Microsurgical Treatment Strategy of Vertebral Artery Fusiform Aneurysm-From the Standpoint of Hemodynamic Integrity and Perforator Preservation.
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ABSTRACT:
SUBMITTER: Tsunoda S
PROVIDER: S-EPMC8488355 | biostudies-literature |
REPOSITORIES: biostudies-literature
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Project description:Basilar artery perforator aneurysms (BAPA's) are a rare entity. Their natural history and treatment are unclear. We describe the largest BAPA reported thus far in literature in a 64-year-old Caucasian woman. This patient did not present with subarachnoid hemorrhage, but with left hemiparesis due to pontine ischemia. The aneurysm was initially misdiagnosed as a tumoral mass in a referring center. Angiography confirmed the presence of a BAPA and a flow diverter was successfully placed. This case shows us that a BAPA can mimic a tumoral mass and can cause ischemia due to mass effect without having ruptured. Both conservative and flow diverter placement seems viable treatment options. Individual patient characteristics and preferences should be considered in decision-making for treatment.
| S-EPMC8762371 | biostudies-literature
Project description:The mortality and disability rate of patients with ruptured anterior communicating artery (AComA) aneurysm after bleeding is high. Even with the most advanced treatment methods, the incidence of complications remains high. The purpose of the present study was to determine the efficacy of microsurgery via supraorbital eyebrow keyhole approach (SOEK) in clipping ruptured AComA aneurysms. Between September 2010 and October 2018, 543 patients with intracranial aneurysms were admitted to the Department of Neurosurgery of the Third Affiliated Hospital of Sun Yat-Sen University (Guangzhou, China). Among them, 85 patients with ruptured AComA aneurysm and subarachnoid hemorrhage (SAH) underwent microsurgical clipping via the SOEK approach. In those patients, the clipping rate, complications and clinical efficacy of treatment were evaluated. The average age of the patients was 52.69±9.94 years (range, 28-78 years). The proportions of small, medium and large aneurysms were 83.5, 15.3 and 1.2%, respectively. Procedural complications occurred in 9 cases (10.5%). The occlusion rate of the aneurysms was 98.8%. The average follow-up period was 37.9 (±24.5) months. A total of 81.2% of the patients with SAH had a good clinical prognosisat 1 year (modified Rankin scale score, ?2). In conclusion, for a skilled and experienced surgeon, SOEK was indicated to be a safe procedure for the treatment of ruptured AComA aneurysms; it provided sufficient intra-operative exposure and a high clipping rate.
| S-EPMC7401238 | biostudies-literature
Project description:BackgroundIn the endovascular era, most of vertebral artery (VA) and posterior inferior cerebellar artery (PICA) aneurysms were mainly treated with endovascular procedures. This study aimed to demonstrate the microsurgical treatment via the far-lateral approach without C1 laminectomy and its clinical outcomes.MethodsForty-eight patients with VA and proximal PICA aneurysms treated by microsurgery through the far-lateral approach without C1 laminectomy, between January 2016 and June 2021, were retrospectively evaluated.ResultsMost patients (87.5%) presented with subarachnoid hemorrhage. Grading at presentation was poor in 41.7%. The rates of VA dissecting aneurysms, saccular aneurysms of the VA-PICA junction, and true PICA saccular aneurysms were 54.2, 18.7, and 14.6%, respectively. All aneurysms were located above the lower margin of the foramen magnum. The far-lateral approach without C1 laminectomy was successfully used in all patients without residual aneurysms. Various surgical strategies were applied depending on the characteristics of the aneurysm. Good outcomes 3 months postoperatively were achieved in 77.1% and 89.3% for the overall and good-grade groups, respectively.ConclusionsMicrosurgery is a safe and effective treatment of VA and proximal PICA aneurysms. Moreover, the far-lateral approach without C1 laminectomy was adequate and effective for aneurysms located above the lower border of the foramen magnum.
| S-EPMC10209739 | biostudies-literature
Project description:Adequate soft tissue coverage is imperative after any interventions performed to maximize or preserve hand function. Although this can most simply be achieved by primary closure or a skin graft if possible, often a vascularized flap will be preferable, especially if a later secondary procedure is planned. Even moderately sized skin deficits of the upper extremity, and especially if involving the hand itself, can be better covered using a free tissue transfer. Many reasonable options in this regard are available. Muscle perforator flaps, as a relatively new variant of a fasciocutaneous flap, have unique attributes, including availability, diversity, accessibility, large size, and lengthy vascular pedicle, and since no muscle need be included, donor site function is preserved. As is shown here in a series of nine muscle perforator flaps in eight patients, these represent yet another alternative that should be considered if selection of a free flap is indicated to maintain hand function.
| S-EPMC2654958 | biostudies-other
Project description:BackgroundIt is well known that intracranial aneurysms can be associated to fibromuscular dysplasia (FMD). Nevertheless, it is not clear the best treatment strategy when there is an association of giant symptomatic cavernous carotid aneurysm with extensive cervical internal carotid artery (ICA) FMD.Case descriptionWe present the case of 63 year-old right-handed female with hypothyroidism, 1 month history of right-sided pulsatile headache and visual disturbances with feeling of fullness sensation and blurry vision. Her neurological exam showed partial right oculomotor nerve palsy with mild ptosis, asymmetric pupils (right 5 mm and left 3mm, both reactive), and mild exotropia, normal visual acuity. Computed tomography angiogram and conventional angiogram showed 2.5 × 2.6 × 2.6 cm non-ruptured aneurysm arising from cavernous segment of the right ICA. She had right hypoplastic posterior communicant artery, and collateral flow through anterior communicant artery during balloon test occlusion and the presence of right cervical ICA FMD. The patient was started on aspirin. After lengthy discussion of treatment options in our neurovascular department, between observations, endovascular treatment with flow diverter device, or high flow bypass, recommendation was to perform high flow bypass and patient consented for the procedure. We performed right-sided pterional trans-sylvian microsurgical approach and right neck dissection at common carotid bifurcation under electrophysiology monitoring (somatosensory evoked potentials and electroencephalography); while vascular surgery department assisted with the radial artery graft harvesting. The radial artery graft was passed through preauricular tunnel, cranially was anastomosed at superior trunk of middle cerebral artery, and caudally at external carotid artery (Video). Intraoperative angiogram showed adequate bypass patency and lack of flow within aneurysm. The patient was extubated postoperatively and discharged home with aspirin in postoperative day 5. Improvement on oculomotor deficit was complete 3 weeks after surgery.ConclusionNowadays, endovascular therapy can manage small to large cavernous ICA aneurysms even if associated to FMD, although giant symptomatic cavernous carotid aneurysms impose a different challenge. Here, we present the management for the association of symptomatic giant cavernous ICA aneurysm and cervical ICA FMD with high flow bypass. We consider important to keep the skills in the cerebrovascular neurosurgeon armamentarium for the safe management of these lesions.
| S-EPMC7395543 | biostudies-literature
Project description:Background and objectiveIntracranial fusiform aneurysms (IFAs) are considered to have a complex pathophysiology process and poor natural history. The purpose of this study was to investigate the pathophysiological mechanisms of IFAs based on the characteristics of aneurysm wall enhancement (AWE), hemodynamics, and morphology.MethodsA total of 21 patients with 21 IFAs (seven fusiform types, seven dolichoectatic types, and seven transitional types) were included in this study. Morphological parameters of IFAs were measured from the vascular model, including the maximum diameter (Dmax), maximum length (Lmax), and centerline curvature and torsion of fusiform aneurysms. The three-dimensional (3D) distribution of AWE in IFAs was obtained based on high-resolution magnetic resonance imaging (HR-MRI). Hemodynamic parameters including time-averaged wall shear stress (TAWSS), oscillatory shear index (OSI), gradient oscillatory number (GON), and relative residence time (RRT) were extracted by computational fluid dynamics (CFD) analysis of the vascular model, and the relationship between these parameters and AWE was investigated.ResultsThe results showed that Dmax (p = 0.007), Lmax (p = 0.022), enhancement area (p = 0.002), and proportion of enhancement area (p = 0.006) were significantly different among three IFA types, and the transitional type had the largest Dmax, Lmax, and enhancement area. Compared with the non-enhanced regions of IFAs, the enhanced regions had lower TAWSS but higher OSI, GON, and RRT (p < 0.001). Furthermore, Spearman's correlation analysis showed that AWE was negatively correlated with TAWSS, but positively correlated with OSI, GON, and RRT.ConclusionThere were significant differences in AWE distributions and morphological features among the three IFA types. Additionally, AWE was positively associated with the aneurysm size, OSI, GON, and RRT, while negatively correlated with TAWSS. However, the underlying pathological mechanism of the three fusiform aneurysm types needs to be further studied.
| S-EPMC10040612 | biostudies-literature
Project description:ObjectiveTo compare in the Vertebral Artery Ischaemia Stenting Trial (VIST) the risks and benefits of vertebral angioplasty and stenting with best medical treatment (BMT) alone for symptomatic vertebral artery stenosis.MethodsVIST was a prospective, randomized, open-blinded endpoint clinical trial performed in 14 hospitals in the United Kingdom. Participants with symptomatic vertebral stenosis ≥50% were randomly assigned (1:1) to vertebral angioplasty/stenting plus BMT or to BMT alone with randomization stratified by site of stenosis (extracranial vs intracranial). Because of slow recruitment and cessation of funding, recruitment was stopped after 182 participants. Follow-up was a minimum of ≥1 year for each participant.ResultsThree patients did not contribute any follow-up data and were excluded, leaving 91 patients in the stent group and 88 in the medical group. Mean follow-up was 3.5 (interquartile range 2.1-4.7) years. Of 61 patients who were stented, stenosis was extracranial in 48 (78.7%) and intracranial in 13 (21.3%). No periprocedural complications occurred with extracranial stenting; 2 strokes occurred during intracranial stenting. The primary endpoint of fatal or nonfatal stroke occurred in 5 patients in the stent group vs 12 in the medical group (hazard ratio 0.40, 95% confidence interval 0.14-1.13, p = 0.08), with an absolute risk reduction of 25 strokes per 1,000 person-years. The hazard ratio for stroke or TIA was 0.50 (p = 0.05).ConclusionsStenting in extracranial stenosis appears safe with low complication rates. Large phase 3 trials are required to determine whether stenting reduces stroke risk.Isrctncom identifierISRCTN95212240.Classification of evidenceThis study provides Class I evidence that for patients with symptomatic vertebral stenosis, angioplasty with stenting does not reduce the risk of stroke. However, the study lacked the precision to exclude a benefit from stenting.
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Project description:ObjectiveInternal iliac artery (IIA) preservation is associated with improved outcomes after both open and endovascular aortoiliac aneurysm repair. Total robotic laparoscopic repair of aortoiliac aneurysms has been reported in the past, but not in combination with sutureless anastomosis applied to the IIAs. The objective of this study was to demonstrate the feasibility of the total robotic laparoscopic technique including a method of deploying the Gore Hybrid Vascular Graft (GHVG; W. L. Gore & Associates, Flagstaff, Ariz) using robotic instruments.MethodsBetween June 2015 and December 2016, four patients underwent total robotic laparoscopic repair of isolated common iliac artery (CIA) aneurysms. Two patients had unilateral aneurysms and two had bilateral aneurysms. Unilateral CIA aneurysms were treated with a graft from the proximal CIA to the proximal external iliac artery, and bilateral CIA aneurysms were treated with a bifurcated graft between the distal aorta and both proximal external iliac arteries. The nitinol reinforced section of the GHVG was then inserted and deployed into the corresponding IIA, and the nonreinforced segment was sewn in an end-to-side fashion to the iliac graft.ResultsThe median age of patients was 55.5 years (range, 48-64 years); median body mass index was 24.9 kg/m2 (range, 23-26.4 kg/m2). All four cases were technically successful. Operative times were 325 and 332 minutes for unilateral cases and 491 and 385 minutes for bilateral cases. For the entire series, median proximal clamping time was 143 minutes (range, 110-163 minutes), and the median time to deploy the GHVG was 15 minutes (range, 8-27 minutes). The median estimated blood loss was 1800 mL (range, 800-2100 mL). Intraoperative cell salvage was used in all cases. No intraoperative or postoperative complications occurred. No patient required blood transfusion. All patients tolerated a regular diet on postoperative day 2 and were discharged on postoperative day 4. Patients returned to work and full physical activity within 6 weeks (range, 2-6 weeks). At 6-month follow-up, computed tomography angiography demonstrated 100% patency of iliac artery grafts as well as of the GHVGs.ConclusionsTotal robotic laparoscopic CIA aneurysm repair is feasible in both unilateral and bilateral cases in carefully selected patients. The GHVG can be successfully deployed using robotic technique for IIA preservation during total robotic CIA aneurysm repair.
| S-EPMC6598873 | biostudies-literature
Project description:Bilateral absence of the common iliac artery is an extremely rare congenital vascular malformation in which the distal aorta divides directly into two external iliac arteries and two internal iliac arteries. In the case of the presence of this vascular malformation in association with an aortic aneurysm, preservation of the internal iliac artery flow during endovascular aortic repair represents a technical challenge. We have reported a case in which the bilateral absence of the common iliac artery associated with an infrarenal abdominal aortic aneurysm was successfully treated by endovascular aortic repair using commercially available iliac branched devices to maintain pelvic perfusion.
| S-EPMC7921189 | biostudies-literature
Project description:This study analyzed morphometric and hemodynamic parameters of aneurysmal and non-aneurysmal middle cerebral artery (MCA) bifurcations and their relationship with optimal values derived from the principle of minimum work (PMW). The study included 96 patients with MCA aneurysm and 94 controls. Aneurysm patients presented with significantly higher values of the radius and cross-sectional area of the MCA trunk, angle between the post-bifurcation branches (α angle) and volume flow rate (VFR) and had significantly lower values of junction exponent and pulsatility index than the controls. The Φ1 and Φ2 angles (angles between the MCA trunk axis and the larger and smaller branch, respectively) and α angle in all groups were significantly larger than the optimal PMW-derived angles. The most important independent predictors of MCA aneurysm were junction exponent (odds ratio, OR = 0.42), α angle (OR = 1.07) and VFR (OR = 2.36). Development of cerebral aneurysms might be an independent effect of abnormalities in hemodynamic and morphometric factors. The risk of aneurysm increased proportionally to the deviation of morphometric parameters of the bifurcation from their optimal PMW-derived values. The role of bifurcation angle in aneurysm development needs to be explained in future research as the values of this parameter in both aneurysm patients and non-aneurysmal controls in were scattered considerably around the PMW-derived optimum.
| S-EPMC7005042 | biostudies-literature