Microsurgical Treatment Research Articles

Contralateral approach to giant ruptured and unruptured ophthalmic artery aneurysms: patient series.

Giant ophthalmic artery (OphA) aneurysms remain surgically challenging despite the progress in endovascular treatments. This study describes the contralateral interoptic corridor in select patients based on imaging criteria suitable for clipping. The aim of this study was to show that despite the growing use of novel endovascular techniques, such as coil embolization and flow diversion, for the treatment of OphA aneurysms, microsurgical clipping may still be preferred for giant ones under certain conditions. The authors retrospectively reviewed the records of the microsurgical treatment of unruptured and ruptured giant OphA aneurysms at the University Hospital Center "Mother Teresa," Tirana, from 2007 to 2016. Four patients were selected for microsurgery and the contralateral approach using ophthalmic evaluations and coronal imaging on computed tomography, magnetic resonance imaging, and digital subtraction angiography that demonstrated aneurysms with a small neck and an orientation between 11 and 13 on the coronal clock face. A prefixed chiasm was a contraindication to this approach. Giant OphA aneurysms can be safely clipped through a contralateral interoptic corridor without creating new visual deficits or a residual aneurysm. https://thejns.org/doi/10.3171/CASE2473.

Model of Arteriovenous Malformation Created in Human Placenta for Training in Vascular Microneurosurgery.

Arteriovenous malformations (AVMs) are congenital lesions, and because of their structure, complexity, flow, size, and location organization, they are lesions that require extensive anatomic knowledge and mastery of microsurgical skills and techniques. Human placentas as a training model for AVM surgery are promising alternatives. This article aims to describe the technique for forming an AVM-type lesion in human placentas and its usefulness in the training of microsurgical treatment techniques. In this study, 15 fresh human placental models were treated. A nidus was created using synthetic material, and dynamic flow was evaluated with intravascular injection of Indocyanine Green. The catheter system was connected to a continuous flow infusion pump. For simulation purposes, 4 vascular neurosurgeons and 4 vascular neurosurgery fellows used the same techniques and instruments used in real surgery to simulate the resection of AVM lesions. Subjective assessments were conducted, evaluating the validity and structured content on a 5-point Likert scale. Evaluation criteria included the execution of technical maneuvers and the model's expression and structural aspects. We describe the step-by-step creation of an AVM in a placental biological model for the performance of vascular microsurgery training in the laboratory. We created in the human placenta a lesion with the characteristics of an AVM for microsurgical training in the laboratory, which presents key features realistic to a real AVM, such as 1 or more feeder arteries, nidus (synthetic), draining vein(s), continuous and pulsatile flow, and 3-dimensional configuration. Furthermore, it demonstrates the applicability of microsurgical techniques to the model compared with performing surgery on a patient. Considering it an effective method for laboratory training, the creation of arteriovenous malformations in human placentas enables students to replicate, comprehend the structure, and master microsurgical techniques in a realistic model.

Outpatient regenerative therapy of a chronic diabetic foot ulcer with exposed bone surface

BACKGROUND: Treatment of deep chronic wounds with the bone tissue involvement against the background of lower limb atherosclerosis and diabetic foot syndrome does not fit any reasonable hospital stay duration and at the same time has no effective outpatient methods. Therapy with conditioned medium derived from human mesenchymal stem cells (CM-MSC) may be a solution for this problem. CLINICAL CASE DESCRIPTION: Patient F., 77-year-old, arrived for an outpatient treatment of local necrosis in the area of the 1st toe of the left foot in April, 2022. The main diagnosis: Peripheral arterial disease of the lower extremities. Multifocal atherosclerosis. Occlusion of the superficial femoral and popliteal arteries, diffuse lesions of the lower leg arteries on the left. Chronic arterial insufficiency of the 4th degree. Attempts of revascularisation of the left lower limb. Limited gangrene (Wagner IV) of the 1st toe of the left foot. Associated diseases: insulin-dependent type 2 diabetes mellitus (for more than 30 years). Diabetic polyneuropathy. Diabetic foot syndrome, neurotrophic form. Local treatment was performed by the microsurgical debridement of the affected surface in combination with the method of multilayered dressings, according to the previously patented technology. The microsurgical treatment of the bone surface in the wound area was carried out with the use of CM-MSC. Positive dynamics in the form of a partial closure of the bone fragment with soft tissue was observed on the sixth month of therapy. The complete closure of the open bone fragment was observed in 12 months from the beginning of the outpatient treatment. CONCLUSION: The developed method of treatment using CM-MSC can be effective for chronic wounds with open bone surfaces.

Microsurgical Treatment of a Giant Thrombosed Basilar Artery-Superior Cerebellar Artery Aneurysm With the Aid of Double Bypass Superficial Temporal Artery-Posterior Cerebral Artery and Superficial Temporal Artery-Superior Cerebellar Artery: 2-Dimensional Operative Video

Giant thrombosed posterior circulation aneurysms are rare lesions with a natural history associated with high morbidity and mortality. 1-6 The treatment has high risk with either microsurgical or endovascular treatment (ET). While ET allows easier access but high recurrence rate, microsurgical treatment has more difficult access but provides more durable lasting treatment. 7-13 A 47-year-old woman presented with left hemiparesis from a right giant thrombosed basilar artery-superior cerebellar artery (BA-SCA) aneurysm buried in the brainstem with surrounding edema. Owing to risk of perforator occlusion and high recurrence rate with ET, we opted for microsurgical clipping with the aid of double protective bypass of superficial temporal artery-posterior cerebral artery (STA-PCA) and STA-SCA. The patient consented to the procedure and publication of her image. Initially, we performed a pterional craniotomy with zygomatic arch removal and exposed the right PCA, right SCA, BA, and aneurysm neck. Then, to perform a safe protective STA-PCA bypass, it was necessary to make a partial temporal lobectomy to avoid injury of a PCA-perforating branch. Subsequently, BA-SCA aneurysm was clipped. After clipping, STA-SCA bypass was performed to prevent possible occlusion of SCA afterward. After initial worsening of left hemiparesis and right oculomotor palsy, the patient recovered with rehabilitation and had no deficits 6 months after surgery. Postoperative imaging confirmed aneurysm exclusion, absence of ischemic lesions, and recovering of brainstem edema. Protective bypasses are a useful technique to improve outcomes in the microsurgical treatment of certain giant posterior circulation aneurysms. This report was approved by the ethics committee of our institution.

Endoscopic-Assisted Microsurgical Removal of a Tectal Plate Pilocytic Astrocytoma Through the Occipital Inter Hemispheric Transtentorial Approach: 2-Dimensional Operative Video

Pilocytic astrocytomas are challenging benign midline lesions which occur rarely in adults where they represent 2.3% of the tumours. 1,2 Posterior fossa location is the most frequent, but they also can be seen in the brainstem, tectal plate, and optochiasmatic region. 1,2 Tectal plate location is very challenging and can be reached through a infraoccipital supracerebellar approach 1,2 or the occipital inter hemispheric transtentorial approach. We present the case of a 32-years-old patient who presented with acute hydrocephalus 2 years previously and was treated by third ventriculostomy in an outside institution. Follow-up showed slight increase of the tumor while the patient remained asymptomatic. Microsurgical treatment was offered to the patient given the size of the lesion, the progression of the tumor, and her young age. We present the main surgical steps of the surgery through an occipital interhemispheric approach with section of the tentorium. The lesion was removed piecemeal through the intercollicular sulcus. The postoperative course was favorable; at 3 months of follow-up, the patient showed no neurological deficit. Brain MRI showed a complete resection of the astrocytoma and no postoperative complications. We present the surgical technique for endoscopic-assisted microsurgical removal of a tectal plate pilocytic astrocytoma through the occipital inter hemispheric transtentorial approach. We discuss the prognostic survival factors reported in the literature. 2 The patient consented to the procedure and to the publication of the images. Our institutional review board ethics committee do not require an approval for this type of publication.

The impact of the Woven EndoBridge device on the treatment of anterior circulation wide-neck bifurcation aneurysms: a single-center experience.

The paucity of literature comparing Woven EndoBridge (WEB) embolization to microsurgical clipping for anterior circulation wide-neck bifurcation aneurysms (WNBAs) underscores the need for further investigation into the optimal management of this patient subpopulation. The objective of this study was to compare the rate of endovascular and microsurgical treatment of WNBAs before and after the introduction of the WEB device. In addition, the authors performed a comparison of demographics, aneurysm characteristics, and treatment outcomes in patients before and after the introduction of the WEB device. This study was a retrospective review of the usage rate of different treatment modalities for WNBAs before and after the WEB device was approved by the US FDA on September 27, 2018. The study cohort comprised 235 patients with anterior circulation WNBAs treated at the authors' institution, including 127 aneurysms treated pre-WEB and 108 treated post-WEB. Generally, the rate of endovascular treatment of anterior circulation WNBAs was significantly higher post-WEB (86.1% vs 46.5%, p < 0.001), while the rate of clipping was significantly lower (13.9% vs 53.5%, p < 0.001). During follow-up, the rate of adequate aneurysm occlusion (Raymond-Roy occlusion classification [RROC] grades 1 and 2) was nonsignificantly higher in the post-WEB cohort (83.9% vs 78.5%, p = 0.34), while the rate of RROC grade 3 was nonsignificantly higher in the pre-WEB cohort (21.5% vs 16.1%, p = 0.34). Additionally, and although nonsignificant, the rates of recurrence (pre-WEB 25.3% vs post-WEB 14.9%, p = 0.12) and retreatment (pre-WEB 22.8% vs post-WEB 14.9%, p = 0.22) were higher in the pre-WEB cohort. Recurrence was assessed before retreatment. After the introduction of the WEB device, the rate of endovascular treatment of WNBAs increased while the rate of microsurgical clipping decreased. It is essential for neurointerventionalists to become familiar with the indications, advantages, and shortcomings of all these different techniques to be able to match the right patient with the right technique to produce the best outcome.

When microsurgery becomes the only lifesaving resource: An institutional experience treating patients from low-income backgrounds affected by posterior circulation brain aneurysms

Background and objectiveAneurysms of the posterior cerebral circulation constitute a burdensome condition with high mortality and morbidity. In the modern era, there has been a trend toward favoring an endovascular approach over microsurgery for aneurysm cases. Nevertheless, this transition has yet to be mirrored in low-to-middle-income countries where endovascular therapy may not be widely available. Herein, we aim to illustrate our experience treating these challenging conditions in patients from low-income backgrounds and discuss the relevance of the clinical setting in the treatment decision. MethodsThe authors conducted a retrospective review of the health records of patients who received microsurgical treatment for aneurysms in the posterior circulation, including the basilar artery (BA), posterior cerebral artery (PCA), and posterior inferior cerebellar artery (PICA) in an institution providing treatment to people of low-income backgrounds. Epidemiological data, microsurgical technique, and neurological function were retrieved and analyzed. ResultsSurgical clipping was employed for 12 patients (75% female) harboring 15 aneurysms (87% in the posterior circulation and 62% ruptured at presentation). Aneurysms were predominately located in the BA (69%), followed by the PCA (15%) and PICA (15%). Among neurological complications, 25% of patients developed oculomotor nerve palsy. The mortality rate was 17% owing to complications such as cerebral vasospasm, infarction, and severe intracranial hypertension. At the 6-month follow-up, 90% of patients had a good clinical outcome (modified Rankin scale scores of 0–2). ConclusionThe present case series illustrates the manifest role of microsurgical techniques for posterior circulation aneurysms, particularly in a scenario where endovascular techniques are not easily accessible. Importantly, this clinical setting pressure could exhort trainees to strive for microsurgical mastery and gain a competitive advantage.

Optimal Timing of Microsurgical Treatment for Ruptured Arteriovenous Malformations: A Systematic Review and Meta-Analysis.

The timing of microsurgical treatment (MST) for ruptured brain arteriovenous malformations (bAVM) is a contentious issue in the literature. This study aimed to investigate the impact of MST timing on outcomes in patients with ruptured bAVMs, considering MST with and without preoperative endovascular treatment (EVT). Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses 2020 guidelines, a comprehensive search was conducted across multiple databases, yielding 15 studies meeting the inclusion criteria. The timing was defined as the duration from the rupture of bAVM to the MST. The patients were divided into 4 different groups based on MST timing: <48 hours, <1 week, <2 weeks, and <1 month. The primary outcome was favorable outcome defined as a modified Rankin Scale score of 0 to 2 or a Glasgow Outcome Scale score of 4 to 5 in the last clinical follow-up. Secondary outcomes included periprocedural mortality and complete excision. MST time >48 hours were associated with a significantly higher favorable outcome rate (odds ratio: 9.71, 95% Cl: 3.09-30.57, P < .01) and a lower mortality rate (OR: 0.15, 95% Cl: 0.02-0.88, P = .04) compared with MST timing ≤48 hours. After exclusion of patients who underwent MST with preoperative EVT, MST time >48 hours had a significantly higher rate of favorable outcome (OR: 9.39, 95% CI: 2.53-34.89, P < .01). This meta-analysis suggests that delayed surgical intervention beyond 48 hours may be associated with improved favorable outcomes in patients who underwent MST with and without preoperative EVT for ruptured bAVMs.

Haemorrhagic Complications After Microsurgical Treatment for Intracranial Aneurysms Under Acetylsalicylic Acid: An Impact Analysis.

Patients with intracranial aneurysms often have comorbidities that require them to take acetylsalicylic acid (ASA). In recent years, many patients with aneurysms have been prescribed ASA to prevent aneurysm enlargement. ASA is also prescribed to patients with intracranial aneurysms in preparation for surgical revascularization. From 2016 to 2021, 64 patients underwent microsurgical aneurysm clipping without revascularization, and an additional 20 patientsunderwent extracranial to intracranial (EC-IC) bypass. The following parameters were analysed: the frequency of hemorrhagic complications, the blood loss volume, the duration of surgery and inpatient treatment, the change inhemoglobin level (Hb), hematocrit (Ht), erythrocytes, and clinical outcomes according to the modified Rankin scale (mRS). At the time of surgery, laboratory-confirmed effect of the ASA was registered in 22 patients (main group). In 42 patients, the ASA was not functional on assay (control group). Hemorrhagic complications were noted in two patients in the ASA group. In both cases, the hemorrhagic component did not exceed 15 ml in volume and did not require additional surgical interventions. Statistical analysis showed no significant differences in hemorrhagic postoperative complications. Taking low doses of acetylsalicylic acid during planned microsurgical clipping of cerebral aneurysms does not affect intraoperative blood loss volume, risk of postoperative hemorrhagic complications, length of stay in the hospital, or functional outcomes.

Influence of the sagittal spinal profile type on the long-term outcome of patients with symptomatic lumbar spinal stenosis after microsurgical decompression

OBJECTIVE Microsurgical decompression for patients with symptomatic lumbar spinal stenosis (LSS) has demonstrated long-term improvement concerning pain and function. Nonetheless, a considerable proportion of these patients do not experience satisfactory alleviation of symptoms. Previous studies have not found a direct influence of single sagittal parameters on patient outcomes. However, recent research indicates that a composite of parameters, presented in specific sagittal profile types (SPTs) that were defined by Roussouly and colleagues, may affect these outcomes. This study aims to investigate the impact of SPT on long-term outcomes of patients with LSS following microsurgical decompression. METHODS This study is a prospective clinical observation. Patients with symptomatic LSS, who underwent microsurgical treatment and had long-term follow-up data for at least 36 months, were included. Patients with spinal deformity, fractures, or significant instability were excluded. Outcomes were measured using the numeric rating scale for pain, 36-Item Short Form Health Survey for quality of life, walking distance, Oswestry Disability Index, Roland-Morris Disability Questionnaire, and Odom’s criteria. SPT was determined in blinded fashion by using preoperative long standing radiographs. RESULTS The initial population of this observational study consisted of 128 patients, with long-term results available for 87 individuals, including 24 patients with SPT1, 20 with SPT2, 27 with SPT3, and 16 with SPT4. The average age was 70 years, with a slight male majority (56.3%) and a mean BMI of 27.9 kg/m2. After a median follow-up of 48 months, all groups showed significant improvement in walking distance, leg pain, and disability. Overall, 75% reported satisfaction with the surgery. However, patients with SPT1, which is characterized by low sacral slope and specific spinal curvatures, experienced significantly less improvement in back pain (p = 0.018) and related disability (p = 0.030), and lower satisfaction compared to other SPT groups (p = 0.008). CONCLUSIONS The sagittal spinal type is influencing the long-term outcome of patients suffering from symptomatic LSS. Patients with a combination of a flat sacral slope and a low overall lumbar lordosis with a high lordosis in the lower lumbar spine (i.e., spinal SPT1) showed worse outcome concerning back pain and had decreased satisfaction with surgery than comparable subjects from other SPT groups. Consequently, the authors recommend the assessment of sagittal spinal types in patients diagnosed with symptomatic spinal stenosis prior to decompression surgery. Inclusion of SPT in the preoperative consultation process can provide valuable insights, potentially guiding practitioners to more tailored patient counseling.

Complementary advantages of microsurgical treatment for vertebral artery dolicoarteriopathies: Mitigating symptoms of restless leg syndrome in refractory vertebrobasilar insufficiency

Objective: This retrospective study examines the impact of microsurgical treatment on vertebral artery (VA) dolicoarteriopathies and associated restless leg syndrome (RLS) in patients with refractory vertebrobasilar insufficiency (VBI). Patients and Methods: We analyzed 78 patients with grade 2 and 3 kinks, and found out that the targeted microsurgical interventions, primarily designed to address VBI, improved secondary RLS symptoms in 12 patients. Procedures included arteriolysis and, depending on severity, grafting. Statistical analysis was conducted using Stata 16 (StataCorp LP, Texas, USA). Results: In twelve patients aged 55 to 72 years with refractory VBI and drug-resistant RLS, micro-neurosurgical correction of V1 segment dolicoarteriopathy, abnormal elongation and kinks in the artery, demonstrated promising outcomes. Postoperatively, 83.33% (10 patients) reported complete resolution of RLS symptoms, and 16.66% (2 patients) experienced partial symptom relief (p&amp;lt;0.05). Overall, 86.8% of various VBI-related symptoms were significantly improved or resolved (p&amp;lt;0.05). The microsurgical technique, avoiding traditional flow-arresting procedures, proved to be highly effective in this preliminary study with no mortality and minimal temporary complications, underscoring its potential treatment avenue for such complex neurovascular conditions. Conclusion: This study illuminates the relationship between VBI and RLS, proposing a potential vascular etiology for RLS, and highlights the need for a broader diagnostic approach for patients with refractory VBI.

Microsurgical central lymphatic reconstruction-the role of thoracic duct lymphovenous anastomoses at different anatomical levels.

In recent years advances have been made in the microsurgical treatment of congenital or acquired central lymphatic lesions. While acquired lesions can result from any surgery or trauma of the central lymphatic system, congenital lymphatic lesions can have a variety of manifestations, ranging from singular thoracic duct abnormalities to complex multifocal malformations. Both conditions may cause recurrent chylous effusions and downstream lymphatic congestion depending on the anatomical location of the thoracic duct lesion and are associated with an increased mortality due to the permanent loss of protein and fluid. We present a case series of eleven patients undergoing central lymphatic reconstruction, consisting of one patient with a cervical iatrogenic thoracic duct lesion and eleven patients with different congenital thoracic duct lesions or thrombotic occlusions. Anastomosis of the thoracic duct and a nearby vein was performed on different anatomical levels depending on the underlying central lymphatic pathology. Cervical (n = 4), thoracic (n = 1) or abdominal access (n = 5) was used for central lymphatic reconstruction with promising results. In 9 patients a postoperative benefit with varying degrees of symptom regression was reported. The presented case series illustrates the current rapid advances in the field of central microsurgical reconstruction of lymphatic lesions alongside the relevant literature.

Impact of preaneurysmal M1 length in unruptured middle cerebral artery aneurysm: mid-term outcome and single-center experience

ObjectiveThis study was design to investigate the surgical and functional outcome based on the preaneurysmal M1 length for unruptured MCA aneurysm. MethodsAmong 250 consecutive patients with unruptured aneurysms operated in our institution between 2015 and 2017, 72 were MCA aneurysms. Risk factors for IR (i.e., intraoperative rupture) were investigated including age, sex, preaneurysmal M1 length, maximal MCA aneurysm diameter, neck size, aneurysm shape, sphenoid ridge proximation sign. Outcome was measured at discharge, 1 yr and last follow-up. Outcome was compared according to the preaneurysmal M1 length. ResultsAmong 68 patients included, five patients (7.3%) suffered IR. Mean maximal diameter of MCA aneurysm (7.9 mm ± 3.4 vs. 4.5 ± 1.8; p = 0.01) was significantly associated with IR risk. Mean M1 length seemed to be shorter in the IR group although not statistically significant (16.2 mm ± 5.1 vs. 11.5 mm ± 4.8; p = 0.053). Mid-term outcome was favorable for all patients at last follow-up but was worsen in case of short preaneurysmal M1 segment (10.7 mm ± 4.8 vs. 16.4 mm ± 5.3, p = 0.02). Complete aneurysm occlusion was achieved for sixty-nine patients (95.5%) with 6.9% of early postoperative complications. ConclusionsThe microsurgical treatment of unruptured MCA aneurysm was associated with favorable mid-term outcome in all patients and high rates of complete occlusion. Aneurysm size was significantly associated with the intraoperative rupture risk for unruptured MCA aneurysm and patients with a short preaneurysmal M1 segment seemed to have a greater risk of intraoperative rupture although not statistically significant. Short preaneurysmal M1 patients had worsen mid-term outcome.

Microsurgical treatment of ophthalmic artery aneurysm, a case series of 55 patients with long-term follow-up

BackgroundOphthalmic artery aneurysm (OAA) can be secured in endovascular or microsurgical approaches. Still there are controversies in technique selection and their long term outcomes.MethodsAll the patients with OAA were treated microsurgically and followed. Demographic data, neurological status, physical examination findings, angiographic data, operation details, and intraoperative and postoperative events were recorded and analyzed. P < 0.05 was considered significant.ResultsAmong 55 patients, 38 were females (69.1%). Median preoperative glasgow coma scale (GCS), Fisher Grade, and Hunt and Hess(HH) scores were 15, 1 and 1, respectively. The most common neurologic manifestation was visual problems (n = 15). The most common anatomical projection was medial (43.6%) oriented lesions. 85.5% of them only had 1 ophthalmic aneurysm while multiple aneurysms were reported in 14.6%. In 52 patients temporary clip was used. in 21 patients (38.2%) intraoperative aneurysm rupture occurred. Larger aneurysm size and preoperative hydrocephalus were associated with higher rates of aneurysm rupture (P = 0.003 and 0.031). 28.5% of the patients with visual problems had clinical improvement in the postoperative period. The mean follow-up period was 5 years. Follow-up angiography showed a 100% obliteration rate with a 0.0% recurrence rate. Median values for follow-up glasgow outcome scale and modified Rankin scale were 5 and 0, respectively. favorable neurological outcomes were associated with better primary GCS and HH scores.ConclusionOAA microsurgery is an effective and safe procedure with significant improvement in both visual and neurological status. Low recurrence rate and excellent clinical recovery are the most important advantages of microsurgery in OAA treatment.

The Art of Cerebral Revascularization: An Illustrative Case Series of Bypass Techniques for Complex Intracranial Aneurysms

Complex intracranial aneurysms (CIAs) comprise a subset of lesions with defiant vascular architecture, difficult access, and prior treatment. Surgical management of CIAs is often challenging and demands an assessment on a case-by-case basis. The generational evolution of bypass surgery has offered a long-standing potential for effective cerebral revascularization. Herein, we aim to illustrate a single-center experience treating CIAs. The authors conducted a retrospective analysis of clinical records of patients treated with cerebral revascularization techniques at Hospital Nacional Dos de Mayo, Lima, Peru, during 2018-2022. Relevant data were collected, including patient history, aneurysm features on imaging, preoperative complications, the intraoperative course, aneurysm occlusion rates, bypass patency, neurological function, and postoperative complications. Seventeen patients (70.59% female; median age: 53years) with 17 CIAs (64.7% saccular; 76.5% ruptured) were included. The most common clinical presentation included loss of consciousness (70.6%) and headaches (58.8%). Microsurgical treatment included first-, second-, and third-generation bypass. In 47.1% of cases, an anastomosis between the superficial temporal artery and the M3 segment was predominantly used, followed by an A3-A3 bypass (29.4%), a superficial temporal artery-M2 bypass (17.6%), and an external carotid artery to M2 bypass (5.9%). The intraoperative aneurysm rupture rate was 11.8%. Postoperative complications included ischemia (40%), cerebrospinal fluid fistulas (26.7%), and pneumonia (20%). At hospital discharge, the median Glasgow Coma Scale score was 14 (range: 10-15). At the 6-month follow-up, 82.4% of patients had a modified Rankin Scale score ≤2, bypass patency was present in all cases, and the morbidity rate was 17.6%. CIAs represent a spectrum of defiant vascular lesions with a poor natural history. Bypass surgery offers the potential for definitive treatment. Our case series illustrated the predominant role of cerebral revascularization of CIAs with a critical case-by-case approach to provide optimal outcomes in a limited-resource setting.

Surgical Outcome of Vestibular Schwannoma in a Tertiary Care Hospital, Dhaka

Background: Presenting symptoms, treatment considerations, and outcome are strongly related to the extension of vestibular schwannomas (VS). The aim of the current retrospective study was to analyze the clinical features, microsurgical treatment, and outcome of VS with brainstem compression. Methods: 130 patients presented with VS who had undergone operative procedures performed in our unit from Jan, 2017 to may, 2022. The facial nerve function and hearing assessment was done according to House-Brackmann [HB] grading and pure tone audiometry (PTA) respectively. All patients were operated by retro-sigmoid retromastoid sub-occipital approach. Results: Most patients had large tumors and had no useful hearing (75.38%), had disabling cerebellar ataxia (84.61%) and presented with features of raised intracranial pressure (46.15%). Complete tumor excision was carried out 92.30% and anatomical preservation of facial nerve was achieved in 87.50% cases. Hearing preservation was achieved in eight patients. Cerebrospinal fluid leak with or without meningitis and transient lower cranial nerve paresis were common complications. The mortality rate was 7.69% Conclusions: Complete tumor excision with good facial nerve preservation can be achieved in large vestibular schwannomas. Hearing preservation is difficult in larger tumors. Primary microsurgical resection is an appropriate management option for large VS. In our experience, this goal can be achieved safely and successfully by using the retromastoid retrosigmoid sub-occipital approach. Bang. J Neurosurgery 2023; 12(2): 86-93

Dolichoectatic Posterior Inferior Cerebellar Artery Aneurysm Treated With Excision and Posterior Inferior Cerebellar Artery Double Reimplantation Bypass: 2-Dimensional Operative Video.

Posterior inferior cerebellar artery (PICA) aneurysms account for 0.3% of all intracranial aneurysms, and they commonly present with a complex fusiform morphology that necessitates unique bypass strategies.1-5 An adolescent boy with a familial predisposition to aneurysmal subarachnoid hemorrhage was identified as harboring a fusiform aneurysm of the right distal PICA, characterized by 2 outflow branches. Our recommended treatment strategy involved a right far lateral craniotomy, followed by P1 PICA reanastomosis and P2 PICA reimplantation. Informed written consent was obtained. On exposure, the aneurysm was trapped, and the inflow and 2 outflow PICA branches were excised. Revascularization was established through a P1 PICA end-to-end reanastomosis using running continuous suturing techniques, followed by P2 PICA end-to-side reimplantation into a more distal portion of PICA. Subsequent indocyanine green videoangiography confirmed patency of the P2 PICA reimplantation; however, the initial P1 PICA reanastomosis was noted to be thrombosed. After several unsuccessful attempts to dissolve the thrombus, the decision was made to proceed with a P2 PICA side-to-side in situ reimplantation into the V4 segment of the vertebral artery. Indocyanine green videoangiography and postoperative digital subtraction angiography confirmed patency of the PICA double reimplantation bypass. The patient tolerated the procedure well and was discharged home at his neurological baseline. This video showcases the microsurgical treatment of a complex dolichoectatic, distal PICA aneurysm using a double reimplantation technique, in addition to highlighting bypass decision-making processes for managing complex PICA aneurysms.

Current State of Microsurgical Treatment of Aneurysms of the Ophthalmic Segment of the Internal Carotid Artery

Current State of Microsurgical Treatment of Aneurysms of the Ophthalmic Segment of the Internal Carotid Artery

Preoperative Angiographic Protocol for the Surgical Management of Spinal Dural Arteriovenous Fistulas: A Technical Nuance for Safe Minimally Invasive Surgery

BackgroundInterruption of the fistoulus point is the goal of the treatment of spinal dural arteriovenous fistula (dAVFs). Microsurgery still represents a highly efficient treatment in terms of complete occlusion with the lowest risk of recurrence rate. It is reported that the hardest step consists in finding the fistulous site itself, potentially extending surgical access and time, and increasing potential post-operative surgical-related complications. The accurate preoperative detection of the shunt and spinal level together is crucial for guiding optimal, fast and safe microsurgical treatment. MethodsIn the present paper, the authors describe a preoperative angiographic protocol for achieving a safe and simple resection of spinal dAVFs based on a six-year Institutional experience of forty-two patients who underwent minimally invasive. Two illustrative cases are also included in order to support the technical descriptions. ResultsThe suspected artery associated to the vascular malformation of interest is studied in our angiographic protocol through non-subtracted selective acquisitions in the lateral projection. The resulting frames are reconstructed with 3D Rotational Angiography. The implementation of the preoperative angiographic protocol allowed 100% of intraoperative identification of the fistoulus point in all cases with the use of minimally invasive approach. ConclusionsNowadays, neurosurgeons advocate for minimally invasive procedures and low morbidity risk procedures for the treatment of spinal dAVFs.Our preoperative approach for accurate angigoraphic localization of the fistoulus point through non-subtracted and 3D reconstructed angiography allowed to achieve safe and definitive occlusion of the shunt.

The role of surgical disconnection for posterior fossa pial arteriovenous fistulas and dural fistulas with pial supply: an illustrative case series.

Pial arteriovenous fistulas (pAVFs) are rare vascular malformations characterized by high-flow arteriovenous shunting involving a cortical arterial supply directly connecting to venous drainage without an intermediate nidus. Dural arteriovenous fistulas (dAVFs) can infrequently involve additional pial feeders which can introduce higher flow shunting and increase the associated treatment risk. In the posterior fossa, arteriovenous fistula (AVF) angioarchitecture tends to be particularly complex, involving either multiple arterial feeders-sometimes from both dural and pial origins-or small caliber vessels that are difficult to catheterize and tend to be intimately involved with functionally critical brainstem or upper cervical cord structures. Given their rarity, published experience on microsurgical or endovascular treatment strategies for posterior fossa pAVFs and dAVFs with pial supply remains limited. Retrospective chart review from 2019-2023 at a high-volume center identified six adult patients with posterior fossa pAVFs that were unable to be fully treated endovascularly and required microsurgical disconnection. These cases are individually presented with a technical emphasis andsupported by comprehensive angiographic and intraoperative images. One vermian (Case 1), three cerebellopontine angle (Cases 2-4) and two craniovertebral junction (Cases 5-6) posterior fossa pAVFs or dAVFs with pial supply are presented. Three cases involved mixed dural and pial arterial supply (Cases 1, 4, and 6), and one case involved a concomitant microAVM (Case 2). Endovascular embolization was attempted in four cases (Cases 1-4): The small caliber and tortuosity of the main arterial feeder prevented catheterization in two cases (Cases 1 and 3). Partial embolization was achieved in Cases 2 and 4. In Cases 5 and 6, involvement of the lateral spinal artery or anterior spinal artery created a prohibitive risk forendovascular embolization, and surgical clip ligation was pursued as primary management. In all cases, microsurgical disconnection resulted in complete fistula obliteration without evidence of recurrence on follow-up imaging (mean follow-up 27.1 months). Two patients experienced persistent post-treatment sensory deficits without significant functional limitation. This illustrative case series highlights thetechnical difficulties and anatomical limitations of endovascular management for posterior fossa pAVFs and dAVFs with pial supply and emphasizes the relative safety and utility of microsurgical disconnection in this context. A combined approach involving partial preoperative embolization-when the angioarchitecture is permissive-can potentially decrease surgical morbidity. Larger studies are warranted to better define the role for multimodal intervention and to assess associated long-term AVF obliteration rates in the setting of pial arterial involvement.