Complications of preoperative embolization of cerebral arteriovenous malformations.

Object: Preoperative embolization is viewed by the authors as a useful adjunct in the surgical management of cerebral arteriovenous malformations (AVMs). This study was performed to determine the rate of significant complication in patients undergoing this procedure.

Methods: Demographic, anatomical, and procedure data were collected prospectively.

Outcome after subarachnoid hemorrhage from a very small aneurysm: a case-control series.

Object: A case-control analysis of patients with SAH was performed to compare risk factors and outcomes at 6 months posthemorrhage in patients with a very small aneurysm compared with those with a larger aneurysm.

Methods: All patients with SAH who were treated between January 1998 and December 1999 were studied. A very small aneurysm was defined as "equal to or less than 5 mm in diameter.

Treatment and outcome in 30 patients with posterior cerebral artery aneurysms.

Object: The records of 30 patients with posterior cerebral artery (PCA) aneurysms treated during a 12-year period were reviewed to determine outcome and the risk of visual field deficit associated with PCA sacrifice.

Methods: Clinical data and treatment summaries for all patients were maintained in an electronic database. The Glasgow Outcome Scale (GOS) and modified Rankin Scale (mRS) scores were determined by an independent registrar.

Factors related to hydrocephalus after aneurysmal subarachnoid hemorrhage.

Objective: The purpose of this study was to identify factors predictive of shunt-dependent hydrocephalus among patients with aneurysmal subarachnoid hemorrhage. The data can be used to predict which patients in this group have a high probability of requiring permanent cerebrospinal fluid diversion.

Methods: Seven hundred eighteen patients with aneurysmal subarachnoid hemorrhage who were treated between 1990 and 1999 were retrospectively studied, to identify factors contributing to shunt-dependent hydrocephalus.

Aneurysm retreatment after Guglielmi detachable coil and nondetachable coil embolization: report of nine cases and review of the literature.

Objective: Guglielmi detachable coil embolization of cerebral aneurysms is becoming increasingly used to manage certain intracranial lesions based on aneurysm geometry, patient condition, and patient and surgeon preferences. Aneurysm recurrences or incomplete initial treatments are not uncommon, making repeat treatment necessary using either surgical or endovascular techniques.

Methods: Between January 1993 and June 1998, 1025 cerebral aneurysms were managed by the authors at a single hospital.

Current results of the surgical management of aneurysms of the basilar apex.

Objective: To provide current information regarding the expected clinical outcomes and sources of morbidity and mortality in the modern surgical management of basilar apex aneurysms.

Method: A retrospective review was conducted of 303 cases of such aneurysms that were treated surgically during 18 years at one institution. Postoperative angiography was performed in 81% of the cases.

Multidisciplinary approach to traumatic intracranial aneurysms secondary to shotgun and handgun wounds.

Background: Traumatic intracranial aneurysms (TICAs) may develop following gunshot injuries to the head. Management of these lesions often combines various aspects of microneurosurgical and endovascular techniques to safely repair or obliterate vessel defects.

Methods: We reviewed our experience over the last 18 years and identified five cases of intracranial aneurysms following gunshot and handgun wounds that were treated surgically and/or endovascularly.

Subarachnoid hemorrhage during arteriovenous malformation embolization as a result of vessel wall "sandblasting".

Preoperative selective particulate embolization of arteriovenous malformations can make subsequent surgical resection of such lesions safer for the patient and easier for the surgeon. Nevertheless, embolization carries intrinsic risks, which include subarachnoid hemorrhage. We report two cases of subarachnoid hemorrhage during particulate embolization that we think was attributable to catheter positioning near a vessel curve and subsequent denudation of the vessel wall to the degree that hemorrhage was induced.

Posteroinferior cerebellar artery aneurysms: surgical results for 38 patients.

Objective: Posteroinferior cerebellar artery aneurysms have an incidence of approximately 0.49%. Reports in the literature are sparse concerning outcomes in this patient population.

A founder mutation as a cause of cerebral cavernous malformation in Hispanic Americans.

Background: Cerebral cavernous malformation is a vascular disease of the brain causing headaches, seizures, and cerebral hemorrhage. Familial and sporadic cases are recognized, and a gene causing familial disease has been mapped to chromosome 7. Hispanic Americans have a higher prevalence of cavernous malformation than do other ethnic groups, raising the possibility that affected persons in this population have inherited the same mutation from a common ancestor.

External carotid-to-middle cerebral bypass in the treatment of complex internal carotid injury.

Patients with penetrating carotid injuries above C2 present special challenges to the cerebrovascular surgeon. A subgroup of patients may lack the vascular collaterals necessary to tolerate carotid sacrifice or prolonged ischemia during direct carotid repair. We present a technique of extracranial-intracranial (EC-IC) saphenous vein bypass in two patients with high cervical and skull base carotid injuries and poor vascular collaterals.

Treatment of dural sinus thrombosis using selective catheterization and urokinase.

Thrombosis of the cerebral dural venous sinuses, cortical draining veins, and deep cerebral veins is a rare clinical finding. Because of its low incidence and multiple etiologies, the optimum therapy for this condition will only be elucidated by a multicenter, randomized prospective study. At our institution, we favor early and aggressive management of cerebral venous sinus thrombosis with transfemoral, venous intradural infusions of the fibrinolytic agent urokinase.

Orbital infarction syndrome after surgery for intracranial aneurysms.

Background: Global orbital infarction results from ischemia of the intraocular and intraorbital structures due to hypoperfusion of the ophthalmic artery and its branches.

Patients: The authors describe six patients in whom acute proptosis, ophthalmoplegia, and blindness developed immediately after surgery for intracranial aneurysms.

Results: All patients underwent standard frontotemporal craniotomies to clip their aneurysms.

Treatment of traumatic arterial vasospasm with intraarterial papaverine infusion.

We report a case of severe posttraumatic arterial vasospasm treated with repetitive intraarterial papaverine infusions. The salient features of the mechanism of action of papaverine are included.

Elevated transcranial Doppler ultrasound velocities following therapeutic arterial dilation.

Background: Elevated transcranial Doppler (TCD) velocities seen after cerebral angioplasty are commonly interpreted as evidence of residual or recurrent stenosis but may conceivably arise from hyperemia and require different clinical management.

Summary Of Report: Four cases of abnormally elevated mean TCD velocities obtained after therapeutic arterial dilation with either balloon angioplasty or intra-arterial administration of papaverine are described. In each case, cerebral angiography revealed a dilated vessel, suggesting that hyperemia and impaired autoregulation were the causes of the high velocities.

An unusual transcranial Doppler waveform associated with vessel distortion in giant intracranial aneurysms.

Although the shapes of velocity waveforms obtained with transcranial Doppler examination can indicate such abnormalities as increased intracranial pressure and proximal arterial compromise, the significance of unusual waveform morphologies is often obscure. In this report, we describe four cases in which an unusual waveform morphology was obtained from vessels distorted and narrowed by intracranial masses. The appearance of this unusual morphology as an isolated signal within a transcranial Doppler examination should, therefore, suggest a structural deformation of the insonated vessel to those who interpret transcranial Doppler studies.

Treatment of spastic gait in cerebral palsy.

The most common presentation of cerebral palsy is spastic diplegia, which in severe cases can impede nursing care and in less severe cases can impair a child's ability to move around with facility. A procedure has been developed to decrease spasticity in which there is selective section of portions of the dorsal roots L2-S2. In a series of such operations in 19 children with spastic diplegia, we were able to decrease their spasticity significantly with resultant improvement in motor function and self care.

Surgery for paraclinoidal carotid artery aneurysms.

Aneurysms arising from the proximal carotid artery between the roof of the cavernous sinus and the origin of the posterior communicating artery pose conceptual and technical surgical problems with regard to acquisition of proximal control and safe intracranial exposure. Over the past 3 1/2 years, 89 patients with paraclinoidal aneurysms have been treated at the University of Texas Southwestern Medical Center. Thirty-nine (44%) of these patients presented with subarachnoid hemorrhage.

Combined transsylvian-subtemporal exposure of cerebral aneurysms involving the basilar apex.

The surgical repair of cerebral aneurysms involving the apex of the basilar artery continues to undergo refinement and evolution. The inherent difficulty in accessing the basilar apex as well as the complexities of the microanatomy render this area a notoriously hazardous and technically challenging region in which to perform microsurgical clipping of cerebral aneurysms. Several operative approaches have been described and are constantly undergoing a state of evolution in the hopes of optimizing the exposure of the distal basilar artery and minimizing the inherent risks of surgery.

The future. Prospects of innovative treatment of intracerebral hemorrhage.

Aggressive surgical as well as medical management strategies have had limited success with improving outcomes from spontaneous intracerebral hematomas. Future prospects of treatment will undoubtedly focus on less invasive, better tolerated procedures to remove hematomas in select patients. Some success has been achieved with a coupling of stereotactic technology, fibrinolytic agents, and mechanical devices, which can remove solid portions of hematoma through narrow probes.

Ventriculopleural shunting used as a temporary diversion.

Due to the limited absorptive capacity of the pleural cavity, infants and young children are not generally ideal candidates for ventriculopleural shunts. We report using chest cavities as alternate for temporary diversion of CSF in a young child. Venous access to the cervical region could not be utilized because of scarring from previous procedures, while peritoneal access was contraindicated due to repeated pseudocyst formation.