small (<5 mm) and saccular aneurysms (96.4%) predominated. Unassisted coiling was the most performed procedure (68.6%). At admission, 83.3% of patients had poor functional outcomes (mRS 3-6), but 68.6% achieved good outcomes (mRS 0-2) by discharge.

Conclusions: Ruptured IAs in Central India predominantly affect females and involve the anterior circulation. Endovascular treatment significantly improves functional outcomes by reducing the re-rupture risk of an aneurysm, underscoring its effectiveness in managing this high-risk condition.

Objective: This study aimed to determine the frequency of hemorrhagic transformation (HT) and evaluate its impact on the clinical course and outcomes of patients with malignant middle cerebral artery (MCA) infarction.

Methods: A retrospective review was conducted of 74 patients with malignant MCA infarction, aged 44 to 92 years (mean age 71.5±2.0 years; 54.0% female), admitted between 2017 and 2025. Conservative therapy was administered to 77.0% of patients, while 22.9% underwent decompressive hemicraniectomy. All cases of HT were assessed using computed tomography according to the ECASS I classification.

Results: In the study cohort, 15% of patients received intravenous thrombolysis (IVT). Significantly, among this group, 100% developed HT as a complication. Hemorrhagic infarction (HI) occurred in 81.8% of these cases and was asymptomatic, not worsening the clinical condition or neurological deficits. Parenchymal hemorrhage (PH) occurred in 18.2% and was associated with clinical deterioration and fatal outcomes. In patients not receiving IVT, HT was observed in 66.6% of cases: HI type 1 occurred in 33.3%, HI type 2 in 47.6%, and PH type 1 in 19.0%. No cases of PH type 2 were reported.

Conclusions: HT is highly prevalent in malignant MCA infarction, regardless of IVT administration, with the majority of cases asymptomatic. Consequently, these findings suggest that asymptomatic HT may represent a natural progression of large infarcts rather than a treatment complication. The results underscore the need for early diagnostic markers and improved management strategies for HT in malignant MCA infarction.

Objective: To investigate the relationship between the Patency after Coil Embolization (PACE) score and subdural hematoma resolution as defined by reduction in hematoma cross-sectional area.

Methods: Patients with standalone coil middle meningeal artery embolization for subdural hematoma treatment were included in this study. Hematoma cross-sectional area (CSA) of the largest preoperative computed tomography (CT) slice and the corresponding postoperative CT slice, average Hounsfield units, and days between embolization and follow-up were recorded for each patient. A receiver operating characteristic (ROC) curve was used to determine the optimal threshold of hematoma resolution percentage at follow-up to differentiate between PACE score 0 and PACE score 1 embolizations. A multivariate logistic regression model of resolution above the calculated threshold adjusted for follow-up time, initial hematoma CSA, average Hounsfield units, and the PACE score was created.

Results: A total of 43 patients with 63 hematomas (20 patients had bilateral hematomas) were included in this study. ROC curve calculated threshold for hematoma resolution was 70.9%. There were univariate statistically significant differences in follow-up time and hematoma size (p=0.021, p=0.006, respectively). In the multivariate model, the PACE score was the only statistically significant predictor of at least 70.9% hematoma resolution at follow-up.

Conclusions: The PACE score is the most statistically significant predictor of at least 70.9% hematoma resolution at follow-up.

Objective: Multiple randomized controlled trials have demonstrated the efficacy of mechanical thrombectomy (MT) for acute ischemic stroke with a large ischemic core caused by large-vessel occlusion. Despite successful recanalization, more than half of the patients do not achieve a favorable prognosis, a phenomenon referred to as futile recanalization (FR). We aimed to identify the risk factors for, and incidence of, FR in patients with large ischemic cores.

Methods: Eighty-four patients with a large ischemic core who underwent MT between January 2015 and December 2024 at three hospitals were retrospectively reviewed. Patients were divided into two groups-FR and no-FR-according to functional independence at 90 days (modified Rankin Scale (mRS) score ≥4). Factors influencing FR were identified using multivariate logistic regression and receiver operating characteristic curve analyses.

Results: Eighty-four patients fulfilled the inclusion criteria, and FR was observed in 57 patients (67.9%). Multivariable regression analysis revealed that older age (odds ratio [OR], 1.09; 95% confidence interval [CI], 1.01-1.18; P=0.011), concomitant diabetes (OR, 11.2; 95% CI, 1.13-111.1; P=0.012), diffusion-weighted imaging-Alberta Stroke Program Early Computed Tomography Score (OR, 0.32; 95% CI, 0.11-0.79; P=0.012), and an increased number of passes (OR, 1.91; 95% CI, 1.00-4.16; P=0.046) were independently associated with FR after MT.

Conclusions: Older age, concomitant diabetes, diffusion-weighted imaging-Alberta Stroke Program Early Computed Tomography Score, and an increased number of passes are independently associated with FR after MT in patients with a large ischemic core.

Objective: Microsurgical excision of intracranial arteriovenous malformations (AVMs) remains a surgical challenge that requires neurosurgical experience as well as neurosurgical tools. Advances in medical devices widen the range of tools that can be used to ensure patients' safety and procedural integrity. There is limited data published regarding the role of intraoperative ultrasound to ensure proper cerebral arteriovenous malformation excision.

Methods: Patients who underwent ultrasound-assisted microsurgical excision of cerebral arteriovenous malformations were reviewed in a single center from 2021 through 2024. Patients' clinical, radiological, and intraoperative data were retrieved and analyzed.

Results: Twenty patients were included in the study. All lesions were in the cerebral regions. The study included 20 patients, 11 (55%) of whom were males and the patients' ages ranged from 5 to 55 years. Sixteen patients (80%) presented with headache, 13 patients (65%) with seizures, 8 patients (40%) with syncope, 2 patients (10%) with vomiting, and 6 patients (30%) with weakness.Thirteen patients (65%) had intracranial hemorrhage (ICH) on presentation. For all cases, intraoperative ultrasound (IOUS) was successful in confirming total resection of the lesion. In 13 cases that involved an intracerebral hematoma took place, the hematoma was visualized easily with grey-scale B-mode ultrasound, as well as its relation to the nidus was clearly delineated.

Conclusions: Intraoperative ultrasonography is a useful, cost-effective, and non-invasive tool for guiding through cerebral arteriovenous malformation microsurgical excision.