Cavernous Internal Carotid Artery Research Articles

Successful Emergency Endovascular Treatment of Cavernous Internal Carotid Artery Stenosis Due to Compression by a Hemorrhagic Pituitary Tumor

Ischemic stroke associated with pituitary apoplexy is an extremely rare but devastating complication. Arterial stenosis or occlusion due to direct compression secondary to acute expansion of the hemorrhagic pituitary adenoma may induce ischemic stroke. In case of presentation of diffusion-perfusion or diffusion-clinical mismatch, urgent tumor resection to decompress the involved arteries should be performed to salvage ischemic penumbra. If emergent surgery is not possible, other therapeutic options are needed to prevent the progression of cerebral ischemia. Herein, we report the case of successful revascularization achieved in a patient with ischemic stroke who underwent balloon angioplasty and stent placement for the non-atherosclerotic steno-occlusion of intracranial internal carotid artery due to pituitary apoplexy.

Contralateral Transmaxillary Corridor Used in Endoscopic Endonasal Approach for Resecting Adenoma Invading the Retrocarotid Area of the Cavernous Sinus and Beyond: Surgical Anatomy, Patient Selection Algorithm, and Illustrative Cases

BACKGROUND AND OBJECTIVES: The cavernous internal carotid artery (cICA) and its branches can make it challenging to approach the lateral portion of the retrocarotid area of the cavernous sinus (RcACS) and surrounding areas during the endoscopic endonasal approach (EEA). This can sometimes require more invasive transcranial approaches, causing a higher risk of complications. We sought to explore the feasibility of adding a contralateral transmaxillary (CTM) corridor to improve access to the RcACS during EEA. METHODS: We performed EEA and CTM extensions on 6 cadavers (12 sides) using image guidance. The depth of the surgical corridor, the surgical exposure, the angle of attack, and the trajectory to the anterior genu of the cICA were measured. Two illustrative clinical cases are presented. RESULTS: Compared with the contralateral transnasal approach, the CTM corridor provided a 10.76 (5.32)-mm shorter distance (P < .001), 36.23% (20.70%) larger surgical exposure (P < .001), and a 24.6° (3.4°) more parallel trajectory to the anterior genu of the cICA (P < .001). The mean angle of the lateral nasal wall line and the middle eye line was equal to the mean angle of the contralateral transnasal (P = .075) and CTM (P = .262) approaches, respectively. The CTM corridor allowed us to achieve near-total resection of the RcACS and beyond in 2 invasive adenomas with significant lateral extension. CONCLUSION: The CTM corridor is a feasible addition to standard EEA to access the RcACS and beyond, providing a more medial-to-lateral trajectory and improved access. The middle eye line can be used as a reference to help select patients for this approach.

A quantitative comparative surgical analysis of the endoscopic transorbital approach and frontotemporal-orbitozygomatic approach for extradural exposure of the cavernous sinus.

Recently, the endoscopic superior eyelid transorbital approach (SETA) has emerged as a potential alternative to access the cavernous sinus (CS). Several previous studies have attempted to quantitatively compare the traditional open anterolateral skull base approaches with transorbital exposure; however, these comparisons have been limited to the area of exposure provided by the bone opening and trajectory, and fail to account for the main avenues of exposure provided by subsequent requisite surgical maneuvers. The authors quantitatively compare the surgical access provided by the frontotemporal-orbitozygomatic (FTOZ) approach and the SETA following applicable periclinoid surgical maneuvers, evaluate the surgical exposure of key structures in each, and discuss optimal approach selection. SETA and FTOZ approaches were performed with subsequent applicable surgical maneuvers on 8 cadaveric heads. The lengths of exposure of cranial nerves (CNs) II-VI and the cavernous internal carotid artery; the areas of the space accessed within the supratrochlear, infratrochlear, and supramaxillary (anteromedial) triangles; the total area of exposure; and the angles of attack were measured and compared. Exposure of the extradural CS was comparable between approaches, whereas access was significantly greater in the FTOZ approach compared with the SETA. The lengths of extradural exposure of CN III, V1, V2, and V3 were comparable between approaches. The FTOZ approach provided marginally increased exposure of CNs IV (20.9 ± 2.36 mm vs 13.4 ± 3.97 mm, p = 0.023) and VI (14.1 ± 2.44 mm vs 9.22 ± 3.45 mm, p = 0.066). The FTOZ also provided significantly larger vertical (44.5° ± 6.15° vs 18.4° ± 1.65°, p = 0.002) and horizontal (41.5° ± 5.40° vs 15.3° ± 5.06°, p < 0.001) angles of attack, and thus significantly greater surgical freedom, and provided significantly greater access to the supratrochlear (p = 0.021) and infratrochlear (p = 0.007) triangles, and significantly greater exposure of the cavernous internal carotid artery (17.2 ± 1.70 mm vs 8.05 ± 2.37 mm, p = 0.001). Total area of exposure was also significantly larger in the FTOZ, which provided wide access to the lateral wall of the CS as well as the possibility for intradural access. This is the first study to quantitatively identify the relative advantages of the FTOZ and transorbital approaches at the target region following requisite surgical maneuvers. Understanding these data will aid in selecting an optimal approach and maneuver set based on target lesion size and location.

703 Identifying Unruptured Cavernous Internal Carotid Artery Aneurysms Growth and Rupture Over Time

INTRODUCTION: Aneurysms in the Cavernous Segment of the Internal Carotid Artery (ICA) often present in an indolent fashion with limited morbidity. However, their growth progression and possible rupture over time remains poorly defined, thereby limiting optimization of serial follow-up. METHODS: We identified a retrospective cohort of 179 patients with cavernous ICA aneurysms. Patient demographic data, possible risk factors, presenting symptoms, radiographic features of aneurysms, size progression, rupture status, and concomitant non-cavernous aneurysm rupture data were manually extracted. RESULTS: 179 patients (mean age at diagnosis 57.2 ± 15.9 years; 86.0% Female) had total 198 cavernous aneurysms. 44.4% of patients had no concomitant non-cavernous aneurysms, 41.9% had 1, and 13.6% had 2. No cavernous aneurysms ruptured during clinical follow-up. 17 non-cavernous concomitant aneurysm ruptured during follow up. 91.5% of cavernous aneurysms showed no change in size, 4.2% increased in size, and 4.2% were initially treated at time of diagnosis. Of the cavernous aneurysms that increased in size, there was a mean increase of 0.97 ± 0.4 mm and 1.1 mm ± 0.7 mm in long and short axis diameter across 5.2 ± 2.3 years. Weakness as a presenting symptom was the only predictor of cavernous aneurysm growth (p-value 0.022). Number of concomitant non-cavernous aneurysms (p-value 0.007) and sub-arachnoid hemorrhage (SAH) as a presenting symptom (p-value &lt;0.0001) were associated with concomitant non-cavernous aneurysmal rupture. CONCLUSIONS: Cavernous ICA aneurysms demonstrate no rupture and limited growth over years of clinical follow-up. No patient radiographic or risk factor suggests increased risk of rupture or other symptomology, thus except for select individuals with concomitant non-cavernous aneurysms and SAH on presentation, there is likely limited clinical benefits in serially following these aneurysms over time.

Association of brain arterial diameters with demographic and anatomical factors in a multi-national pooled analysis of cohort studies.

Brain arterial diameters are markers of cerebrovascular disease. Demographic and anatomical factors may influence arterial diameters. We hypothesize that age, sex, height, total cranial volume (TCV), and persistent fetal posterior cerebral artery (fPCA) correlate with brain arterial diameters across populations. Participants had a time-of-flight MRA from nine international cohorts. Arterial diameters of the cavernous internal carotid arteries (ICA), middle cerebral arteries (MCA), and basilar artery (BA) were measured using LAVA software. Regression models assessed the association between exposures and brain arterial diameters. We included 6,518 participants (mean age: 70 ± 9 years; 41% men). Unilateral fPCA was present in 13.2% and bilateral in 3.2%. Larger ICA, MCA, and BA diameters correlated with older age (Weighted average [WA] per 10years: 0.18mm, 0.11mm, and 0.12mm), male sex (WA: 0.24mm, 0.13mm, and 0.21mm), and TCV (WA: for one TCV standard deviation: 0.24mm, 0.29mm, and 0.18mm). Unilateral and bilateral fPCAs showed a positive correlation with ICA diameters (WA: 0.39mm and 0.73mm) and negative correlation with BA diameters (WA: -0.88mm and -1.73mm). Regression models including age, sex, TCV, and fPCA explained on average 15%, 13%, and 25% of the ICA, MCA, and BA diameter interindividual variation, respectively. Using height instead of TCV as a surrogate of head size decreased the R-squared by 3% on average. Brain arterial diameters correlated with age, sex, TCV, and fPCA. These factors should be considered when defining abnormal diameter cutoffs across populations.

Does tumoral cavernous carotid stenosis predict an increased risk of future stroke in skull base meningiomas?

Skull base meningiomas (SBMs) involving the cavernous sinus encase the internal carotid artery (ICA) and may lead to stenosis of the vessel. Although ischemic stroke has been reported in the literature, there are to the authors' knowledge no reported studies quantifying the risk of stroke in these patients. The authors aimed to determine the frequency of arterial stenosis in patients with SBMs that encase the cavernous ICA and to estimate the risk of ischemic stroke in these patients. Records of all patients with SBM encasing the ICA whose cases were managed by the skull base multidisciplinary team at Salford Royal Hospital between 2011 and 2017 were reviewed using a two-stage approach: 1) clinical and radiological strokes were identified from electronic patient records, and 2) cases were reviewed to examine the correlation between ICA stenosis associated with SBM encasement and anatomically related stroke. Strokes that were caused by another pathology or did not occur in the perfusion territory were excluded. In the review of patient records the authors identified 118 patients with SBMs encasing the ICA. Of these, 62 SBMs caused stenosis. The median age at diagnosis was 70 (IQR 24) years, and 70% of the patients were female. The median follow-up was 97 (IQR 101) months. A total of 13 strokes were identified in these patients; however, only 1 case of stroke was associated with SBM encasement, which occurred in the perfusion territory of a patient without stenosis. Risk of acute stroke during the follow-up period for the entire cohort was 0.85%. Acute stroke in patients with ICA encasement by SBMs is rare despite the propensity of these tumors to stenose the ICA. Patients with ICA stenosis secondary to their SBM did not have a higher incidence of stroke than those with ICA encasement without stenosis. The results of this study demonstrate that prophylactic intervention to prevent stroke is not necessary in ICA stenosis secondary to SBM.

Combined endoscopic endonasal and transcranial approach for internal carotid artery aneurysms: usefulness and safety of endonasal proximal control.

It is necessary to secure both the proximal and distal sides of the parent artery to prevent premature rupture when clipping cerebral aneurysms. Herein, we describe four cases in which the proximal internal carotid artery (ICA), affected by a paraclinoid aneurysm, was secured using an endoscopic endonasal approach. We used various tools, including a surgical video, cadaver dissection picture, artist's illustration, and intraoperative photographs, to elucidate the process. No patient experienced postoperative complications at our institution. Compared to the cervical or cavernous ICA, the ICA adjacent to the clivus (paraclival ICA) can be anatomically safely and easily exposed using an endoscopic endonasal approach because there is no need to consider cerebrospinal fluid leakage or hemorrhage from the cavernous sinus. Securing the proximal side of the parent artery using an endoscopic endonasal approach may be a viable method for clipping selected ICA aneurysms, such as paraclinoid aneurysms especially for upward or outward aneurysms of the C2 portion.

Factors Limiting Complete Resection in the Subarachnoid Space in Endoscopic Surgery for Giant Pituitary Adenoma

Giant pituitary adenomas (>4 cm, GPAs) have presented great challenges to surgeons because the residual tumor in the subarachnoid space can cause hemorrhage or vessel injury following apoplexy. This study aimed to investigate the factors limiting surgical success in endoscopic skull base surgery (ESS) for GPAs. ESS was performed on 67 consecutive patients with GPAs from 2010 to 2020. We retrospectively analyzed the clinical and radiological features and surgical outcomes. Correlations between the tumor characteristics and extent of resection were statistically presented with odds ratios (ORs). Preoperative visual and hormonal impairments were present in 59 (88.1%) and 55 patients (82.1%), respectively. Gross total resection (GTR) was achieved in 58.2% of patients, and the tumor remained on the lateral side of the subarachnoid space or the cavernous sinus when complete resection failed. The tumor volume, maximal diameter, multilobulated shape, cavernous sinus invasion, posterior fossa extension, and extent of suprasellar lateral extension of tumors were significantly correlated with incomplete resection. In tumors with subarachnoid lateral extension, greater distances from the medial wall of the proximal cavernous internal carotid artery to the most lateral tumor significantly increased the risk of incomplete resection for the suprasellar lateral portion of the tumor, with an OR of 1.21. Considerable surgical planning in ESS for GPAs is crucial for complete resection and patient safety. We elucidated that lateral extension of tumors in the subarachnoid space hindered the surgical success of the suprasellar portion of the tumor.

Imaging findings of juvenile nasopharyngeal angiofibroma invading orbital apex and middle cranial fossa: a case report

BackgroundJuvenile nasopharyngeal angiofibroma (JNA) is an infrequent, highly vascular tumor that predominantly affects male adolescents. Although benign, it rarely may exhibit invasive growth, leading to significant morbidity, as in our case presentation. Diagnosis relies on clinical evaluation and imaging, with MR and CT playing vital roles in confirming the tumor's presence, determining its extent, and aiding in treatment planning. MR shows a mass with signal voids at T2-weighted images and intense contrast enhancement at T1-weighted images, while CT shows bone remodeling and destruction. A biopsy is usually avoided due to bleeding risks.Case presentationWe present a case of a 16-year-old male with nasal obstruction and recurrent epistaxis from the right nostril, headache, and mucopurulent rhinorrhea. Furthermore, he had vision impairment in the right eye for one week associated with proptosis and periorbital swelling. MR and CT imaging evidenced the presence of JNA with extensive involvement in the nasal cavity, nasopharynx, pterygopalatine fossa, and infratemporal fossa. Moreover, the mass invaded the orbital apex and middle cranial fossa contacting the cavernous sinus and internal carotid artery. Preoperative embolization and complete surgical resection were performed. No complications occurred in the postoperative period and histopathological analysis confirmed the diagnosis of JNA. No recurrences were found at 12 months MR follow-up.ConclusionsEarly detection and accurate imaging evaluation are essential for the effective management of JNA. Regular post-treatment MR follow-ups are crucial to detect recurrences or assess fibrosis stability. MR and CT continue to be indispensable tools in the diagnosis and follow-up of JNA.

Mass Effect After Flow Diversion for Unruptured Large and Giant Cavernous or Paraclinoid Internal Carotid Artery Aneurysm

The mass effect associated with large or giant intracranial aneurysms is difficult for traditional endovascular treatment. This study investigated whether flow diverters can relieve the aneurysmal mass effect caused by aneurysmal compression symptoms. Fifty-five patients with unruptured large and giant intracranial aneurysms treated by a flow diverter at our institution from January 2014 to February 2022 were retrospectively evaluated. In this study, 53 patients were included. Initially, 27 patients (51.9%), including 10 with compressive optic neuropathy, 12 with third nerve palsy, 2 with facial hyperesthesia, and 11 with sixth nerve palsy, were symptomatic. The symptom duration was shorter in the improved group (n=2.2±4.0 vs. n=3.1±3.9, P=0.49). Thrombus formation following the flow diversion procedure was typically observed on magnetic resonance imaging (MRI) performed immediately and was not significantly associated with symptomatic improvement (OR=0.395; 95% CI (0.058-2.698), P=0.343). However, symptomatic improvement was seen in most patients when the aneurysm size decreased on MRI. A reduction in the aneurysm size on the MRI at the 3-month follow-up was correlated with symptomatic improvement in the multivariate analysis (OR=0.08, 95% CI (0.013-0.485), P<0.05). A flow diverter might help alleviate compression symptoms caused by large or giant intracranial aneurysms. Shrinkage of the aneurysm within 3months postoperatively and a shorter duration of symptoms contribute to the favorable outcomes of mass effect. Ultimately, prompt treatment is crucial for improving symptomatic intracranial artery aneurysms.

Magnetic resonance imaging in COVID-19-associated acute invasive fungal rhinosinusitis - Diagnosis and beyond.

The aim of the study was to evaluate the magnetic resonance imaging (MRI) features of acute invasive fungal rhinosinusitis (AIFRS) at presentation and on follow-up imaging when patients receive treatment with systemic antifungal therapy and surgical debridement. This is a retrospective analysis of imaging data from a cohort of patients diagnosed with AIFRS during the second wave of COVID-19 in single tertiary referral hospital in South India between March 2021 and May 2021 (n = 68). Final diagnosis was made using a composite reference standard which included a combination of MRI findings, clinical presentation, nasal endoscopy and intraoperative findings, and laboratory proof of invasive fungal infection. Analysis included 62 patients with "Definite AIFRS" findings on MRI and another six patients with "Possible AIFRS" findings on MRI and laboratory proof of invasive fungal infection. Follow-up imaging was available in 41 patients. The most frequent MRI finding was T2 hypointensity in the sinonasal mucosa (94%) followed by mucosal necrosis/loss of contrast-enhancement (92.6%). Extrasinosal inflammation with or without necrosis in the pre-antral fat, retroantral fat, pterygopalatine fossa, and masticator space was seen in 91.1% of the cases. Extrasinosal spread was identified on MRI even when the computed tomography (CT) showed intact bone with normal extrasinosal density. Orbital involvement (72%) was in the form of contiguous spread from either the ethmoid or maxillary sinuses; the most frequent presentation being orbital cellulitis and necrosis, with some cases showing extension to the orbital apex (41%) and inflammation of the optic nerve (32%). A total of 22 patients showed involvement of the cavernous sinuses out of which 10 had sinus thrombosis and five patients had cavernous internal carotid artery involvement. Intracranial extension was seen both in the form of contiguous spread to the pachymeninges over the frontal and temporal lobes (25%) and intra-axial involvement in the form of cerebritis, abscesses, and infarcts (8.8%). Areas of blooming on SWI were noted within the areas of cerebritis and infarcts. Perineural spread of inflammation was seen along the mandibular nerves across foramen ovale in five patients and from the cisternal segment of trigeminal nerve to the root exit zone in pons in three patients. During follow-up, patients with disease progression showed involvement of the bones of skull base, osteomyelitis of the palate, alveolar process of maxilla, and zygoma. Persistent hyperenhancement in the post-operative bed after surgical debridement and resection was noted even in patients with stable disease. Contrast-enhanced MRI must be performed in all patients with suspected AIFRS as non-contrast MRI fails to demonstrate tissue necrosis and CT fails to demonstrate extrasinosal disease across intact bony walls. Orbital apex, pterygopalatine fossa, and the cavernous sinuses form important pathways for disease spread to the skull base and intracranial compartment. While cerebritis, intracranial abscesses, and infarcts can be seen early in the disease due to the angioinvasive nature, perineural spread and skull base infiltration are seen 3-4 weeks after disease onset. Exaggerated soft-tissue enhancement in the post-operative bed after debridement can be a normal finding and must not be interpreted as disease progression.

Cavernous Carotid Aneurysm Presenting as Direct Carotid-Cavernous Fistula with Contralateral Ocular Symptoms: A Rare Case Report

ABSTRACT Carotid-cavernous fistula (CCF) resulting from intracavernous carotid artery aneurysms is uncommon. However, if rupture does occur, it can lead to a CCF, which causes sudden onset of unilateral ophthalmoplegia. In this report, we present a case of a ruptured giant intracavernous carotid artery aneurysm leading to a direct CCF with contralateral ocular features. The aim is to discuss the distinctiveness of this case and the most challenging aspects of identifying similar cases. A woman in her sixties developed a sudden direct CCF, resulting in proptosis in the opposite eye. Magnetic resonance angiography revealed that the left cavernous sinus (CS) and superior ophthalmic vein were dilated, whereas the right side was unaffected. However, digital subtraction angiography (DSA) revealed a large aneurysm in the right cavernous internal carotid artery (ICA) and a direct connection between the right ICA and CS, with venous drainage exclusively occurring in the opposite direction via the intercavernous sinus. To address the issue, the aneurysm and fistula underwent Coil and Onyx embolisation, successfully closing the fistula and leading to a regression in the orbital symptom. This presents a unique scenario of an unexpected unilateral CCF with contralateral symptoms in a direct CCF, which demands immediate attention. It is crucial to remain alert for CCF and verify the diagnosis through DSA when dealing with such patients to avoid severe outcomes. Prompt identification and intervention can enhance the patient’s chances of a positive outcome.

Long-term outcomes of coils embolization for superior hypophyseal artery aneurysms.

Superior hypophyseal artery (SHA) aneurysms are intradural, and their rupture can result in subarachnoid hemorrhage. Considering the related surgical difficulty and anatomical restrictions, endovascular treatment (EVT) is considered the most favorable modality for SHA aneurysms; however, the long-term outcomes of EVT have rarely been reported. The study assessed the incidence of and risk factors for recurrence of SHA aneurysms after EVT as well as the correlation factors for SHA aneurysm rupture. We included 112 patients with SHA aneurysms treated with EVT at our facility between 2009 and 2020. Here, EVT included non-stent-assisted (simple or balloon-assisted) or stent-assisted coiling. Flow diverter was not included because it was barely used due to its high cost under our national insurance's limitation, and a high proportion of ruptured aneurysms in our series. Univariate and multivariate logistic regression was performed to evaluate the correlation factors for SHA aneurysm rupture, along with the incidence of and risk factors for post-EVT SHA aneurysm recurrence and re-treatment. In our patients, the mean angiographic follow-up period was 3.12 years. The presence of type IA or IB cavernous internal carotid artery (cICA) was strongly correlated with SHA aneurysm rupture. Recurrence occurred in 17 (13.4%) patients, of which only 1 (1.4%) patient had received stent-assisted coiling. All cases of recurrence were observed within 2 years after EVT. The multivariate logistic regression results showed that ruptured aneurysm and non-stent-assisted coiling were independent risk factors for aneurysm recurrence. Of the 17 cases of aneurysm recurrence, 9 (52.9%) received re-treatment. Moreover, aneurysm rupture was the only factor significantly correlated with re-treatment in multivariate logistic regression. No re-recurrence was observed when a recurrent aneurysm was treated with stent-assisted coiling. Type I cICA was common factor for aneurysm rupture. Although flow-diverter treatment serves as another suitable technique that was not compared with, coils embolization was effective treatment modality for SHA aneurysms, leading to low recurrence and complication rates, especially with stent use. All cases of recurrence occurred within 2 years after EVT; they were strongly associated with prior aneurysm rupture. Further stent-assisted coiling was noticed to prevent re-recurrence.

A Case of Oral Flora Related Carotid Vasculitis (P2-10.007)

<h3>Objective:</h3> NA <h3>Background:</h3> A 41-year-old immunocompetent female with a history of uterine cancer status post hysterectomy, migraines, and anxiety presented to the hospital with a one-month history of headache, myalgias, and subjective fevers. Blood work showed a leukocytosis (16.9) and elevated C-reactive protein (98.3). Other inflammatory markers including erythrocyte sedimentation rate, C3, and C4 were normal. Blood cultures (bcx) were drawn. Physical exam noted neck hypertonicity along with tenderness along vertebral column and neck musculature. Initial computed tomography angiography (CTA) of the head and neck showed narrowing of the left internal carotid artery (ICA) at the junction of horizontal and vertical petrous segments and present to the mid cavernous ICA, which were concerning for dissection/intramural hematoma. MRI with and without contrast did not reveal any other acute pathology. On Hospital Day 3, 1 of 2 bcx grew gram-negative and gram-positive rods. On Hospital Day 6 a repeat MRI showed mild dural thickening and enhancement involving the walls of the left cavernous sinus extending posteriorly along the tentorial leaf and the left cavernous ICA appeared small in size compared to the right ICA. On day 7 cultures speciated to <i>Parvimonas micra</i> 2 of 2 bcx and <i>fusobacterium nucleatum</i> 1 of 2 bcx. Due to the presence of oral flora in bcx, additional history was gathered from the patient. The patient shared with staff a history of incomplete dental work. Oral exam revealed several partially extracted teeth with intact roots. This was felt to be the source of her infection and that her “dissection” was actually an infectious vasculitis. The patient underwent successful root extraction and was treated with 4 weeks of intravenous antibiotics. Interval CTA showed improvement in the left ICA narrowing. <h3>Design/Methods:</h3> NA <h3>Results:</h3> NA <h3>Conclusions:</h3> Here we present to our knowledge the first case of carotid vasculitis secondary to <i>Parvimonas micra</i> and <i>fusobacterium nucleatum.</i> <b>Disclosure:</b> Dr. Hackmyer has nothing to disclose. Dr. Ko has nothing to disclose. Dr. Hanrahan has received personal compensation for serving as an employee of Nowyouknow Neuro.

Endoscopic Repair of Internal Carotid Artery Injury with a Lateral Tongue Muscle Patch Graft: Novel Technique and Literature Review.

Objectives Iatrogenic injury to the internal carotid artery (ICA) is one of the most catastrophic complications of endoscopic sinus and skull base surgery. Previous research has shown that packing with a crushed muscle graft at the injury site can be an effective management technique to control bleeding and prevent the need for ICA sacrifice. Here, we describe a novel and readily available repair donor site-an autologous lateral tongue muscle patch. Design Three representative cases of a successful repair of ICA injuries using a lateral tongue muscle patch are included in this study. The graft measured approximately 2 × 3 cm and was taken from the lateral intrinsic tongue musculature. We describe the harvest of the graft, its advantages, and the details of operative repair. Results The lateral tongue provides a large and readily accessible source of muscle within the surgical field that can be quickly harvested during an endoscopic procedure. For the first case, an expanding parasellar ICA pseudoaneurysm was managed with a tongue muscle patch and nasal packing. In the second case, a cavernous ICA injury was sustained during craniopharyngioma resection. Case three involved an ICA injury during endonasal debridement of invasive fungal rhinosinusitis. None of the patients required embolization or neurovascular stenting. Postoperative angiograms and serial computed tomography angiograms showed complete resolution of the pseudoaneurysm, and the patients continued to do well at least 1 year after repair. Conclusion Lateral tongue muscle graft is an effective and efficient method to manage ICA injuries during endoscopic endonasal surgery. Advantages include the speed of harvest, donor site being readily accessible in the surgical field, and low donor site morbidity. It should be added to the repertoire of possible donor sites for addressing catastrophic sinonasal bleeding.

Anatomical variations of the cavernous Internal Carotid Artery: Validation of an MRI-based classification

ObjectiveVariations of the cavernous Internal Carotid Artery (ICA) angulation (C4-bend) have been classified into 4 anatomical subtypes with particular surgical relevance, as a very angulated ICA comes in closest contact with the pituitary gland leading to higher risk of iatrogenic vascular injury. This study aimed to validate this classification using current routine imaging techniques. MethodsThe different cavernous ICA bending angles were measured on 109 MRI TOF sequences, within a retrospective database of patients with no sellar lesions. Each ICA was classified into one of 4 anatomical subtypes as already defined in a previous study [1]. Interrater agreement was assessed by a Kappa Correlation Coefficient. ResultsKappa Correlation Coefficient was of 0.90 [0.82–0.95], validating the strong level of agreement between all observers when using the present classification. ConclusionClassification of the cavernous ICA in 4 subtypes appears statistically valid on routinely used pre-operative MRI, providing an efficient tool to estimate the vascular iatrogenic risk prior to endoscopic endonasal transsphenoidal surgery.

Abstract Number ‐ 68: Thrombectomy Through Persistent Trigeminal Artery In A Patient With P2 Occlusion: Case Report

Introduction Mechanical thrombectomy for distal medium vessel occlusions (DMVO) of the posterior circulation has been shown to be safe and technically feasible. Additionally, mechanical thrombectomy through a persistent trigeminal artery (PTA) for occlusions near the superior bifurcation of the basilar artery has been described before. However, the safety and efficacy of such procedures for DMVO remain unclear. We present a case of thrombectomy through a Saltzman type 1 PTA in an acute P2 occlusion. Methods A woman in her 80s with atrial fibrillation was admitted after undergoing a thrombectomy for a left M1 occlusion. Two days post‐procedure, she developed a right P2 occlusion with severe motor deficit secondary to thalamic hypoperfusion. She underwent mechanical thrombectomy through a right PTA. A balloon guide catheter (BGC) was placed in the right internal carotid artery (ICA). Initially, a 4F catheter over a 0.014 microwire was introduced but failed to navigate through the PTA. Afterward, the system was exchanged for a 5F aspiration catheter over a 0.021 microcatheter and 0.014 microwire which successfully tracked up through the PTA to the face of the clot. Aspiration alone was attempted initially, followed by the combined technique of aspiration with stent‐retriever. Results Our initial attempt to navigate the 4F catheter over the microwire through the PTA and up the basilar artery was unsuccessful as it continued to herniate into the cavernous ICA. Switching to the triaxial approach with the 5F catheter over the microsystem allowed navigation to the clot, however, aspiration alone was not sufficient to recanalize the occlusion and led to significant vasospasm which later self‐resolved. Instead, the combined technique resulted in successful thrombectomy with no untoward emboli into the right anterior circulation. The post‐procedural MRI showed multiple, scattered infarcts which were not evident on the MRI after the patient’s initial M1 thrombectomy. These infarcts involved the cerebellar and cerebral hemispheres bilaterally as well as the right thalamus. There was no evidence of subarachnoid hemorrhage on MRI. The patient continued to have significant left‐sided hemiparesis and could not be extubated, at which point the decision was made to transition to comfort measures until she passed. Conclusions Mechanical thrombectomy of a posterior circulation DMVO through a Saltzman type 1 PTA using the combined technique can be performed safely and effectively.

Abstract Number ‐ 178: Optimizing Skin to Device at Occlusion Time Utilizing A Non‐exchange Technique with Novel Steerable Microcatheter

Introduction Vascular tortuosity and difficult access to the target vessel during mechanical thrombectomy is one of the reasons for failed reperfusion. The 021 Bendit adjustable micro catheter is a torqueable microcatheter with an adjustable, 360 rotating, bendable tip. Its unique structure provides it with trackability and support allowing it to be used as a select catheter for the guide and to directly access the target vessel without a guidewire. This feature can result in significant reduction in groin puncture to recanalization time, with possible implications on patient outcomes. It is also designed to fit in a standard sized aspiration catheter and allow delivery of a stentriever device if needed. Herein we describe the first US experience in 021 Bendit adjustable microcatheter in vessel selection and intracranial navigation in patients with large vessel occlusions. Methods We describe our experience with three patients who presented with large vessel occlusions for mechanical thrombectomy in July 2022. The system with guide catheter loaded with aspiration catheter and Bendit adjustable microcatheter was used to directly select the target vessels starting at the arteriotomy site, off the aortic arch and its support was used to advance the guide catheter into the cervical segment. It was then delivered to the intracranial circulation where it was used to deliver the aspiration catheter. Results Patient A is a 73‐year‐old man with a left M1 occlusion. The Bendit microcatheter was advanced through a 071 intermediate catheter and through a 088 guide catheter and was used to select the left common carotid artery. Time between device entering the body to clot touch time of 18 minutes. Patient B is a 57‐year‐old man who presented with a left cavernous internal carotid artery occlusion. The Bendit microcatheter was advanced through a 071 intermediate catheter and a 088 guide catheter was used to successfully select the left common carotid artery.Time between device entering body and bendit being at first lesion is 3 minutes. Patient C is a 60‐year‐old woman with a basilar occlusion. A 088 guide catheter was advanced over 071 intermediate catheter which was advanced over the Bendit microcatheter into the aortic arch. The Bendit microcatheter was maneuvered to select the right subclavian artery and the right vertebral artery, the system was subsequently advanced over the Bendit microcatheter intracranially. Time between groin puncture to aspiration device at the clot was 5 minutes. Conclusions The Bendit steerable microcatheter can be used to maneuver through the aortic arch and successfully select the target vessel without an exchange and without a guidewire. This approach can dramatically reduce access to recanalization time and ultimately neurologic outcomes in patients undergoing mechanical thrombectomy. As more experience is obtained, best practices will be able to achieve consistently lower times.

Side-Firing Intraoperative Ultrasonograhy for Resection of Giant Pituitary Adenomas

Suprasellar extension, cavernous sinus invasion, and involvement of intracranial vascular structures and cranial nerves are among the challenges faced by surgeons operating on giant pituitary macroadenomas. Intraoperative tissue shifts may render neuronavigation techniques inaccurate. Intraoperative magnetic resonance imaging can solve this problem, but it may be costly and time consuming. However, intraoperative ultrasonography (IOUS) allows for quick, real-time feedback and may be particularly useful when facing giant invasive adenomas. Here, we present the first study examining technique for IOUS-guided resection specifically focusing on giant pituitary adenomas. To describe the use of a side-firing ultrasound probe in the resection of giant pituitary macroadenomas. We describe an operative technique using a side-firing ultrasound probe (Fujifilm/Hitachi) to identify the diaphragma sellae, confirm optic chiasm decompression, identify vascular structures related to tumor invasion, and maximize extent of resection in giant pituitary macroadenomas. Side-firing IOUS allows for identification of the diaphragma sellae to help prevent intraoperative cerebrospinal fluid leak and maximize extent of resection. Side-firing IOUS also aids in confirmation of decompression of the optic chiasm via identification of a patent chiasmatic cistern. Furthermore, direct identification of the cavernous and supraclinoid internal carotid arteries and arterial branches is achieved when resecting tumors with significant parasellar and suprasellar extension. We describe an operative technique in which side-firing IOUS may assist in maximizing extent of resection and protecting vital structures during surgery for giant pituitary adenomas. Use of this technology may be particularly valuable in settings in which intraoperative magnetic resonance imaging is not available.

Abstract TMP64: Association Of Brain Arterial Diameters With Demographic And Anatomical Factors In A Multi-national Pooled Analysis Of Cohort Studies

Objectives: Brain arterial dilation is an increasingly recognized cerebrovascular disease marker. However, demographic and anatomical factors may influence brain arterial diameters within the normal spectrum. We hypothesize that age, sex, height, total cranial volume (TCV) and fetal posterior cerebral arteries (fPCA) presence correlate with brain arterial diameters across diverse populations. Methods: We included participants with available time-of-flight MRA from 9 cohort studies across the United States (4), Ecuador (1), Venezuela (1), South Africa (1) and Singapore (2). Arterial diameters of the basilar artery (BA), cavernous internal carotid arteries (ICAs) and middle cerebral arteries (MCAs) were measured using LKEB Automated Vessel Analysis (LAVA) software. Linear regression models were fitted to assess the association between brain arterial diameters and exposures. The R-squared was calculated to assess the extent of brain arterial diameter variation explained by the variables studied. Results: The sample included 6,269 participants (mean age 68 years; 42% men). Unilateral fPCA was found in 12.6% and bilateral fPCAs in 3.0%. Older age, male sex and TCV were uniformly correlated with larger BA, ICA and MCA diameters (Table). Unilateral and bilateral fPCAs showed a negative correlation with BA diameter and a positive correlation with ICA diameters in a dose-dependent manner. Models fitted for age, sex, TCV, and fPCA presence explained on average 24, 16 and 12 % of the BA, ICAs and MCA diameter interindividual variation, respectively. Using height instead of TCV decreased the R-squared by 2% on average. Conclusions: In this pooled analysis of cohort studies, we found brain arterial diameters consistently correlate with age, sex, TCV and fPCA presence. These factors should be considered to define abnormal arterial diameter cut-offs across populations. If resources are limited or if bedside applicability is desired, height could be used instead of TCV.