Showing papers on "Cerebral Revascularization published in 2013"
Medical College of Wisconsin1, Harvard University2, University of Cincinnati3, Dresden University of Technology4, University of California, Los Angeles5, Stanford University6, Northwestern University7, Mayo Clinic8, Vanderbilt University9, University of Edinburgh10, Oregon State University11, University of Pittsburgh12, Cardiovascular Institute of the South13, University at Buffalo14, University of Virginia15, Stony Brook University16, University of Toronto17, Heidelberg University18, Washington University in St. Louis19, Case Western Reserve University20, Emory University21, University of Miami22, University of Calgary23
TL;DR: A multidisciplinary panel of neurointerventionalists, neuroradiologists, and stroke neurologists with extensive experience in neuroimaging and IAT, convened at the “Consensus Meeting on Revascularization Grading Following Endovascular Therapy” with the goal of addressing heterogeneity in cerebral angiographic revascularization grading.
Abstract: See related article, p 2509
Intra-arterial therapy (IAT) for acute ischemic stroke (AIS) has dramatically evolved during the past decade to include aspiration and stent-retriever devices. Recent randomized controlled trials have demonstrated the superior revascularization efficacy of stent-retrievers compared with the first-generation Merci device.1,2 Additionally, the Diffusion and Perfusion Imaging Evaluation for Understanding Stroke Evolution (DEFUSE) 2, the Mechanical Retrieval and Recanalization of Stroke Clots Using Embolectomy (MR RESCUE), and the Interventional Management of Stroke (IMS) III trials have confirmed the importance of early revascularization for achieving better clinical outcome.3–5 Despite these data, the current heterogeneity in cerebral angiographic revascularization grading (CARG) poses a major obstacle to further advances in stroke therapy. To date, several CARG scales have been used to measure the success of IAT.6–14 Even when the same scale is used in different studies, it is applied using varying operational criteria, which further confounds the interpretation of this key metric.10 The lack of a uniform grading approach limits comparison of revascularization rates across clinical trials and hinders the translation of promising, early phase angiographic results into proven, clinically effective treatments.6–14 For these reasons, it is critical that CARG scales be standardized and end points for successful revascularization be refined.6 This will lead to a greater understanding of the aspects of revascularization that are strongly predictive of clinical response.
The optimal grading scale must demonstrate (1) a strong correlation with clinical outcome, (2) simplicity and feasibility of scale interpretation while ensuring characterization of relevant angiographic findings, and (3) high inter-rater reproducibility.
To address these issues, a multidisciplinary panel of neurointerventionalists, neuroradiologists, and stroke neurologists with extensive experience in neuroimaging and IAT, convened at the “Consensus Meeting on Revascularization Grading Following Endovascular Therapy” with the goal …
1,162 citations
TL;DR: Despite excellent bypass graft patency and improved cerebral hemodynamics, STA-MCA anastomosis did not provide an overall benefit regarding ipsilateral 2-year stroke recurrence, mainly because of a much better than expected strokes recurrence rate in the medical group, but alsoBecause of a significant postoperative stroke rate.
Abstract: Object The Carotid Occlusion Surgery Study (COSS) was conducted to determine if superficial temporal artery–middle cerebral artery (STA-MCA) bypass, when added to the best medical therapy, would reduce subsequent ipsilateral stroke in patients with complete internal carotid artery (ICA) occlusion and an elevated oxygen extraction fraction (OEF) in the cerebral hemisphere distal to the occlusion. A recent publication documented the methodology of the COSS in detail and briefly outlined the major findings of the trial. The surgical results of the COSS are described in detail in this report. Methods The COSS was a prospective, parallel-group, 1:1 randomized, open-label, blinded-adjudication treatment trial. Participants, who had angiographically demonstrated complete occlusion of the ICA causing either a transient ischemic attack or ischemic stroke within 120 days and hemodynamic cerebral ischemia indicated by an increased OEF measured by PET, were randomized to either surgical or medical treatment. One hund...
155 citations
TL;DR: This series demonstrates that both direct and indirect bypasses can be equally effective in preventing stroke, however, in adult patients, direct bypass patients had significantly greater improvement in symptoms, as seen in modified Rankin Scale scores.
Abstract: Background Untreated, moyamoya angiopathy is a progressive vaso-occlusive process that can lead to ischemic or hemorrhagic stroke. Objective To review 1 institution's surgical experience with both direct and indirect bypass (encephaloduroarteriosynangiosis) in adult and pediatric groups. Methods A retrospective review was conducted of a consecutive series of patients treated for moyamoya angiopathy between 1995 and 2009. Results Thirty-nine adult patients underwent indirect bypass as their initial therapy; 29 adult patients underwent direct bypass. Twenty-four pediatric patients included 20 indirect bypasses and 4 direct bypasses. Overall, 140 hemispheres were treated; 48 patients received revascularization of both hemispheres. There were 14 additional revascularization procedures (10% per hemisphere) performed over a site of continued hypoperfusion postoperatively. Fourteen postoperative ischemic strokes occurred during the entire follow-up (10% per hemisphere), and the Kaplan-Meier analysis was not significantly different between groups (P = .59). Four grafts (9.09%) had failed at radiographic follow-up of the 44 direct bypasses performed. Before the initial surgery, the modified Rankin Scale score was 1.58 ± 0.93, 1.48 ± 0.74, and 1.8 ± 1.1 in the pediatric, adult direct, and adult indirect groups (P = .39). At last follow-up, it was 1.29 ± 1.31, 1.09 ± 0.90, and 1.94 ± 1.51 (P = .04) in the pediatric, adult direct, and adult indirect groups. Conclusion This series demonstrates that both direct and indirect bypasses can be equally effective in preventing stroke. However, in adult patients, direct bypass patients had significantly greater improvement in symptoms, as seen in modified Rankin Scale scores. Pediatric patients, despite undergoing predominantly indirect bypasses, fared roughly the same as the adults in the direct bypass group.
78 citations
TL;DR: Surgical revascularization for children with NF1 appears safe and is protective against further ischemic and neurological damage, with a 27-fold reduction in stroke rate.
Abstract: Object Children with neurofibromatosis Type 1 (NF1) can present with progressive arteriopathy of the branches of the internal carotid artery consistent with moyamoya syndrome Clinical symptoms, radiographic evidence of ischemia, and the potential for disease progression may necessitate surgical revascularization to minimize the risk of stroke and progressive neurological deficits This study aims to evaluate the presentation and surgical outcomes of these patients by reviewing clinical, radiographic, and angiographic data Methods A retrospective review was conducted of clinical and radiographic records of all children with NF1 who were diagnosed with moyamoya syndrome and underwent surgical revascularization between January 1988 and April 2012 at Boston Children's Hospital Results During this period, 39 patients (27 female and 12 male, ages 02–193 years) had both NF1 and moyamoya syndrome, of whom 32 underwent surgical revascularization with pial synangiosis Of the 32 patients treated by surgical re
66 citations
TL;DR: Despite maximal surgical intervention, including ICA sacrifice at the skull base with revascularization, patient survival was dismal, and the complication rate was significant, so the authors no longer advocate such an aggressive approach in this patient population.
Abstract: Object Resection of cancer and the involved artery in the neck has been applied with some success, but the indications for such an aggressive approach at the skull base are less well defined. The authors therefore evaluated the outcomes of advanced skull base malignancies in patients who were treated with bypass and resection of the internal carotid artery (ICA). Methods The authors retrospectively reviewed the charts of all patients with advanced head and neck cancers who underwent ICA sacrifice with revascularization in which an extracranial-intracranial bypass was used between 1995 and 2010 at the Barrow Neurological Institute. Results Eighteen patients (11 male and 7 female patients; mean age 46 years, range 7–69 years) were identified. There were 4 sarcomas and 14 carcinomas that involved the ICA at the skull base. All patients underwent ICA sacrifice with revascularization. One patient died of a stroke after revascularization. A second patient died of the effects of a fistula between the oral and cr...
53 citations
TL;DR: A comprehensive review of the literature on CHS after revascularization in MMD patients is presented, focusing on the pathogenesis, clinical features, imaging techniques, treatment, and prognosis of CHS.
Abstract: Moyamoya disease (MMD) is a progressive occlusive disease of the distal internal carotid artery that is primarily treated by superficial temporal artery-middle cerebral artery (STA-MCA) bypass. Despite its effectiveness, several postoperative complications have been reported with STA-MCA bypass. Cerebral hyperperfusion syndrome (CHS) after STA-MCA has attracted considerable attention as a hemodynamics-related complication because more cases of CHS after STA-MCA bypass are reported in MMD than in non-MMD patients. The mechanisms underlying CHS after revascularization in MMD patients are poorly understood. This report presents a comprehensive review of the literature on CHS after revascularization in MMD patients, focusing on the pathogenesis, clinical features, imaging techniques, treatment, and prognosis of CHS. Impaired cerebrovascular autoregulation has been implicated in the pathogenesis of CHS, which is characterized by unilateral headache, face and eye pain, seizures, and focal neurological deficits secondary to cerebral edema, and intracranial hemorrhage. Imaging techniques, such as single photon emission computed tomography (SPECT), 3-T magnetic resonance imaging/angiography, and selective arterial spin-labeling magnetic resonance imaging, are valuable for identifying patients at risk for CHS. Treatment strategies include strict blood pressure control, intracranial hemorrhage prevention, and free oxygen radical scavenger administration. Most patients can achieve a satisfying prognosis after effective treatment.
38 citations
TL;DR: Of the growth factors tested, PlGF emerged as the most efficient and safe angiogenic factor, hence making it a candidate for therapeutic CNS revascularization.
36 citations
TL;DR: In both circulatory beds, endovascular treatments were more efficacious at achieving reperfusion than peripherally administered fibrinolytics, and cerebral circulation–specific technical advances are required for physicians to become as capable at safely restoring blood flow to the isChemic brain as the ischemic heart.
Abstract: Background and Purpose—Early reperfusion is the most effective therapy for both acute brain and cardiac ischemia. However, the cervicocephalic circulatory bed offers more challenges to recanalization interventions. The historical development of reperfusion interventions has not previously been systematically compared. Methods—Medline search identified all multi-arm, controlled trials of coronary revascularization for acute myocardial infarction and multicenter trials of cerebral revascularization for acute ischemic stroke reporting angiographic reperfusion rates. Results—Thirty-seven trials of coronary reperfusion enrolled 10 908 patients from 1983 to 2009, and 10 trials of cerebral reperfusion enrolled 1064 patients from 1992 to 2009. Coronary reperfusion trials included 10 of intravenous fibrinolysis alone, 8 combined intravenous fibrinolysis and percutaneous transluminal coronary angioplasty with or without stenting, 3 intra-arterial fibrinolysis, and 16 percutaneous transluminal coronary angioplasty w...
32 citations
TL;DR: Direct revascularization is the optimal choice to prevent subsequent events in adult patients with moyamoya, and should be reserved for patients with an inadequate donor vessel.
Abstract: Although cerebral revascularization is an accepted treatment for moyamoya, the precise impact of direct or indirect bypass methods on subsequent event rates is infrequently addressed in adult cohorts. We reviewed 45 consecutive adults with 69 hemispheres affected by moyamoya. We evaluated stroke and hemorrhage rates prior to and following revascularization. Direct revascularization was performed for 35 hemispheres (51 %) in 29 patients (64 %). The annual stroke, hemorrhage and overall event rates in this cohort diminished from 8.9 %, 2.0 %, and 11 % per hemisphere-year to 4.5 %, 0 %, and 4.5 % per hemisphere-year after treatment, respectively (p = 0.06). Excluding perioperative events, no events occurred over 41.1 hemisphere-years of follow-up (p = 0.0017). After a mean clinical follow-up period of 1.3 years, 72 % of patients were improved, 24 % the same, and 3 % worse in this cohort. Indirect revascularization was performed for 18 hemispheres (26 %) in 13 patients (29 %). The annual stroke, hemorrhage and overall event rates were 13 %, 0 %, and 13 % per hemisphere-year prior to treatment, and 6.8 %, 4.5 %, and 11 % per hemisphere-year after treatment, respectively (p = 0.67). Excluding perioperative events, the overall annual event rate was 7.1 % (p = 0.69). After a mean clinical follow-up of 2.7 years, 46 % of patients were improved, 38 % were the same and 15 % were worse. Direct revascularization is the optimal choice to prevent subsequent events in adult patients with moyamoya. A favorable impact of indirect revascularization was less clear in this cohort, and should be reserved for patients with an inadequate donor vessel.
31 citations
TL;DR: The imaging features of different types of surgical cerebral revascularization techniques have distinctive imaging features as well as direct and indirect techniques.
Abstract: OBJECTIVE. The purpose of this article is to describe the imaging features of different types of surgical cerebral revascularization techniques. CONCLUSION. Surgical cerebral revascularization involves direct and indirect techniques. Direct revascularization entails anastomosing a branch of the external carotid artery to a cerebral artery. Indirect revascularization involves delivering an extracranial vascular supply in proximity to the surface of the brain. The results of these techniques have distinctive imaging features.
29 citations
TL;DR: Double-barrel STA-MCA bypass is both feasible and potentially advantageous, and both bypass branches remained patent, augmenting flow to the territories most at need in this series.
Abstract: Background In selected patients, extracranial-intracranial bypass remains an important treatment for the prevention of stroke. Traditionally, superficial temporal artery-middle cerebral artery (STA-MCA) bypass uses 1 STA branch. We have adopted a "double-barrel" technique in which both branches are joined with MCA recipients in distinct vascular territories. Objective To assess the feasibility of routinely using both branches of the STA for cerebral revascularization. Methods Ten consecutive patients underwent double-barrel bypass. Patients were selected if they demonstrated symptomatic MCA hypoperfusion resistant to medical therapy or had symptomatic moyamoya disease. Flow-directed bypass was performed to augment flow to the territories most at risk in each case, based on preoperative and intraoperative data. Computed tomography perfusion was routinely performed to evaluate baseline deficits and postoperative augmentation. Clinical data were analyzed to assess patient demographics and outcomes. Results The double-barrel bypass was no more difficult technically than the traditional approach, with the second branch harvested through a small satellite incision. By isolating temporary occlusion to each territory, there was no additional ischemia to each brain region. No intraoperative complications or wound-healing issues occurred. Postoperative computed tomography perfusion studies all showed improvement, and delayed vascular imaging demonstrated universal graft patency. Nine of 10 patients have been asymptomatic since surgery, whereas 1 patient demonstrated symptoms in a separate vascular distribution. Conclusion Double-barrel STA-MCA bypass is both feasible and potentially advantageous. In our series, both bypass branches remained patent, augmenting flow to the territories most at need.
TL;DR: This study demonstrates that STA-MCA bypass is a safe and effective surgical treatment for Moyamoya disease and enables an effective and objective assessment of hemodynamics before and after STA- MCA bypass surgery in patients with Moyamoy disease.
Abstract: Background: The best strategy to assess the changes in brain hemodynamics following superficial temporal artery (STA)-middle cerebral artery (MCA) bypass in patie
TL;DR: Treatment for moyamoya disease accompanied with distal choroidal artery aneurysms is described, and experience suggests that cerebral revascularization combined with obliteration of the complicated distalAneurysm in the same session is a possible treatment.
Abstract: Prevention of rebleeding plays an important role in the treatment of hemorrhagic moyamoya disease, because rebleeding results in high mortality and morbidity We discuss possible treatment for patients with moyamoya disease accompanied with distal choroidal artery aneurysms and review the literature to summarize clinical treatment and mechanisms The cases of three male patients who suffered from intraventricular hemorrhage are presented Computed tomography (CT) and digital subtractive angiography (DSA) revealed that bleeding was believed to be caused by ruptured aneurysms originating from distal choroidal artery aneurysms Two patients successfully underwent superficial temporal artery (STA)-middle cerebral artery (MCA) bypass combined with encephalo-duro-myo-synangiosis (EDMS) and the obliteration of the aneurysm The follow-up DSA or CT scan demonstrated that the aneurysms completely disappeared with the patency of the reconstructed artery Neither of the patients experienced rebleeding during the follow-up period (up to 34 months) Given conservative treatment, the third patient experienced recurrent hemorrhages 4 months after the first ictus This study describes treatment for moyamoya disease accompanied with distal choroidal artery aneurysms Our experience suggests that cerebral revascularization combined with obliteration of the complicated distal aneurysm in the same session is a possible treatment
TL;DR: The proposed animal model permits reliable and consistent thromboembolic occlusion of the target vasculature and allows for an assessment of both pharmacologic and mechanical revascularization strategies for acute ischemic stroke.
Abstract: Background and purpose Recanalization strategies mediated by intra-arterial fibrinolytic therapy in combination with mechanical clot disruption may be a more effective treatment approach than either therapy used alone. There are few preclinical animal models to evaluate these strategies. Here we report on a model to simultaneously evaluate both of these treatment approaches. Methods Allogeneic clot was injected through the 6 F guide catheter after creating >50% luminal stenosis of the common carotid arteries of New Zealand White rabbits. The stenosis was released after 1 h, allowing sufficient time for clot-vessel wall interaction. Occlusion was confirmed and each vessel was assigned to receive either balloon angioplasty alone, intra-arterial tissue plasminogen activator (tPA, Alteplase, Genentech, San Francisco, California, USA), tPA delivery through prototype balloon infusion wire (NIT Therapeutics, Pittsburgh, Pennsylvania, USA), partial stent deployment or partial stent deployment with locally delivered tPA. The negative control received no treatment. Results In vivo revascularization Thrombolysis in Cerebral Infarction (TICI) score revealed that the balloon infusion wire achieved a stable and higher revascularization score of TICI 2B, with a lower dose of tPA in comparison with other treatment strategies. All treatment strategies resulted in endothelial denudation and exposure of the internal elastic lamina. Conclusions The proposed animal model permits reliable and consistent thromboembolic occlusion of the target vasculature and allows for an assessment of both pharmacologic and mechanical revascularization strategies for acute ischemic stroke.
TL;DR: Six patients who experienced transient neurological deteriorations with no evidence of hemorrhage and infarction after encephaloduroarteriogaleosynangiosis for moyamoya disease were evaluated with semiquantitative analysis using brain perfusion SPECT.
Abstract: Six patients who experienced transient neurological deteriorations with no evidences of hemorrhage and infarction after encephaloduroarteriogaleosynangiosis for moyamoya disease were evaluated with semiquantitative analysis using brain perfusion SPECT. Postoperative transient neurological deteriorations topographically corresponded to hyperperfusion areas on SPECT. Cerebral blood flows of both the operated hemisphere and focal hyperperfusion area increased significantly after surgery (P=0.046 and 0.028, respectively), compared with the preoperative ones. Symptomatic cerebral hyperperfusion may occur transiently after indirect revascularization surgery for adult moyamoya disease. Further study is needed to clarify the exact mechanism of cerebral hyperperfusion after indirect surgery.
TL;DR: The authors' results suggest that continuous neurophysiological monitoring during EC-IC bypass surgery has relevant advantages over flow-oriented monitoring techniques such as intraoperative flowmetry or indocyanine green-based angiography.
Abstract: Object Intraoperative neurophysiological monitoring (IONM) represents an established tool in neurosurgery to increase patient safety. Its application, however, is controversial. Its use has been described as helpful in avoiding neurological deterioration during intracranial aneurysm surgery. Its impact on extracranial-intracranial (EC-IC) bypass surgery involving parent artery occlusion for the treatment of complex aneurysms has not yet been studied. The authors therefore sought to evaluate the effects of IONM on patient safety, the surgeon's intraoperative strategies, and functional outcome of patients after cerebral bypass surgery. Intraoperative neurophysiological monitoring results were compared with those of intraoperative blood flow monitoring to assess bypass graft perfusion. Methods Compound motor action potentials (CMAPs) were generated using transcranial electrical stimulation in patients undergoing EC-IC bypass surgery. Preoperative and postoperative motor function was analyzed. To assess graft...
TL;DR: A novel bypass option for augmenting blood flow to the basilar apex and brainstem is reported, using double-barrel anastomoses of the superficial temporal artery to the superior cerebellar artery and the posterior cerebral artery.
TL;DR: Insurance cerebral revascularization of the ACA territory enabled appropriate direct surgical strategies for giant AComA or ACA aneurysms tailored to each individual case, including trapping with or without removal of theAneurysm, and reanastomosis of the Affordable Care Act (ACA) with removal ofThe outcome of direct surgical treatment of giant intracrania using vascular reconstruction techniques was assessed in five patients treated between 2006 and 2009.
Abstract: Giant intracranial aneurysms on the anterior communicating artery (AComA) or anterior cerebral artery (ACA) are rare and treatment is very difficult. The outcome of direct surgical treatment of giant intracranial aneurysms on the AComA or ACA using vascular reconstruction techniques was assessed in five patients treated between 2006 and 2009. In all five patients, cerebral revascularization of ACA territory was performed to ensure blood flow in the distal ACA prior to treating the aneurysm. Trapping was performed in two patients, trapping and partial removal of the aneurysm in two patients, and total removal of the aneurysm with reanastomosis of ACA in one patient. Minor ischemic complication due to perforator ischemia was recognized in one patient and frontal lobe contusion in one patient. All patients were able to achieve functionally favorable outcome (modified Rankin scale 0 or 1). Insurance cerebral revascularization of the ACA territory enabled appropriate direct surgical strategies for giant AComA or ACA aneurysms tailored to each individual case, including trapping with or without removal of the aneurysm, and reanastomosis of the ACA with removal of the aneurysm.
TL;DR: Tibial arteries are safe, contingent alternatives to conventional conduits for performing high flow cerebral revascularizations and conduit reconstructions in EC-IC bypass patients.
TL;DR: The authors summarize the current “state-of-art” of treatment of giant cavernous aneurysms, comparing the overall outcomes, complications, morbidity and mortality rates of new flow-diverting devices in relation to traditional microsurgical series.
Abstract: The classic surgical treatment for symptomatic giant aneurysms originating from the cavernous segment of the carotid artery has been either microsurgical direct clip-reconstruction or carotid occlusion followed by additional cerebral bypass for those patients who fail in a balloon test occlusion. Nevertheless the emergence of new endovascular techniques, especially flow-diverting devices, has promised to revolutionize the treatment of giant cavernous aneurysms, possibly avoiding major microsurgical operations. In this review the authors summarize the current "state-of-art" of treatment of giant cavernous aneurysms, comparing the overall outcomes, complications, morbidity and mortality rates of new flow-diverting devices in relation to traditional microsurgical series.
TL;DR: Aspirin resistance is common in the population of patients with hemodynamic cerebral ischemia scheduled for cerebral revascularization and may have an adverse impact on the outcome of surgery.
Abstract: Background: Aspirin (acetylsalicylic acid, ASA) is the treatment of choice for prevention of vascular events in symptomatic steno-occlusive cerebrovascular disease (CVD). Cerebral revascularization using standard extracranial-intracranial (EC-IC) bypass surgery may be used to revert hemodynamic compromise. Aspirin is prescribed as standard medication in order to avoid bypass failure. Accumulating evidence of an increased risk of major adverse clinical events led to this study, in which we aimed to assess the prevalence of aspirin resistance and prothrombotic disorders among patients scheduled for EC-IC bypass surgery, and the effectiveness of aspirin dose escalation. Methods: We prospectively screened patients with circumscribed high-grade stenosis or occlusion of brain-supplying vessels fulfilling the hemodynamic criteria for EC-IC bypass surgery for aspirin resistance using a platelet function analyzer (PFA-100®) test. We also determined their smoking habits and screened for prothrombotic disorders and comorbidities. The patients were divided into 2 major groups: group A had atherosclerotic steno-occlusive CVD and group B consisted of patients with nonatherosclerotic steno-occlusive CVD (moyamoya disease) and a subgroup of pediatric moyamoya patients (pediatric subgroup). Bypass patency was documented via digital subtraction angiography. Standard initial ASA dose applied was 100 mg/day. In cases of aspirin resistance, doses were increased and the PFA-100 test was repeated. Results: A total of 56 patients were included over a time period of 6 months. In group A (n = 25), we found a ratio of 40% of patients with primary resistance to aspirin 100 mg/day. In contrast, in group B (n = 25), only 20% of the patients were resistant to aspirin 100 mg/day; in the pediatric population (n = 6), there was no primary aspirin resistance. After a dose escalation to 300 mg/day, the ratio of aspirin resistance was reduced to 20% in group A and to 0% in group B. Altogether 5 patients with atherosclerotic steno-occlusive CVD remained aspirin-resistant despite the dose escalation; 2 of them suffered an early bypass failure. Smoking habits and diabetes mellitus were positively correlated with aspirin resistance. Moreover, 25% of all patients had laboratory signs of a prothrombotic disorder, but this had no influence on aspirin response or bypass patency. Conclusions: Aspirin resistance is common in the population of patients with hemodynamic cerebral ischemia scheduled for cerebral revascularization. It may have an adverse impact on the outcome of surgery. Screening and treatment via dose escalation of aspirin is a straightforward and sensible routine for patients undergoing EC-IC bypass surgery.
TL;DR: In this article, a case of a recurrent malignant frontal falx meningioma with encasement of both pericallosal arteries (PcaAs) was reported.
Abstract: Background and importance Trapping with distal revascularization is a therapeutic option for giant aneurysms that cannot be clipped or coiled. In skull base lesions such as meningiomas, arterial encasement is often present, requiring, in some cases, revascularization procedures: extracranial-to-intracranial bypass and more recently intracranial-to-intracranial techniques. These techniques are used only in exceptional cases of tumors in other localizations. Clinical presentation We report a case of a recurrent malignant frontal falx meningioma with encasement of both pericallosal arteries (PcaAs). During resection of the lesion, the left PcaA was sectioned and the right PcaA was occluded for manipulation and coagulation of the tumor. The occlusion was diagnosed with indocyanine green videoangiography. A Y-shaped superficial temporal artery graft was obtained in the right side, and the anterior cerebral artery circulation was reconstructed using an intracranial-to-intracranial bypass in the following fashion: right A2 to superficial temporal artery Y-shaped graft for both PcaAs. The patient's postoperative period was uneventful with no deficit, and the computed tomography angiography showed the preservation of both PcaAs. Conclusion To the best of our knowledge, this microsurgical reconstruction of the PcaAs has not been performed before in a meningioma or a complex aneurysm case. We think the use of a superficial temporal artery as an in situ graft is more straightforward compared with other interposition grafts such as the radial artery graft or saphenous vein graft. The use of intracranial-to-intracranial techniques is the proper evolution of the use of classic extracranial-to-intracranial cerebral revascularization techniques.
TL;DR: This is an extremely unusual case of surgical flow reduction treatment using bypass surgery for a complicated cerebral aneurysm in a patient with SLE.
Abstract: A 37-year-old male with a 20-year history of systemic lupus erythematosus (SLE) was referred to our hospital for an unruptured right middle cerebral artery (MCA) aneurysm. Right cerebral angiography detected a saccular aneurysm (9.6 × 7.1 mm) arising from the bifurcation of the right MCA, and a dilatation of the inferior trunk M2 in which three small branches were involved. The MCA aneurysm was treated with neck clipping. The aneurysmal dilatation of the inferior trunk M2 was treated with proximal clipping, followed by double superficial temporal artery-MCA anastomosis. The patient was discharged from our hospital without complications. This is an extremely unusual case of surgical flow reduction treatment using bypass surgery for a complicated cerebral aneurysm in a patient with SLE.
TL;DR: This study is the first postoperative 3.0-T DWI study of CRS and related clinical events and found CRS was found to be safe with a low risk of symptomatic ischemia.
TL;DR: In this issue of Radiology, Eilaghi et al demonstrate that reperfusion is more critical than recanalization for improved tissue and clinical outcomes; in multivariate analysis, recanAlization did not add any further prognostic information to knowledge of reperfusions.
Abstract: In this issue of Radiology, Eilaghi et al demonstrate that reperfusion is more critical than recanalization for improved tissue and clinical outcomes; in multivariate analysis, recanalization did not add any further prognostic information to knowledge of reperfusion.
TL;DR: An overview of moyamoya disease including pathophysiology, epidemiology, clinical presentation, diagnosis, treatment, and prognosis is provided to reduce the morbidity and mortality associated with MMD.
Abstract: Purpose
To provide an overview of moyamoya disease (MMD) including pathophysiology, epidemiology, clinical presentation, diagnosis, treatment, and prognosis.
Data sources
Selected clinical and epidemiological studies, review articles, and diagnostic guidelines for MMD.
Conclusions
MMD is a rare cerebrovascular disease characterized by progressive stenosis of the distal internal carotid arteries and their major branches. The dilated and fragile basal collateral circulations display a “puff of smoke” appearance and thus are called moyamoya vessels. Other unique features of MMD include 2:1 female preponderance and its peak incidence in two age groups: early childhood and adults in their mid-40s. The pathophysiology of MMD is unclear and possible causes include genetic linkage, angiogenesis, autoimmune disease, cranial radiation, and infection of the head and neck. Most patients are symptomatic and may present with ischemic or hemorrhagic strokes, seizure, or headache. The diagnosis depends on clinical presentation and radiographic imaging, and disease progression may be halted with direct or indirect cerebral revascularization.
Implications for practice
It is important to make a correct diagnosis and provide appropriate treatment to reduce the morbidity and mortality associated with MMD. A prompt referral for possible surgical revascularization offers the best chance to reduce additional cerebral injuries and improve clinical outcomes.
TL;DR: The future of intra‐arterial cerebral revascularization will depend on an accurate preintervention patient selection, and important clinical and ethical aspects learned from the own experience are discussed.
Abstract: In acute ischemic stroke, rapid revascularization of the cerebral 'penumbra volume' is the key to better patient outcome. The largest and most proximal cerebral thrombotic artery occlusions can in most cases only be opened by intra-arterial intervention. The use of intra-arterial revascularization is rapidly expanding throughout Europe and North America, despite the risk for serious complications and the fact that the benefit of this treatment has not yet been proven in large, randomized clinical trials. Oslo University Hospital has performed approximately 60 intra-arterial procedures annually in acute ischemic stroke during the last few years. In this paper, we discuss important clinical and ethical aspects learned from our own experience. The future of intra-arterial cerebral revascularization will depend on an accurate preintervention patient selection.
01 Jan 2013
TL;DR: The Color Atlas of Cerebral Revascularization focuses on cerebral bypass techniques pioneered by leading surgeons at the world-renowned Barrow Neurological Institute in Phoenix, Arizona, and is an ideal reference for practicing neurosurgeons, neurosurgical residents, and interventional neuroradiologists.
Abstract: Gold winner in 2014 IBPA Ben Franklin Awards! "...the images are second-to-none in their ability to present the subject material...The authors have made this atlas an efficient and informative read. It is this pairing of operative photographs with high-quality illustrations that raises this text to a level superior to that of its competitors." -- American Journal of Neuroradiology A highly-anticipated addition to Thieme's classic color atlas collection, Color Atlas of Cerebral Revascularization focuses on cerebral bypass techniques pioneered by leading surgeons at the world-renowned Barrow Neurological Institute in Phoenix, Arizona. Each procedure is presented with intraoperative photographs and exquisite anatomical illustrations to help surgeons master the complex microsurgical anatomy and subtle surgical technique used in managing the potential onset and condition of stroke and other causes of cerebral ischemia. Key Features: * Side-by-side photo and illustration format aids in interpretation of intricate surgical procedures * More than 1300 figures elucidate clinical cases from the Barrow Neurological Institute and other centers of neurosurgical excellence* A DVD, featuring more than 30 related surgical cases and narrated by the authors, is included with the book* Cases illustrate how to successfully achieve revascularization for conditions such as moyamoya disease, recurrent aneurysms after endovascular treatment, giant aneurysms, vertebral artery insufficiency, and severe stenosis* The vascular anatomy related to each bypass technique is illustrated and described in the sections showcasing the clinical cases treated by the technique This comprehensive atlas is an ideal reference for practicing neurosurgeons, neurosurgical residents, and interventional neuroradiologists, and it will be a relevant volume in their medical library for years to come.
TL;DR: "Tasuki" clipping can overcome the dilemma between achieving early complete thrombosis in the blind sac and maintaining anterograde flow of the parent artery to prevent inadvertent occlusion of the perforators and anterior choroidal artery.
Abstract: A 33-year-old woman presented with a ruptured, partially thrombosed carotid bifurcation aneurysm after partial coiling, which was successfully treated by "tasuki" (a cloth sash crossing from one shoulder to the opposite hip, worn by relay marathon runners) clipping combined with radial artery and external carotid artery-to-middle cerebral artery bypass. "Tasuki" clipping can overcome the dilemma between achieving early complete thrombosis in the blind sac and maintaining anterograde flow of the parent artery to prevent inadvertent occlusion of the perforators and anterior choroidal artery.