Superior Cerebellar Research Articles

Observational studies on the efficacy of carbamazepine and ascorbyl palmitate in managing trigeminal neuralgia.

Ascorbyl palmitate is a fat-soluble ester of vitamin C and is used as an antioxidant food additive. While literature reports that ascorbyl palmitate can prevent exacerbation of pain and improve the quality of life of patients suffering from pain, this is not yet supported by clinical trial data. Our study aimed to investigate the effectiveness of ascorbyl palmitate in managing trigeminal neuralgia. This study was carried out in a single-centre clinical trial in which subjects suffering from trigeminal neuralgia (N=11) were included. All patients were on carbamazepine when first included and, after washout period, received Ascorbyl palmitate. Eligible patients had the most severe trigeminal neuralgia pain in the oral cavity or pain on touching trigger zones, aged 20 years or older, were capable of proper assessment of the severity of pain and their condition, and had experienced multiple episodes of intraoral pain for at least 3 months with a pain intensity of more than 4 points on the numerical rating scale. The Brief Pain Questionnaire was used to evaluate patient's quality of life. A total of 11 patients were included with a mean age 55.36±10.67 years (7 males, 4 females). Most patients had compression by the superior cerebellar artery and vascular loops upon magnetic resonance examination. The mean numerical rating scale score for carbamazepine after one month was 7.9±0.56 (95% CI 7.49, 8.30). Similarly, for ascorbyl palmitate was 5.5±1.50 (95% CI 4.42, 6.57) (p<0.001). Ascorbyl palmitate can be used as an adjunct intervention in managing trigeminal neuralgia pain. According to the results, ascorbyl palmitate prevents frequent exacerbation of pain and improves patient quality of life.

Optoacoustic imaging of the glymphatic system

Background: The glymphatic system is a brain waste clearance system mediated via cerebrospinal fluid (CSF) flow,1 with implications for influence on neurodegenerative diseases.2 Most preclinical glymphatic studies employ fluorescence imaging, which provides higher specificity, but a smaller field-of-view (FOV), or magnetic resonance imaging (MRI), which provides brain-wide FOV, but lower specificity. Functional optoacoustic neuro-tomography3 (FONT) offers a larger FOV compared to classical optical methods, and higher specificity compared to MRI. However, FONT has not yet been applied to probe the glymphatic system. In this study, we used fluorescence and optoacoustic imaging of a near-infrared dye, Janelia Fluor 669 (JF669), to track CSF and multimodal CSF-hemodynamic flows in mice.&#x0D; Methods: After observing strong fluorescence and optoacoustic signatures of JF669 in phantom experiments, we performed a series of in vivo experiments in isoflurane-anesthetized C57BL/6 mice (n=3 fluorescence and n=4 FONT experiments, respectively) (Figure 1A). The lumbar injection was applied to deliver JF669 at a rate of 2 µL/min for 30 minutes. A polyethylene tube was placed intrathecally at the lumbar region (L4-L5). The scalp was removed. Fluorescence or FONT images were obtained every 5 minutes after injection.&#x0D; Results: Fluorescence imaging and FONT probe CSF flow Images (Figure 1B) and time traces (Figure 1C) revealed time-dependent anatomical routes of paravascular influx, including the transport along the olfactory artery (OFA), superior cerebellar artery (SCA), and bilateral middle cerebral artery (MCA). For FONT imaging, since the OFA showed strong fluorescence (Figure 1B), we positioned the ultrasound transducer array at the anterior of the mouse brain with a FOV of 5x5 mm2 (Figure 1A). Standard filtered back-projection reconstruction was applied. Besides the OFA route of the paravascular influx, the dynamic images (Figure 1D) and time-traces (Figure 1E) also revealed time-dependent anatomical routes of CSF-interstitial fluid (ISF) exchange in the olfactory bulb (OFB) and paravascular efflux in the superior sagittal sinus (SSS) and the bilateral inferior cerebral vein (ICV). Next, we studied the aquaporin-4 (AQP4) dependence of glymphatic flow by subcutaneously injecting AQP4 inhibitor TGN020, in addition to the prior procedures. Under fluorescence imaging and FONT, we observed that TGN020 significantly decreased and spatially restricted the spread of JF669 in the brain. FONT spectral unmixing separates CSF and blood We swept the OPO through 680 nm to 750 nm, with 10 nm steps at 10 Hz in the phantom and in each animal. The multispectral reconstructions were unmixed using the known absorption spectra of hemoglobin and the JF669 OA spectrum obtained from the phantom.4 This enabled the separation of blood and JF669 signal (Figure 1D).&#x0D; Conclusions: We characterized anatomical routes of paravascular influx (OFA), CSF-ISF exchange (OFB) and paravascular efflux using FONT, while fluorescence imaging only enabled visualization of the paravascular influx. We thus demonstrated the feasibility and advantages of FONT for probing the glymphatic system. These findings present great opportunities for monitoring and understanding the glymphatic system during development, aging, disease, pharmacological interventions and genetic modifications.

Occlusion type and posterior communicating artery patency may predict favorable outcome after endovascular thrombectomy in selective basilar top occlusion.

The top of the basilar artery is a five-branched junction, consisting of two superior cerebellar arteries (SCAs), two posterior cerebellar arteries (PCAs), and the basilar artery itself. This study aimed to investigate prognostic factors in patients with selective acute basilar top occlusion managed with mechanical thrombectomy, focusing on occlusion type and posterior communicating artery (PCoA) patency. Eligible patients who underwent endovascular treatment (EVT) for acute basilar top occlusion were reviewed. Patterns of basilar top occlusion were categorized as types I-III according to whether the SCA and PCA were visible on angiography. The PCoA was categorized as hypoplastic or non-visible (type I), normal patency but non-visible PCA through PCoA flow (type II), and fetal type (type III). Good outcomes were observed in 50% (21/42) and mortality in 11.9% (5/42) of the cases at 90 days. Patients with good outcomes showed lower baseline National Institutes of Health Stroke Scale (NIHSS) score (P = 0.001) and a higher proportion of type III basilar top occlusion (P = 0.004) and type III PCoA (P = 0.001). Multivariable logistic analysis showed that baseline NIHSS score [odds ratio (OR), 0.84; 95% confidence interval (CI), 0.73-0.97; P = 0.017) and type III PCoA (OR, 21.54, 95% CI, 1.33-347.97; P = 0.031) were independent predictors of good functional outcomes. A low initial NIHSS score and good PCoA patency were independent predictors of favorable clinical outcomes after EVT in patients with acute basilar top occlusion. Furthermore, the favorable outcome group showed a high proportion of type III basilar top occlusions.

Outcomes of Arterial Bypass for Posterior Circulation Atherosclerosis: A Case Series.

Extracranial-intracranial bypass is an effective treatment option for moyamoya disease and in well-selected cases of anterior circulation intracranial atherosclerotic disease; however, the effectiveness of bypass is less evident in posterior circulation atherosclerosis. Updated surgical techniques and clinical guidelines necessitate modern appraisal of arterial bypass for symptomatic patients with posterior circulation atherosclerotic disease who are refractory to medical management. To evaluate the complications, graft patency, and postoperative outcomes of arterial bypass for posterior circulation intracranial atherosclerotic disease. Perioperative records of consecutive bypass patients were retrospectively evaluated to determine the clinical course and surgical outcomes. Arterial bypass was performed in 8 cases with a median age of 62 years. All 8 patients underwent direct bypass with an autologous occipital artery donor vessel. Recipient vessel selection varied on a case-by-case basis, with the superior cerebellar artery used in 4 cases, the posterior inferior cerebellar artery in 3 cases, and the anterior inferior cerebellar artery in 1 case. There were no significant intraoperative or postoperative complications. Postoperatively, all 8 patients displayed clinical improvement of their preoperative symptoms, with a significant decrease of 2.5 points on the modified Rankin Scale (P < .001). Postoperative imaging confirmed full graft patency in 7 patients and partial patency in 1 patient. Excellent postoperative outcomes and no major complications after posterior circulation arterial bypass for intracranial atherosclerotic disease highlight the utility of this intervention for the treatment of medically refractory or symptomatic posterior circulation intracranial atherosclerotic disease. Larger studies may be valuable to validate these findings.

ODP334 Must we Wait for the Development of Metastasis to be Able to Distinguish Dopamine Resistant Aggressive Prolactinoma from Prolactin Producing Pituitary Carcinomas? Case Report and Literature Review

Abstract Background Prolactinomas, the most prevalent type of neuroendocrine disease, account for approximately 40% of all pituitary adenomas. In the vast majority of cases, these are benign tumors with excellent clinical response to medical therapy with dopamine agonist agents such as bromocriptine and cabergoline. Rarely medical treatment fails to normalize prolactin levels and/or decrease the size of the tumor, posing a challenge to the clinician. Case presentation 40-year-old man who underwent resection of a 7.4 cm pituitary prolactinoma via frontal craniotomy followed by radiotherapy. He developed panhypopituitarism and was placed on chronic hormonal replacement therapy plus high dose cabergoline. Two years later he presented with recurrence of his disease and was diagnosed with an unresectable 4.9 cm pituitary adenoma showing cortical breakthrough of the sellar floor, invasion into the optic chiasm, erosion of the posterior sphenoid walls, extension into the sphenoid sinuses and posteriorly into the pons, midbrain and third ventricle, as well as complete encasement of the distal, superior cerebellar and posterior cerebral arteries. The patient underwent endoscopic trans sphenoidal partial tumor resection and CSF leak repair. Pathology revealed a pituitary prolactinoma with Ki-67 of up to 8% and positive p53 immunostaining. His cabergoline dose was adjusted to 0.5 mg PO daily and he was also started on Sandostatin 20 mg IM monthly as well as appropriate hormonal replacement of the other deficient pituitary hormonal axes. Follow up imaging revealed stability of the lesion. The patient continues to do clinically well and actively follows with endocrinology and neurosurgery with serial brain MRIs and laboratory workup. Discussion The histological and biochemical characteristics of aggressive prolactin secreting tumors has been reported to be of minimal utility in distinguishing benign from malignant lesions. Tumors can only be diagnosed as carcinomas after they have metastasized and they can only be classified as aggressive after treatment failure or unusual growth, which creates a disadvantage for the prognosis and management of these patients. Clinicians are in need of better guidelines that can help them identify the rare cases that might warrant more aggressive clinical interventions beyond dopamine agonists such as surgery, radiation, temozolomide, somatostatin receptor agonists and others, with the hope of delaying or preventing the development of metastasis. Case reports of atypical presentations of aggressive prolactinomas such as the one here presented, can help broaden our understanding of the predictable signs of poor prognosis. Presentation: No date and time listed

Endovascular treatment of challenging aneurysms with FRED Jr flow diverter stents: a single-center experience.

To analyze clinical safety and efficacy of flow re-direction endoluminal device (FRED) Jr flow diverter for treatment of unruptured, ruptured, or recanalyzed aneurysms. Between October 2019 and February 2022, 25 patients with 31 aneurysms treated with FRED Jr were included in the study. Clinical and radiological records, procedural details, and follow-up outcomes were retrospectively evaluated. Eighteen (72%) patients were female. Median age was 48.8 (age range 9-85). Mean follow-up was 21months (6-28months). Location of the aneurysms were as follows; 13 in middle cerebral artery (MCA), 7 in anterior cerebral artery (ACA), 4 in posterior cerebral artery (PCA), 3 in true posterior communicating artery (PCom), 2 in anterior communicating artery (ACom), 1 in superior cerebellar artery (SCA), 1 in true ophthalmic artery. Five patients (20%) presented with acute subarachnoid hemorrhage (aSAH). In all procedures, FRED Jr was successfully deployed. Three true Pcom aneurysms and a true ophthalmic aneurysm were treated with FRED Jr. Three patients with two adjacent aneurysms were treated with a single FRED Jr. In two (8%) patients in-stent thrombosis occurred intraoperatively, they were treated with iv tirofiban and thrombectomy without any sequelae. Post-discharge 2weeks later, intraparenchymal hemorrhage occurred in a patient. He was treated with surgical drainage, the clinical course was modified Rankin score (mRS) 2. Digital subtraction angiography (DSA) was performed on 16 (64%) patients with 21 (67%) aneurysms. Near complete-complete occlusion (O'Kelly-Morata grading scale (OKM C-D) was documented in 15/16 (93.7%) patients, 20/21 (95.2%) aneurysms. In nine (36%) patients, no residual filling was observed in the magnetic resonance angiography (MRA). Good clinical outcome (mRS 0-1) was achieved in 24/25 (96%) of patients. Endovascular treatment of small cerebral aneurysms with FRED Jr is safe and effective even in complex and challenging morphologies allowing high rates of aneurysm occlusion with low periprocedural complications. Our cohort, consisting of a rate 20% acute ruptured aneurysms, is the major additive data to the published literature.

Rare case of trigeminal neuralgia due to vascular compression presenting with severe headache – A case report

Trigeminal neuralgia (TN) is a nerve disorder of the face. Tic douloureux is another name for it. It is regarded to be among the most severe human illnesses. A 55-year-old elderly female with a migraine background appeared with a severe headache and terrible intermittent ache on the left part of her face for the previous 3 weeks. Migraine medicines and over-the-counter analgesics did not ease the agony. A magnetic resonance imaging scan with contrast demonstrated direct contact between the superior cerebellar artery and the trigeminal nerve on the left face. Oral medicine is the primary way of management for TN due to its non-invasiveness, minimal price, and effectiveness rate. Surgical therapy for TN tries to release the strain of the problematic artery or vein pressing the trigeminal nerve, halting the uncontrolled pain impulses. A crucial requirement for TN diagnosis is pain that cannot be ascribed to any other scenario and the absence of any apparent CNS pathology. Patients will be relieved from discomfort and unneeded dental and medical therapy if they receive an early, accurate diagnosis, and formulate an ideal therapy plan based on their age and general health. This article aims to present a case of classical TN caused by vascular compression that presented with severe headache and was successfully treated with microvascular decompression surgery.

A Combination of 3D TOF MRA and FIESTA Predicts Surgery-Needed Primary Trigeminal Neuralgia and Specific Offending Vessels.

To investigate the predictive accuracy of three-dimension (3D) time-of-flight (TOF) MR angiography (MRA) and 3D Fast Imaging Employing Steady-state Acquisition (FIESTA) techniques in assessing neurovascular compression (NVC) with specific vessels in patients with primary trigeminal neuralgia (TN). Patients with single-site primary TN undergoing microvascular decompression (MVD) were retrospectively recruited. All patients had available preoperative magnetic resonance imaging (MRI) scans. A quantitative NVC scoring system was applied to assess the severity of NVC on MRI. The radiological findings were correlated with the intraoperative result to determine the diagnostic accuracy of MRI techniques. Besides, the radiological indicator of MVD was determined. Seventy-three TN patients were recruited. Thirty-three patient had bilateral NVC but with unilateral neuralgia. The average NVC score of the asymptomatic side was significantly lower than that of the symptomatic side (1.6 vs. 6.7; p < 0.001). A cut-off value of NVC >4 was determined as a radiological indicator of MVD with sensitivity and specificity of 82.2% and 98.6%, respectively Area Under Curve (AUC = 0.97; p < 0.001). Approximately 90% of symptomatic patients had the distance to REZ ≤3 mm. 68.5% of patients had a single conflicting vessel, and superior cerebellar artery (SCA) was the predominate vessel (46.6%). The sensitivity and specificity of MRI to detect NVC were 95.8% and 100%, respectively. Regarding each vessel, the cohen's kappa statistic (K) was 0.632 overall. 3D TOF MRA and FIESTA show an overall good ability to predict specific offending vessels. NVC score >4 is identified to predict TN, suggestive of subsequent surgical treatment.

A study on trigeminal nerve: Does superior cerebellar artery causes trigeminal neuralgia

Our brain is the most complex organ in our body which conducts various complex functions and this level of complexity is operated by different structures of the brain. The complexity of relaying information between brain and different parts of the body is conducted by 12 pairs of cranial nerves. Out of 12 pairs of cranial nerves, the most complex and largest nerve is know as trigeminal nerve which is responsible for sensation of face and motor functions such as biting and chewing. Sometimes due to offendation of this nerve typically by Superior Cerebellar Artery leads to most excruciating painful disorder humanity have ever witnessed.: A systemic self-study was planned to determine and review with proper enlightenment on the existing facts to find the root sources of trigeminal neuralgia.This article discussed and focused on the exact cause of trigeminal neuralgia it’s association with Superior Cerebellar Artery along with descriptive analysis on the available treatments for this disorder. We concluded with the fact that based on our thorough review and analysis Superior Cerebellar Artery is the main artery which typically causes world’s most excruciating painful Suicide Disease.

Oculomotor nerve segment between proximal posterior and superior cerebellar arteries: an MRI study.

No study has documented the oculomotor nerve (OMN) segment lying between the posterior cerebral (PCA) and superior cerebellar (SCA) arteries adjacent to the brainstem. The present study aimed to characterize it. A total of 71 patients underwent thin-sliced, sagittal T2-weighted magnetic resonance imaging for analysis. The OMN segments lying between the PCA and SCA were identified in all patients. The OMN segment in relation to the PCA and SCA was classified into five types. Of them, the PCA-OMN contact type was the most frequent and found in 35.2% of 71 sides on the right and 39.4% on the left. Also, the PCA-OMN compression type was identified in 12.7% on the right and 15.5% on the left. In these types, the mean distance between the brainstem and contact/compression sites were measured 4.4 ± 2.3mm on the right and 4.4 ± 1.6mm on the left. In more than forty percent, the sites were located at the level of the pontomesencephalic junction. The OMN may be frequently in contact with the PCA near the brainstem. The site located more distal than the central-peripheral myelin junction of the OMN can attribute to a low frequency of neurovascular compression syndrome of the nerve.

Effect of the anastomosis between the posterior inferior cerebellar artery and the superior cerebellar artery on outcomes of acute basilar artery occlusion after endovascular treatment

BackgroundThe effects of secondary collateral compensation on outcomes remain unclear in patients with acute basilar artery occlusion (BAO) after endovascular treatment (EVT). This study aimed to evaluate the benefits of...

Microvascular triple decompression for combined simultaneous trigeminal neuralgia, hemifacial spasm, and pulsatile tinnitus due to separate offending vessels

Neurovascular compression syndrome is generally caused by vascular compression at the root entry or exit zone of the corresponding cranial nerve. Trigeminal neuralgia is the most frequent syndrome, followed by hemifacial spasm. Despite ongoing debate in the literature, pulsatile tinnitus is also known to be a neurovascular compression syndrome resulting from vascular compression of the vestibulocochlear nerve. Combined manifestations of neurovascular compression symptoms are very rare. We report a case with a simultaneous manifestation of trigeminal neuralgia, hemifacial spasm, and pulsatile tinnitus as neurovascular compression syndrome with separate offending vessels. A 53-year-old female presented with lancinating pain in the left face, left hemifacial spasm, and ipsilateral pulsatile tinnitus for 2 years. Trigeminal neuralgia and hemifacial spasm were diagnosed after a neurological examination, imaging study, and electromyography. Microvascular decompression via a retrosigmoid approach for separate offenders, including the superior cerebellar artery, anterior inferior cerebellar artery, and posterior inferior cerebellar artery was performed using Teflon sponges. The patient’s hemifacial spasm, pulsatile tinnitus, and hemifacial pain improved immediately after microvascular decompression.

Incidence and clinical features of acute multiple small cerebellar infarction

ObjectiveTo investigate the clinical and imaging features and to identify possible etiology of acute multiple small cerebellar infarction (MSCI). MethodsWe retrospectively enrolled 220 patients with acute cerebellar infarction, divided them into MSCI and large cerebellar infarction (LCI) groups, according to the quantity and size of lesions confirmed by MRI analysis. Clinical and imaging features were compared between the two groups to explore the possible etiology and pathogenesis. ResultsAmong 220 patients, 90 patients presented MSCI symptoms. The proportions of extracerebellar lesions (P = 0.001) and bilateral infarction (P = 0.001) in the MSCI group were higher than those in the LCI group. No significant differences were found in terms of age, gender, and common vascular risk factors between the two groups. The proportions of vertigo and headache in the MSCI group were significantly lower than those in the LCI group (P < 0.000 and 0.034, respectively), and limb weakness was significantly higher (P = 0.039) in the MSCI patients. Moreover, the proportions of nystagmus and ataxia in the MSCI group were significantly lower than those in the LCI group (P < 0.043 and 0.003, respectively). The MSCI group had higher proportions of ACA and MCA stenosis, while the proportion of posterior circulation stenosis was similar between the two groups. Infarctions involving the posterior inferior cerebellar (PICA) region and mixed territories were far more frequent than those involving the anterior inferior cerebellar artery (AICA) region and superior cerebellar artery (SCA) territory (P < 0.05). Large-artery atherosclerosis and multiple plus undetermined etiology were the main etiological factors of MSCI. ConclusionIn patients with acute cerebellar infarction, 30% of patients presented with MSCI. MSCI and LCI showed similar vascular risk factors and vascular stenosis in the posterior circulation system. Patients with MSCI should pay more attention to evaluating anterior circulation vessels’ anatomy. Large-artery atherosclerosis was the main pathogenesis of acute MSCI. Assessment of cerebral vessels might be critically required in patients with MSCI complicated atrial fibrillation.

Microsurgical Anatomy of the Cerebellar Interpeduncular Entry Zones

The cerebellar interpeduncular region, particularly the middle cerebellar peduncle (MCP) and interpeduncular sulcus (IPS) are significant surgical relevance areas due to the high prevalence of vascular and tumoral pathologies, such as cavernomas, arteriovenous malformations, and gliomas. We defined safer access areas of the MCP and the IPS, according to the surface anatomy, involved vessels, and fiber tracts of the cerebellar interpeduncular region. Fifteen formalin-fixed and silicone-injected cadaveric heads and 23 human brainstems with attached cerebellums prepared with the Klingler's technique were bilaterally dissected to study the vascular and intrinsic anatomy. Surface anatomy: The mean length of the IPS was 12.73mm (standard deviation [SD],2.15mm), and the average measured angle formed by the IPS and the lateral mesencephalic sulcus was 144.53°. The mean distance from the uppermost point of the IPS to cranial nerve IV was 2.63mm (SD, 2.84mm). Vascular anatomy: The perforating branches of the superior cerebellar peduncle, IPS, and MCP originated predominantly from the caudal trunk of the superior cerebellar artery. The inferior third of the superior cerebellar peduncle and IPS was the third most pierced by perforating arteries, and for the MCP, was its superior third. Crossing vessels: The branches of the pontotrigeminal vein and the caudal trunk of the superior cerebellar artery crossed the IPS mostly. The superior third of the IPS was the most crossed by arteries and veins. The middle thirds of the IPS and MCP as entry zones might be safer than their superior and inferior thirds due to fewer perforating branches, arterial trunks, and veins crossing the sulcus as fewer eloquent tracts.

Vertebrobasilar artery elongation in migraine—a retrospective cross-sectional study

BackgroundNumerous but inconclusive findings have sparked an ongoing debate about whether the arteries of migraine patients undergo vascular alterations. The outlet angle of the superior cerebellar artery (SUCA) and the lateral displacement of basilar arteries are good surrogate parameters for determining elongation of the vertebrobasilar arteries.MethodsWe retrospectively determined the SUCA outlet angle and the lateral displacement of the basilar artery in 63 patients with migraine (30.6 ± 8.9 years, 84% women, 16% chronic migraine, 60% migraine with aura) and compared these with 126 age- and sex-matched control subjects.ResultsIn patients with migraine, the SUCA outlet angle was lower (159 ± 26° vs. 169 ± 29°, p = 0.020) and the lateral displacement of the basilar artery was greater (3.7 ± 2.7 mm vs. 2.8 ± 2.4 mm, p = 0.020) than in the control subjects. Age, gender, migraine characteristics and presence of any cardiovascular risk factors did not affect the SUCA outlet angle or lateral displacement of the basilar artery.ConclusionMigraine patients exhibited a lower SUCA outlet angle and greater lateral displacement of the basilar arteries. Both may be attributable to the elongation of the vertebrobasilar arteries, which is an indication of arterial wall pathology in migraine.

The majority of ruptured aneurysms are small with low rupture risk scores

BackgroundUnderstanding the rupture risk of unruptured intracranial aneurysms has important clinical implications given the morbidity and mortality associated with subarachnoid hemorrhage (SAH). The ISUIA, UCAS, and PHASES studies provide rupture risk calculations. ObjectiveWe apply the risk calculations to a series ruptured intracranial aneurysms to assess the rupture risk for each aneurysm (had they been discovered in the unruptured state). MethodsThis is a retrospective study of 246 patients with SAH from a ruptured saccular aneurysm. The ISUIA, UCAS, and PHASES calculators were applied to each patient/aneurysm to demonstrate a theoretical annual risk of rupture dichotomized by aneurysm location. ResultsThe average diameter of the aneurysms was 5.5 ± 3.1 mm. Three quarters (75%) of the aneurysms measured <7 mm and 48.8% were <5 mm. The anterior communicating artery (Acomm) was the most common location of rupture (24.7%). Posterior communicating artery aneurysms (Pcomm) were the third most common at 16.2%. The average ISUIA 1-year rupture risk was 0.46 ± 0.008%. The average UCAS 1-year rupture risk was 0.93% ± 0.01. The annualPHASESrupture risk was0.32 ± 0.004%. The highest risk locations were the vertebral artery (up to 10.3% per year) and superior cerebellar artery (up to 2.7% per year). On average, Acomm aneurysms had 1 year risk no higher than 1.1% and Pcomm aneurysms no higher than 1.2% per year. ConclusionWe observed that in a small retrospective series of ruptured aneurysms, the majority were <7 mm and that the theoretical rupture risk of these aneurysms, had they been discovered in the unruptured state, is low (<1% per year). Our study has a number of limitations and these results should be validated in a larger multicenter study.

A single centre case series of microvascular decompression surgery for classical trigeminal neuralgia: functional outcomes and report of a unique conflict

BackgroundMicrovascular decompression surgery for trigeminal neuralgia is now considered the benchmark surgical procedure for intractable trigeminal neuralgia of any variety. The objective of this study is to share our experience in managing classical trigeminal neuralgia with microvascular decompression surgery looking into both immediate and late functional outcomes at 3 and 6 months post op. We also report a unique case of trigeminal neuralgia due to a tributary of the petrosal vein passing through the substance of the trigeminal nerve itself at its root entry zone.ResultsThis study included 20 patients; it showed that microvascular decompression surgery of the trigeminal nerve is an effective method for treatment of classic trigeminal neuralgia (p value < 0.001). The trigeminal root was compressed by the superior cerebellar artery in 75% of patients. A vein contributed to the compression in 45% of patients and was the only compressing vessel in 15%.ConclusionMicrovascular decompression surgery is the treatment of choice in patients with medically refractory trigeminal neuralgia, unless their general condition prohibits it. It’s also worth noting that the normal anatomy of the veins in this region is quite variable and the venous structures causing a neurovascular contact are more or less inconsistent. To the best of our knowledge and despite the wide range and progress in microvascular decompression surgery for trigeminal neuralgia, this is the first reported case in the literature for a neurovascular conflict caused by a vein passing through the trigeminal nerve itself.

Clinical Importance of the Persistent Primitive Trigeminal Artery in Vascular Lesions and Its Role in Endovascular Treatment.

The persistent primitive trigeminal artery (PPTA) extends from the internal carotid artery to the basilar artery between the origins of the anterior inferior cerebellar artery and superior cerebellar artery. PPTAs have complex anatomical characteristics. Salas and Saltzman classifications are most often used in PPTAs. The PPTA can play many roles in vascular lesions, including intracranial aneurysms, brain arteriovenous malformations, trigeminal artery-cavernous fistulas, Moyamoya disease, and large vessel occlusion. For these lesions, surgical treatment is difficult due to the deep location and complex anatomy of the PPTA, but endovascular treatment (EVT) has emerged as a good alternative. Currently, a complete review of the clinical importance of the PPTA in terms of its role in the development and EVT of vascular lesions is lacking. Therefore, we conducted a PubMed search, performed a review of the relevant extracted literature and cataloged our experience with PPTAs. By review, we found that a thorough understanding of the anatomical and angiographic features of this PPTA is of utmost importance when making therapeutic decisions for any of these pathological conditions.

Function of oculumotor, trochlear and abducens nerves in patients with cerebral aneurysms undergoing endovascular treatment

Background. Functional impairment of nerves, which move an eyelid, is a serious problem in patients with aneurysms, especially concerning enlarging number of endovascular procedures on cerebral aneurysms.Aim. To evaluate frequency of malfunction of oculomotor, trochlear, abducens nerves in patients with cerebral aneurysms.Methods. From 2019 to 2021 189 patients with 202 aneurysms underwent endovascular treatment. Location of the aneurysms: cavernous, clinoid and communicating segments of the internal carotid arteries, superior cerebellar arteries, P1 and P2 segments of the posterior cerebral arteries. Patients did not have dislocation syndrome as a result of a stroke. There were 37 male patients and 152 female patients. The age of patients ranged from 17 to 78 years, the mean age was 52±12 years. Distribution of aneurysm location: 42 (21%) – cavernous segment of the internal cerebral artery, 25 (12%) – clinoid segment, 110 (55%) – communicating segment, 18 (9%) – superior cerebellar arteries, 7 (3%) – P1 and P2 segments of the posterior cerebral arteries. Morphologically 11 (5%) of the aneurysms were fusiform, 191 (95%) of the aneurysms were saccular. 43 aneurysms (21%) were embolized with coils, 49 (24%) were treated using assisted coiling (balloon- and/or stent-assistance), 83 (42%) of the aneurysms were treated with flow-diverters. 27 (13%) patients underwent several endovascular procedures, including a combination of aforementioned techniques. Function of oculomotor, trochlear and abducens nerves was evaluated at the admission, during the hospitalization and at the discharge. Follow-up was achieved in 102 (54%) patients with 115 aneurysms, the mean follow-up period in June 2022 is 13 months. Checking cerebral angiography was performed 8months after the operation on the average.Results. In 89 (77%) patients checking cerebral angiography showed complete obliteration of the aneurysms, in 26 (23%) filling part of the aneurysm was found out to be smaller. 11 patients had preoperative oculomotor nerve paresis, after the procedure 1 patient had no oculomotor nerve impairment and made a complete recovery, 2 patients had partial improvement, 7 patients had no changes, in 1 patient paresis worsened. In our group we did not observe any case of trochlear nerve palsy either prior or after the operation during follow-up. 6 patients had preoperative abducens nerve paresis, after the treatment 1 patients had a complete recovery of abducens nerve function, 3 patients had partial improvement, 2 patients had no changes.Conclusion. In patients with cerebral aneurysms without cerebral dislocation as result of a stroke function of trochlear nerve did not suffer either prior or after endovascular treatment. Endovascular treatment in this category of patients may positively affect the oculomotor and abducens nerve impairment, but in rare cases it can lead to deterioration of neurological deficit.

Dolichoectasia of cerebellar arteries is the basis of neurovascular conflict as an etiological factor of classical trigeminal neuralgia in residents of the Rostov region

Objective: to study the formation of neurovascular conflicts of two types in patients with classical trigeminal neuralgia, depending on the influence of the environment of the Rostov region.Materials and methods: a retrospective study of the features of neurovascular conflict was conducted in 175 patients from the Rostov region who suffered from classical trigeminal neuralgia. The diagnosis of a variant of neurovascular conflict was carried out using spiral computed tomography on the device «Philips Ingenuity Core 128» The variant of neurovascular conflict was verified intraoperatively, when performing microvascular decompression of the trigeminal nerve root.Results: neurovascular conflict, both of the first and second types, occurs twice as often in women as in men. The development of the adhesive process in the zone of neurovascular conflict, which brings the root even closer to the artery that injures it, is due to the duration of the pathological process, during which inflammatory diseases of the paranasal sinuses, carious teeth, persistent herpesvirus infection play a significant role.Conclusions: variants of the syntopia of the trigeminal nerve root with the superior cerebellar artery in neurovascular conflict do not depend on environmental factors, and the frequency of occurrence of one type or another, as well as the gender ratio, correspond to the population.