Neurosurgery
-
The optimal management of unruptured brain arteriovenous malformations (AVMs) is controversial after the ARUBA trial. ⋯ The ARUBA trial conclusion that medical management is superior to medical management with interventional therapy for all unruptured AVMs could be repudiated.
-
This video illustrates access to tortuous distal intracranial vasculature and the use of intra-arterial (IA) tissue plasminogen activator (tPA) for the revascularization of small vessel occlusion. IA tPA is a reasonable approach for distal arterial occlusion resistant to intravenous tPA or mechanical thrombectomy. In this video, the patient had a posterior circulation stroke with elevated time-to-peak in the cerebellar hemispheres. ⋯ For occlusion of small intracranial vessels where IV tPA is ineffective and mechanical thrombectomy is unsafe, local administration of IA tPA can be an effective therapy. Consent was obtained from the patient prior to performing the procedure. Institutional review board approval is not required for the report of a single case.
-
We present the case of a 68-yr-old woman who presented with an acute left middle cerebral artery syndrome. Noninvasive angiography obtained 13 h after last known well time demonstrated both left M1-segment middle cerebral artery (MCA) occlusion and near-complete occlusion of the left internal carotid artery (ICA) just distal to the carotid bifurcation. Intervention was offered given the sizeable mismatch demonstrated by computed tomography (CT) perfusion imaging. ⋯ Postprocedural imaging demonstrated preservation of the at-risk brain parenchyma. The patient demonstrated significant improvement in strength and speech after the procedure, and she was discharged to an inpatient rehabilitation center for further treatment. The patient and her family gave consent for this report.
-
Fragile, dilated moyamoya vessels are the main source of hemorrhagic stroke in moyamoya disease (MMD). However, the prevalence of hemorrhagic stroke largely differs between Asian and western countries, although the underlying pathophysiology has not been clarified. ⋯ The marked dilatation of PChoA and PcomA is considered a powerful predictive marker of hemorrhage in MMD. Collateral channels spontaneously shift from the anterior to posterior circulation in Japanese patients during ageing but not in European Caucasian patients. These different dilation patterns of the collateral pathway may be associated with an ethnic difference of the clinical onset type in MMD.
-
The hemodynamic changes that occur after high-flow (extracranial-intracranial) EC-IC bypass surgery with internal carotid artery (ICA) ligation are not well known. ⋯ After high-flow EC-IC bypass with permanent ICA ligation, the bypass artery could partially compensate for the loss of BFV of the sacrificed ICA. The increased flow of the contralateral ICA and BA supply collateral blood flow. Clinically irrelevant hyperperfusion was observed.