World Neurosurg
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Case Reports
Interval Thrombosis of Arteriovenous Malformation Draining Vein after Stereotactic Radiosurgery.
Arteriovenous malformations (AVMs) are high-pressure vascular lesions that can present formidable therapeutic challenges. One treatment option for these lesions is stereotactic radiosurgery, which may be used to provoke progressive thrombosis of the draining veins and subsequent obliteration of the AVM nidus. In this clinical image, we successfully demonstrate this therapeutic modality with the case of a 26-year-old man with a large frontal AVM, treated with stereotactic radiosurgery.
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The authors present a 3-dimensional surgical video of a half-and-half, transcavernous approach for microsurgical clipping of a giant basilar tip aneurysm that recurred twice after endovascular treatment. The case refers to a 60-year-old man who presented with subarachnoid hemorrhage, was treated with coiling, and had a good clinical and radiographic outcome. At 3 months, he was found to have recurrent filling at the neck of the aneurysm and was treated again endovascularly with stent coiling. ⋯ The transcavernous approach is then performed, followed by a posterior clinoidectomy and division of the posterior communicating artery. After multiple failed clipping attempts, the aneurysm was trapped and opened to remove some of the coils from the neck. This accommodated permanent clipping with preservation of all major vessels and complete obliteration of the aneurysm neck.
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Wide-necked intracranial aneurysms present unique treatment challenges in the setting of subarachnoid hemorrhage. New generations of endoluminal devices (stents) have expanded our ability to treat complex aneurysms. The PulseRider Aneurysm Neck Reconstruction Device (PulseRider [Cerenovus, Irvine, California, USA]) is new to the U.S. market after receiving Food and Drug Administration approval in June 2017. Official recommendation for use of the PulseRider is with dual antiplatelet therapy (DAPT). Its design has been hypothesized to carry a lower risk of thromboembolic complications in the circumstance that DAPT needs to be discontinued. ⋯ The PulseRider device represents a novel design for stent-assisted coil embolization. We report a small but promising series of its successful use in the acute treatment of wide-necked, ruptured basilar artery aneurysms. Additional experience is needed to determine if this device has a place in our armamentarium for treatment of ruptured aneurysms.
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Basilar invagination (BI) is a developmental anomaly and commonly presents with neurologic findings. The incidence of BI associated with other osseous anomalies of the craniovertebral junction is high, including incomplete ring of C1 with spreading of the lateral masses, atlanto-occipital assimilation, hypoplasia of the atlas, basiocciput hypoplasia, and occipital condylar hypoplasia. However, BI combined with C1 prolapsing into the foramen magnum (FM) is an extremely rare condition. ⋯ We present 2 rare cases of BI combined with C1 prolapsing into the FM. We adopted different surgical strategies with satisfying outcome for these patients. We deem that the treatment of unique BI should be individualized according to the different image characteristics. The image-based modern rapid prototyping and 3D printed techniques can provide invaluable information in presurgical planning for complex craniovertebral junction anomalies.
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Almost 30% of patients with subarachnoid hemorrhage (SAH) are found to have multiple aneurysms. This can potentially present a serious management dilemma when planning treatment. Magnetic resonance imaging vessel wall imaging (VWI) has been proposed as a reliable technique in differentiating between ruptured and unruptured aneurysms in patients with multiple intracranial aneurysms who present with SAH. Expert consensus now supports this as a possible use for the technique. ⋯ Although a case of concurrent false positive and false negative in the same patient has not previously been reported, the positive predictive value of VWI for rupture status is known to be much lower than its negative predictive value, and a case like this might be expected to occur in 0.6% of patients. Therefore, whereas VWI is a valuable tool, it should be used in conjunction with, and not in lieu of, traditional indicators of aneurysm rupture.