Journal of neurosurgery
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Journal of neurosurgery · Apr 2011
The azygos anterior cerebral artery bypass: double reimplantation technique for giant anterior communicating artery aneurysms.
The authors introduce the azygos anterior cerebral artery (ACA) bypass as an option for revascularizing distal ACA territories, as part of a strategy to trap giant anterior communicating artery (ACoA) aneurysms. In this procedure, the aneurysm is exposed with an orbitozygomatic-pterional craniotomy and distal ACA vessels are exposed with a bifrontal craniotomy. The uninvolved contralateral A(2) segment of the ACA serves as a donor vessel for a short radial artery graft. ⋯ Retrograde flow from the CmaA supplies the ipsilateral recurrent artery of Heubner, and the aneurysm lumen thromboses. The azygos bypass was successfully performed to treat a 47-year-old woman with a giant, thrombotic ACoA aneurysm supplied by the A(1) segment of the left ACA, with left PcaA and CmaA originating from the aneurysm base. The authors conclude that the azygos ACA bypass is a novel option for revascularizing PcaA and CmaA, as part of the overall treatment of giant ACoA aneurysms.
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Journal of neurosurgery · Apr 2011
Cerebral watershed hypoperfusion in subarachnoid hemorrhage: computed tomography perfusion analysis.
A better understanding of the pathophysiology of vasospasm-induced delayed cerebral ischemia and earlier detection of hypoperfusion before ischemic injury are needed to guide therapy in subarachnoid hemorrhage (SAH). The cerebrovascular physiology of the major arterial territories differs from that of the watershed zones (WZs) in a way that would suggest a differential topographic sensitivity of the brain to vasospasm. The primary end point of the study was to investigate the vasospasm-induced hypoperfusion in relation to cerebrovascular topography and timing from the onset of SAH. ⋯ This study suggests the existence of a cerebral topographic heterogeneity to the hemodynamic effects of SAH and differential pathogenetic mechanisms of hypoperfusion according to timing, age, and brain topography. Hypoperfusion in the WZs may be an early precursor to more profound ischemic events. The PW CT detection of such brain-sensitive zones could offer a warning signal of the early hemodynamic effects of SAH and cerebral vasospasm.
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Journal of neurosurgery · Apr 2011
HyperForm balloon remodeling in the endovascular treatment of anterior cerebral, middle cerebral, and anterior communicating artery aneurysms: clinical and angiographic follow-up results in 800 consecutive patients.
The purpose of this paper was to present the safety, efficacy, and clinical/angiographic follow-up results of HyperForm balloon-assisted endosaccular coil occlusion of distal anterior circulation bifurcation aneurysms. ⋯ The satisfactory results obtained in this experience demonstrate that HyperForm balloon remodeling provides strong benefits for the endovascular management of middle cerebral, anterior cerebral, and anterior communicating artery aneurysms without increasing the risk of treatment. Not only does this technique allow for the safe treatment of these aneurysms, but it also expands the indications of endovascular treatment to include aneurysms that otherwise cannot be treated with simple coil embolization.
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Journal of neurosurgery · Apr 2011
Risk of ventriculostomy-related hemorrhage in patients with acutely ruptured aneurysms treated using stent-assisted coiling.
Intracranial stenting has improved the ability to treat wide-neck aneurysms via endovascular techniques. However, stent placement necessitates the use of antiplatelet agents, and the latter may complicate the treatment of patients with acutely ruptured aneurysms who demonstrate hydrocephalus and require ventriculostomy. Antiplatelet agents in this setting could increase the incidence of ventriculostomy-related hemorrhagic complications, but there are insufficient data in the medical literature to quantify this potential risk. The aim of this study was to directly quantify the risk of ventriculostomy-related hemorrhage in patients with acute aneurysmal subarachnoid hemorrhage treated with stent-assisted coiling. ⋯ The application of dual antiplatelet therapy in stent-assisted coiling of acutely ruptured aneurysms is associated with an increase in the risk of hemorrhagic complications following ventriculostomy or VP shunt placement, as compared with its use in a coiling procedure without a stent.
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Journal of neurosurgery · Apr 2011
Anatomical triangles defining surgical routes to posterior inferior cerebellar artery aneurysms.
Surgical routes to posterior inferior cerebellar artery (PICA) aneurysms are opened between the vagus (cranial nerve [CN] X), accessory (CN XI), and hypoglossal (CN XII) nerves for safe clipping, but these routes have not been systematically defined. The authors describe 3 anatomical triangles and their relationships with PICA aneurysms, routes for surgical clipping, outcomes, and angiographically demonstrated anatomy. ⋯ The anatomical triangles and zones clarify the borders of operative corridors to PICA aneurysms and define the depth of dissection through the CNs. Deep dissection to aneurysms in the anterior medullary zone traverses CNs X, XI, and XII, whereas shallow dissection to aneurysms in the lateral medullary zone traverses CNs X and XI. Posterior inferior cerebellar artery aneurysms outside the vagoaccessory triangle are frequently distal and superficial to the lower CNs, and associated surgical morbidity is minimal. Angiography may preoperatively localize a PICA aneurysm's triangular anatomy based on the distal PICA origin or distal aneurysm location.