Rupture of an intracranial aneurysm is the leading cause of subarachnoid hemorrhage not due to trauma. This review summarizes both the approach to establishing the diagnosis and treatment options, including the placement of intravascular coils to arrest the bleeding. Common management problems include vasospasm, hydrocephalus, and rebleeding.

/pdf/aneurysmal-subarachnoid-hemorrhage-1hwq1inmbs.pdf

Aneurysmal subarachnoid hemorrhage.

The results of this systematic review and meta-analysis indicate that CT angiography is an accurate tool for the diagnosis of ruptured intracranial aneurysms and can be integrated as a primary examination tool into the imaging and treatment algorithm for patients with subarachnoid hemorrhage at presentation; the chance of missing a ruptured aneurysm at CT angiography is no more than 2%.

Intracranial Aneurysms in Patients with Subarachnoid Hemorrhage: CT Angiography as a Primary Examination Tool for Diagnosis—Systematic Review and Meta-Analysis

OBJECTIVE Complications of laser interstitial thermal therapy (LITT) are underreported. The authors discuss how they have modified their technique in the context of technical and treatment-related adverse events. METHODS The Medtronic Visualase system was used in 49 procedures in 46 patients. Between 1 and 3 cooling catheters/laser fiber assemblies were placed, for a total of 62 implanted devices. Devices were placed using frameless stereotaxy (n = 3), frameless stereotaxy with intraoperative MRI (iMRI) (n = 9), iMRI under direct vision (n = 2), MRI alone (n = 1), or frame-based (n = 47) techniques. LITT was performed while monitoring MRI thermometry. Indications included brain tumors (n = 12), radiation necrosis (n = 2), filum terminale ependymoma (n = 1), mesial temporal lobe epilepsy (n = 21), corpus callosotomy for bifrontal epilepsy (n = 3), cavernoma (n = 1), and hypothalamic hamartomas (n = 6). RESULTS Some form of adverse event occurred in 11 (22.4%) of 49 procedures. These included 4 catheter malpositions, 3 intracranial hemorrhages, 3 cases of neurological deficit related to thermal injury, and 1 technical malfunction resulting in an aborted procedure. Of these, direct thermal injury was the only cause of prolonged neurological morbidity and occurred in 3 of 49 procedures. Use of frameless stereotaxy and increased numbers of devices were associated with significantly increased complication rates (p < 0.05). A number of procedural modifications were made to avoid complications, including the use of 1) frame-based catheter placement, a 1.8-mm alignment rod to create a track and titanium skull anchors for long trajectories to improve accuracy; 2) a narrow-gauge instrument for dural puncture and coregistration of contrast MRI with CT angiography to reduce intracranial hemorrhage; 3) general endotracheal anesthesia for posterior-placed skull anchors to reduce the likelihood of damage to the cooling catheter; 4) use of as few probes as possible to reduce complications overall; and 5) dose modification of thermal treatment and use of short (3-mm) diffusing tips to limit treatment when structures to be spared do not have intervening CSF spaces to act as heat sinks. CONCLUSIONS Laser ablation treatment may be used for a variety of neurosurgical procedures for patients with tumors and epilepsy. While catheter placement and thermal treatment may be associated with a range of suboptimal operative and postoperative courses, permanent neurological morbidity is less common. The authors' institutional experience illustrates a number of measures that may be taken to improve outcomes using this important new tool in the neurosurgical arsenal.

/pdf/complication-avoidance-in-laser-interstitial-thermal-therapy-55oouefiam.pdf

Complication avoidance in laser interstitial thermal therapy: lessons learned.

Spontaneous subarachnoid hemorrhage (SAH) is most commonly caused by rupture of a saccular aneurysm or other structural pathologies. Occasionally, no structural cause for the hemorrhage can be identified by radiographic imaging. These hemorrhages, termed angiogram-negative SAH, are generally considered to have a better prognosis than aneurysmal SAH. Angiogram-negative SAH subgroups include benign perimesencephalic SAH (PMH) and aneurysmal-type SAH. Outcome data for these subgroups differ from those for the group as a whole. We report data for 31 patients who presented to our institution from 2006 to the present. We performed a retrospective chart review, and report outcome data that include rates of rehemorrhage, hydrocephalus, vasospasm, permanent ischemic deficits, headaches, and outcomes based on modified Rankin Scale scores. We also performed a review of the literature and meta-analysis of the data therein. We compared rates of complications in the PMH subgroup and the diffuse-type hemorrhage subgroup. The chart review revealed no poor outcomes and no rehemorrhages in the patients with PMH. In the diffuse hemorrhage subgroup, 1 patient had a rehemorrhage and 2 patients had a poor outcome. Our literature review found an OR of 6.23 for a good outcome for PMH versus diffuse-type hemorrhage, and an OR of 2.78 for rehemorrhage in PMH versus diffuse-type hemorrhage. Angiogram-negative SAH is not a benign entity. Complications are present but are significantly reduced, and outcomes are improved, compared with aneurysmal SAH.

Angiogram-Negative Subarachnoid Hemorrhage: Outcomes Data and Review of the Literature

Angiogram-negative subarachnoid hemorrhage (anSAH) accounts for 15% of spontaneous SAH. Recent studies suggest the outcome and diagnostic yield in anSAH differ based on initial bleeding pattern. We present a single-center experience in managing patients with SAH and negative initial digital-subtracted angiogram (DSA). Records of all patients with anSAH were reviewed. Bleeding pattern was determined from computed tomography (CT) and was categorized as perimesencephalic (PMN), diffuse, cortical, or xanthochromia (blood not detectable by CT). Diagnostic yield, in-hospital complications, and outcome parameters were analyzed. Of 352 patients admitted with spontaneous SAH from 2003 to 2008, 68 (19.3%) had negative initial DSA. Mean age was 59.5 ± 14, and 33 were female. By CT, 27 (39.7%) patients exhibited PMN SAH, 33 (48.5%) diffuse SAH, 6 (8.8%) cortical SAH, and 2 (2.9%) xanthochromia only. Sixty-one patients had good Hunt and Hess (H/H) grades (I–III) and seven had poor grades (IV–V). Additional diagnostic studies included repeat angiogram (54), brain and C-spine magnetic resonance imaging (20), and repeat CTA (15). A structural bleeding cause was determined in six (8.8%) patients, 4 of which had diffuse SAH and 2 cortical SAH. Among these, two aneurysms (2.9%) were detected and surgically clipped, and both had diffuse SAH. Twenty-nine patients (42.6%) experienced medical complications, with infection (18), cardiovascular problems (12), and vasospasm (10) being the most frequent events. Additional surgeries included 13 ventriculoperitoneal shunts, 4 tracheostomies, and 9 gastric tube placements. Favorable outcome (mRS = 0–2) was recorded in 49 (72.1%) patients and unfavorable (3–6) in 19 (17.49%), with 1 (1.2%) in-hospital death. Multivariable logistic regression revealed older age and diffuse bleeding pattern were significant predictors of unfavorable outcome. The overall incidence of true aneurysms in patients with angiogram-negative SAH is low (2.9%). Initial bleeding pattern strongly correlates with diagnostic yield and clinical outcome. Diffuse bleeding pattern is associated with significantly higher diagnostic yield, more in-hospital complications, and worse clinical outcome. Patients with initial imaging characteristics other than diffuse pattern SAH developed few disease related complications, with the majority of in-hospital adverse events treatment related.

Angiogram-negative subarachnoid hemorrhage: relationship between bleeding pattern and clinical outcome.

Objective The evaluation of patients with subarachnoid hemorrhage (SAH) with negative initial catheter-based angiography is a diagnostic challenge. Better diagnostic strategies based on hemorrhage patterns are needed. Methods We retrospectively investigated the yield of focused history taking, magnetic resonance imaging of the brain and cervical spine, follow-up vascular imaging, laboratory investigations, and craniotomy for vessel exploration in 100 patients with SAH and negative initial catheter-based angiography. Results The most common distribution of hemorrhage was in a "classic" aneurysmal pattern filling the basal cisterns or posterior fossa (44 patients). A cause was determined in 13 patients (13%), the most common of which was aneurysm (7 patients). Repeat angiography was the most useful diagnostic modality, detecting seven lesions. The yield of the second angiogram was best in patients with a classic hemorrhage pattern (10%) and worse in patients with a negative computed tomographic scan and positive lumbar puncture (0%). The most common reason that a lesion was not detected on initial angiography was aneurysmal thrombosis (five patients). Magnetic resonance imaging of the brain and cervical spine detected one cervical ependymoma. Factors that may contribute to SAH, such as antiplatelet agent use and drug use, were found in 13 patients (13%). Adjunctive laboratory studies alerted practitioners to modifiable risk factors. Conclusion These data suggest useful modifications to current diagnostic paradigms for patients with angiographically negative spontaneous SAH.

Evaluation of patients with spontaneous subarachnoid hemorrhage and negative angiography.

OBJECTIVE: The microvascular anastomosis (MA) technique remains an important aspect End-to-end, end-to-side, MA may be performed on this model. obtainable and inexpensive, pulsatile flow through the arteries is realistic the model is easy to mamage, and there is no need for special facilities for animal care or anesthesia that required for live animals. The diameter and structure of turkey carotid arteries are essentially identical to the human cortical vossels and distal branches of the superficial temporal artery. CONCLUSION : The pulstatile perfused carotid a arteries model presents a realistic Ma training model, It provides an inexpensive and simple setup for educational purposes. This technique can minimize live and anesthesia needs for MA training. Wide use of this model may enhanced carotid arteries model presents a realistic MA training. Tubing connection with both proximal and distal ends of the carotid arteries allowed circulatory patency during vessel clamping and anastomosis creation. Different fluids ranging from simple water to various colored solutions or even whole blood could be used for vascular perfusion in this experimental setup. Fluid output was maintained between 11 and 16 ml/min. Minimum pressure was set at 80 cm/H 2 0, and maximum pressure was set at 160 cm/H 2 O. Mean fluid flow through the arteries was 8 and 13 ml/min. End-to-end, end-to-side MA may be performed on this model. RESULTS: This training model provides several advantages: the materials are easily obtainable and inexpensive, pulsatile flow through the arteries is realistic, the model is easy to manage, and there is no need for special facilities for animal care or anesthesia that are required for live animals. The diameter and structure of turkey carotid arteries are essentially identical to the human cortical vessels and distal branches of the superficial temporal artery. CONCLUSION: The pulsatile perfused carotid arteries model presents a realistic MA training model. It provides an inexpensive and imple setup for educational purposes. This technique can minimize live animal and anesthesia need for MA training. Wide use of this model may enhance and popularize MA training and education.

MICROVASCULAR ANASTOMOSIS TRAINING MODEL BASED ON A TURKEY NECK WITH PERFUSED ARTERIES. Commentaries

In contrast to cervical and lumbar fusion procedures, the principal aim of disk arthroplasty is to recapitulate the normal kinematics and biomechanics of the spinal segment affected. Following decompression of the neural elements, disk arthroplasty allows restoration of disk height and maintenance of spinal alignment. Based on clinical observations and biomechanical testing, the anticipated advantage of arthroplasty over standard arthrodesis techniques has been a proposed reduction in the development of symptomatic ALD. In this review of cervical and lumbar disk arthroplasty, we highlight the clinical results and experience with standard fusion techniques, incidence of ALD in the population of patients with surgical fusion, and indications for arthroplasty, as well as the biomechanical and clinical outcomes following arthroplasty. In addition, we introduce the devices currently available and provide a critical appraisal of the clinical evidence regarding arthroplasty procedures.

http://www.ajnr.org/content/ajnr/33/9/1631.full.pdf

Rasha Germain

Papers

Evaluation of patients with spontaneous subarachnoid hemorrhage and negative angiography.

MICROVASCULAR ANASTOMOSIS TRAINING MODEL BASED ON A TURKEY NECK WITH PERFUSED ARTERIES. Commentaries

Cervical and Lumbar Spinal Arthroplasty: Clinical Review

Utility of the CO2 laser in the microsurgical resection of cavernous malformations.

Subdural Hematoma from a Cavernous Malformation