Journal of cerebrovascular and endovascular neurosurgery最新文献

Objective: Saccular aneurysms of the basilar artery (BA) trunk are a significant challenge in neurosurgery due to their rarity and the complexity of surgical approaches. This study examines the efficacy and outcomes of microsurgical treatment for these aneurysms, highlighting the advantages over endovascular methods in terms of occlusion rates and complication management.

Methods: A retrospective review of 23 patients with BA trunk aneurysms treated microsurgically at the Moscow Regional Clinical Research Institute from June 2019 to April 2024 was conducted. Patient demographics, aneurysm characteristics, surgical techniques, and postoperative outcomes were analyzed.

Results: The study group included 16 women and 7 men, with an average age of 51.2 years. Notably, 19 of 23 patients (82.6%) presented with subarachnoid hemorrhage (SAH), while 4 had unruptured aneurysms (2 asymptomatic, 2 with mass effect). Aneurysms were predominantly located at the origin of the superior cerebellar artery (SCA). Surgical approaches varied based on aneurysm location, with most utilizing the orbito-pterional approach. Complete occlusion was achieved in all cases and was maintained over the follow-up period without signs of recanalization. Complications included transient oculomotor nerve dysfunction in 5 patients, with a substantial recovery rate. Favorable outcomes (mRS 0-2) were achieved in 87% of patients, including most SAH cases, highlighting the safety and effectiveness of treatment.

Conclusions: Microsurgical treatment of BA trunk aneurysms provides a reliable occlusion with a low rate of complications and excellent clinical outcomes. This series supports microsurgery as a preferred option for managing these challenging aneurysms, particularly when located at the SCA origin.

Carotid webs are endoluminal shelf-like projections caused by fibrous dysplasia observed along the dorsal carotid bulb of the internal carotid artery (ICA). Symptomatic lesions have historically been treated with endarterectomy or stent placement and there is little data to support treating a patient with medical management alone. An asymptomatic contralateral carotid web may be discovered during stroke work-up. In this study, we evaluate the safety and efficacy of staged bilateral carotid artery stenting for bilateral carotid webs. We report three cases: the first patient presented with recurrent transient ischemic attacks attributable to an ipsilateral ICA with associated carotid web and the other two presented with right middle cerebral artery strokes requiring emergent endovascular mechanical thrombectomy. Bilateral carotid webs were identified, with the ipsilateral lesion considered the likely embolic source. All three patients underwent successful carotid stenting of their symptomatic carotid webs followed by staged contralateral stenting of their asymptomatic webs. All patients were premedicated with a dual antiplatelet regimen of aspirin and clopidogrel. There was no clinical history of recurrent stroke/transient ischemic attack (TIA) or death peri-procedurally or in follow-up. Bilateral carotid web stenting is a safe and effective treatment in patients presenting with symptomatic carotid webs with associated contralateral lesions.

Dural arteriovenous fistulas (dAVFs) are uncommon intracranial vascular shunts that typically cause hemorrhage when retrograde cortical venous drainage and diffuse venous hypertension are present. Venous aneurysms are usually considered a sequela of sustained venous hypertension; however, localized focal hemodynamic stress may also contribute to aneurysm formation and rupture. We report a rare case of a 51-year-old woman who presented with acute expressive aphasia and dense right hemiparesis. Imaging revealed a large left temporoparietal intracerebral hemorrhage with subarachnoid extension. Digital subtraction angiography demonstrated a left temporal dAVF supplied by the middle meningeal artery and draining via the veins of Trolard and Labbé into the superior sagittal sinus. A discrete saccular venous aneurysm was identified at a sharply angulated and stenotic draining segment, suggesting localized venous hypertension without diffuse angiographic congestion. Transarterial embolization using Onyx-18 achieved complete obliteration of the fistula and aneurysm. At one-month follow-up, the patient showed complete recovery of aphasia and marked motor improvement. This case illustrates that focal venous hypertension, even without diffuse angiographic congestion, can result in aneurysm formation and rupture. Early angiographic assessment and endovascular intervention remain critical for favorable outcomes.

Alagille syndrome (ALGS), also known as arteriohepatic dysplasia, is a rare multisystem vascular disorder affecting brain, liver, heart, ophthalmic and skeletal systems. Moyamoya syndrome is a rare arteriopathy due to an underlying cause that can lead to ischemic and hemorrhagic strokes. Here, we report a rare case of ALGS in a patient with congenital narrowing of bilateral internal carotid arteries (ICA) with superimposed intracranial arteriopathy and associated moyamoya syndrome. A 34-year-old female presented with progressively worsening intermittent right eye visual blurriness, associated headache, and dizziness. Digital subtraction angiogram findings were consistent with the bilateral intracranial steno-occlusive disease at the ICA terminus with moyamoya collaterals at the skull base; bilateral posterior communicating arteries supplied the bilateral middle cerebral arteries, and the left ophthalmic artery supplied the distal right anterior cerebral artery. Her right-sided vision abnormalities were highly concerning for branch retinal artery occlusion based on fundoscopic exam. She continued antiplatelet therapy and was scheduled for an ophthalmology follow-up as an outpatient. The patient was monitored in outpatient stroke clinic with surveillance scans. Due to patient preference and the absence of further strokes on preventive medications, the initial plan of external carotid artery to ICA bypass was deferred. Early identification of moyamoya syndrome and initiation of secondary stroke preventive therapy in symptomatic patients can reduce the incidence of ischemic strokes. This is an important consideration for patients transitioning from pediatric to adult neurologists, as the latter may not be as familiar with managing this condition.

Objective: We aimed to investigate the predictors of aneurysm occlusion following flow diversion treatment for unruptured intracranial aneurysms (UIA) using the Surpass Evolve (SE) stent.

Methods: The radiological and clinical outcomes of UIAs treated using SE stent at a single tertiary hospital were reviewed retrospectively. We categorized radiological outcome into the poor (O'Kelly-Marotta [OKM] grade A-B) and favorable occlusion group (OKM grade C-D). Univariate and multivariate analyses were conducted to identify risk factors associated with poor occlusion.

Results: A total of 68 unruptured intracranial aneurysms in 52 patients were treated in our institution from December 2019 to July 2024. At last radiological follow-up (mean 17.5±10.1 months), the overall favorable occlusion rate was 79.4% (n=52). Multivariate analysis showed larger aneurysm (p=0.011, OR=0.89, 95% CI [0.81-0.98]) and presence of incorporated branch (p=0.007, OR=8.26, 95% CI [1.78-38.28]) were associated with independent factors for poor occlusion, respectively. Procedural mortality and morbidity were 0% (n=0) and 1.9% (n=1). One patient presented with delayed ischemic stroke (1.9%, n=1) without permanent neurological deficit.

Conclusions: Treatment for UIAs using the Surpass Evolve flow-diverting stent might be feasible for efficacy and safety. In this study, larger size of aneurysm and branch incorporated aneurysm were associated with poor occlusion after flow-diversion using SE stent.

The adhesion of arteries to aneurysm domes can pose significant technical challenges during surgical clipping. Dissection of these vessels carries a risk of iatrogenic wall damage and subsequent complications. We present the case of a 67-year-old woman with three unruptured intracranial aneurysms. Following successful coil embolization of a right posterior communicating artery aneurysm, surgical clipping was planned for the remaining left middle cerebral artery and anterior choroidal artery aneurysms. Intraoperatively, the M2 inferior division was found to be densely adherent to an aneurysm located at the bifurcation of the M2 superior division. After temporary clipping of the parent artery, careful dissection was performed, and the aneurysm was successfully clipped. Postoperatively, the patient failed to regain consciousness. A computed tomography scan revealed diffuse subarachnoid hemorrhage, and subsequent angiography confirmed active contrast extravasation from the dissected M2 inferior division. The family declined reoperation, and the patient subsequently expired after brain death was declared. This case illustrates that in instances of strong arterial adhesion, extreme caution is warranted during dissection. Even without evident intraoperative bleeding, subtle vessel wall injury can lead to fatal delayed rupture. Meticulous inspection and, when necessary, reinforcement of dissected arterial segments is crucial to prevent such devastating outcomes.

Middle meningeal arteriovenous fistulas (MMAVFs) are known as rare diseases, often associated with head trauma, with idiopathic cases being exceedingly uncommon. Here, we present a clinical case of spontaneous and simultaneous bilateral MMAVFs in a 37-year-old woman. She presented with persistent pulsatile tinnitus but no history of head trauma. Bilateral MMAVFs were identified via Time-of-Flight Magnetic Resonance Angiography. Subsequent digital subtraction angiography revealed a fistula between the middle meningeal artery (MMA) and middle meningeal vein (MMV) without definite intracranial venous reflux. We had planned coil embolization via a trans-arterial approach for both sides. Remarkably, after six days, the right-sided MMAVF observed in the previous external carotid artery (ECA) angiogram disappeared spontaneously. The left-sided MMAVF was successfully treated with coil embolization, achieving complete obliteration of fistula flow. Postoperatively, the patient's pulsatile tinnitus disappeared, and she was discharged without medication. There are a few possible mechanisms of spontaneous MMAVFs, such as middle meningeal artery aneurysm and trivial head trauma. Trans-arterial embolization with coils appears to be an effective and safe treatment option for complete obliteration of fistula flow.

Central nervous system (CNS) aspergillosis is a life-threatening infection primarily affecting immunocompromised patients and may lead to severe cerebral infarction through vascular invasion. However, there is limited data on the treatment options for aspergillosis-induced cerebral infarction especially surgical treatments such as superficial temporal artery (STA)-middle cerebral artery (MCA) bypass surgery. Herein, we present a case of cerebral infarction in a 59-year-old male with progressive right eye ptosis. Specifically, he had ipsilateral MCA stenosis originating from paranasal sinusitis due to invasive aspergillosis. After 3 months, the patient was readmitted due to worsening cerebral infarction and complete internal carotid artery (ICA) occlusion. Conservative treatment failed to improve cerebral perfusion, leading to gradual neurological decline. Consequently, STA-MCA bypass was performed to stabilise the patient. Postoperative imaging revealed a patent bypass graft and an enhanced cerebral perfusion. Although the patient experienced persistent left-sided hemiparesis, his overall neurological condition remained stable for 1 year, with a Glasgow Coma Scale score of 15. STA-MCA bypass should be considered a potential treatment option for patients with aspergillosis-induced vasculitis resulting in cerebral infarction secondary to total ICA occlusion.

Introduction: Dural arteriovenous fistulae (dAVFs) can lead to subarachnoid hemorrhage and other devastating complications. A rare subtype of dAVFs is those located in the anterior condylar confluence adjacent to the hypoglossal canal. These dAVFs can be difficult to treat, with some electing to utilize endovascular approaches for these lesions. There is a need to further assess the safety and efficacy of this approach.

Case description: All patients that underwent endovascular treatment of dAVFs affecting the anterior condylar confluence at our center were included. Pre-treatment factors including anatomy and presentation were recorded, as were follow-up data including angiographic cure and clinical or technical complications. Three patients were included in this study. Presenting symptoms included ocular hyperemia, proptosis, auditory symptoms (whooshing, tinnitus), and Cranial Nerve 6 palsy. Both transarterial and transvenous embolization were employed in select cases, with Onyx HD-500 and coils both used as embolic materials. No clinical or technical complications were reported in these patients, and patients were asymptomatic at final follow-up without recurrence or regrowth of their dAVF.

Conclusions: Treatment of dAVFs located in the anterior condylar confluence can be achieved endovascularly using both transarterial and transvenous approaches.

The irony of life is that in the complex world of neurosurgery, where the skilled mind of the neurosurgeon navigates the delicate terrain of cerebral aneurysm, the same mind can be affected by the very thing it treats. Sometimes the healer becomes the one in need of healing. This predicament highlights the reality of existence that vulnerability transcends professional boundaries, and any individual can become a target.