World Neurosurg
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Rootlets of the lower cranial nerves create a web that limits microsurgical maneuverability in the cerebellomedullary cistern (CMC). The vagoaccessory triangle (VAT) and 2 triangles within it were defined to identify surgical routes to aneurysms of the posterior inferior cerebellar artery (PICA). Dividing the VAT into 2 triangles (suprahypoglossal [SHT] and infrahypoglossal [IHT]), although elegant, oversimplifies CMC anatomy. The triangle formed by the superior and inferior hypoglossal rootlets (hypoglossal-hypoglossal triangle [HHT]) needs consideration as well. ⋯ Based on this study, VAT should be divided into 3 triangles, not 2. Splayed rootlets of cranial nerve XII and multiple outlet foramina create an important space different from the previously recognized SHT and IHT. These triangles provide corridors to vascular pathologies. V4 subsegments may be approximated from imaging studies and may help with preoperative planning.
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To delineate the fractional anisotropy (FA) and apparent diffusion coefficient (ADC) values of patients with cervical spondylotic radiculopathy by diffusion tensor imaging and fiber bundle tracing. ⋯ Fiber tractography is capable of delineating microstructural changes of cervical nerve roots and cervical spondylotic radiculopathy exhibits significant changes in FA and ADC values.
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Case Reports
Microsurgical Clip Reconstruction of a Ruptured Dissecting PICA Aneurysm: a 2D Operative Video.
This case is a presentation of technical tenets for the microsurgical clipping of a ruptured posterior inferior cerebellar artery (PICA) aneurysm (Video 1). The patient described in this case was a 19-year-old male with a history of polysubstance abuse who presented from an outside hospital after being found unresponsive and admitted for a subarachnoid hemorrhage 7 days earlier. Noninvasive vascular imaging completed at the outside hospital showed no clear intracranial aneurysm except some irregularity of left PICA proximally. ⋯ Endovascular options were considered to be high risk for this patient due to the wide neck of the aneurysm. Stent coiling was not considered the best option given the concern about recent subarachnoid hemorrhage and the need for antiplatelets. This case is valuable to the literature as it illustrates technical steps required for reconstructing an aneurysm with a dissected wall with pseudoaneurysmal formation, the need for early proximal control, and the use of intraoperative adenosine for temporary cardiac standstill.
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Dural arteriovenous fistulae (dAVFs) of the anatomically complex anterior condylar confluence (ACC) are often examined by computed tomography (CT) angiography and conventional angiography before treatment. Contrasted vessels often overlap with skull bones in enhanced CT scan and make it difficult to detect the shunt point of the dAVF. Bone subtraction CT angiography (BSCTA) can overcome this limitation and allow for superior imaging of dAVFs that may help to find an alternative access for catheterization. ⋯ Understanding the inherently complex and individually unique venous anatomy of the ACC is crucial for treatment of dAVFs. BSCTA is an effective visualization technique for dAVFs of the ACC and allows for precise preoperative vascular structure evaluation. We suggest that in the case of the angle between the ACV and the IJV being too sharp to catheterize vessels through the ipsilateral IJV, TVE via the intercavernous sinus can be efficiently used.
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Optimal transfusion thresholds have been extensively studied for various surgical procedures; however, no transfusion threshold has been set for patients undergoing complex spine surgery. The aim of this study was to compare postoperative outcomes relative to perioperative hemoglobin (Hb) levels for patients undergoing complex spine surgery for adult spinal deformity and to evaluate impact of blood transfusion timing on clinical outcomes. ⋯ In patients with adult spinal deformity undergoing complex spine surgery, earlier targeted blood transfusions during surgery, rather than in the postoperative period, may lead to improved postoperative outcomes.