Neurosurgery
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Case Reports Comparative Study
Artificial pedicle screw reconstruction of the cervical spine after lateral paramedian transpedicular approach for lesions of the ventral cervical spinal canal.
We describe in detail the anatomic and surgical principles of a lateral cervical paramedian transpedicular approach, a novel technique that provides access to the ventral cervical spinal canal. We also describe single-stage posterior column reconstruction of the cervical spine in which traditional cervical lateral mass screws are used simultaneously to reconstruct the cervical pedicle and to allow for three-column stabilization in a continuous posterior screw-rod construct after this approach. ⋯ Cervical spinal stability is enhanced, because all cervical levels are incorporated into the final screw-rod construct.
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Comparative Study
Microsurgical anatomy and quantitative analysis of the transtemporal-transchoroidal fissure approach to the ambient cistern.
Surgical approaches to ambient cistern lesions are complex. We investigated the microanatomy of the transtemporal-transchoroidal fissure approach to the ambient cistern with emphasis on exposure of the posterior cerebral artery. ⋯ The transtemporal-transchoroidal fissure approach provides a corridor to the ambient cistern and P2-P3 junction while minimizing temporal lobe retraction and avoiding interruption of temporal lobe venous drainage. Because of widely variable vascular anatomy, access to posterior cerebral artery lesions using this approach requires preoperative imaging to identify the specific location of the P2-P3 junction.
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Hemangioblastomas are not uncommon intramedullary spinal cord neoplasms. They are highly vascular, benign tumors that occur either sporadically or in the presence of von Hippel-Lindau disease. Despite their exceptionally vascular nature, these lesions can consistently be resected completely and safely with minimal blood loss. We describe a microsurgical method for removal of these tumors from the spinal cord.
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Case Reports
Ruptured internal carotid artery anterior wall aneurysm identified during vasospasm: case report.
Aneurysms of the paraclinoid segment arising from the anterolateral wall of the proximal internal carotid artery (ICA) are usually located in the intradural space, and the proximal neck of the aneurysm is closely adjacent to the dural ring. Although most of these aneurysms can be identified by cerebral angiography, the top of the aneurysm can be flattened because of its relationship to the undersurface of the clinoid process. We report a rare case of a ruptured ICA anterolateral wall aneurysm that was not identified by initial angiography but was clearly observed at the time of vasospasm. ⋯ The presented case suggests that this type of aneurysm may be missed by routine angiography performed before and after vasospasm. If initial angiography fails to reveal the origin of the subarachnoid hemorrhage but computed tomography still discloses hemorrhage from an ICA aneurysm, repeated angiography should be considered within 14 days after the onset of subarachnoid hemorrhage to confirm whether the aneurysm has arisen from the anterior clinoid segment of the ICA.
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The present case report is the first one to report a bilateral anastomotic artery between the internal carotid artery and the anterior communicating artery in the presence of a bilateral A1 segment, fenestrated anterior communicating artery (AComA), and associated aneurysm of the AComA, which was discovered by magnetic resonance angiography and treated surgically. ⋯ The postoperative course was uneventful, with complete recovery. Follow-up angiograms documented the successful exclusion of the aneurysm. Defining this particular internal carotid-anterior cerebral artery anastomosis as an infraoptic anterior cerebral artery is not appropriate because there is already an A1 segment in its habitual localization. Therefore, it is also thought that, embryologically, this anomaly is not a misplaced A1 segment but the persistence of an embryological vessel such as the variation of the primitive prechiasmatic arterial anastomosis. The favorable outcome for our patient suggests that surgical treatment may be appropriate for many patients with this anomaly because it provides a complete and definitive occlusion of the aneurysm.