World Neurosurg
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Acute basilar artery occlusion is a devastating life-threatening condition. Early recanalization is the therapeutic goal in patients with acute ischemic stroke. Despite the high rates of recanalization achieved with modern devices for basilar occlusions, many patients have had poor clinical outcomes. This study aimed to assess the predictors of good and poor outcomes among patients with basilar artery occlusion treated with thrombectomy. ⋯ After thrombectomy for posterior circulation strokes, young patients, V4-proximal basilar occlusion, (high) baseline posterior circulation Alberta Stroke Program Early CT Score, and complete recanalization were independent predictors of good neurologic outcomes. Failure to recanalize was strongly related to sICH and mortality. In addition, diabetes, atrial fibrillation, and baseline National Institutes of Health Stroke Scale scores ≥10 had an independent association with mortality. This study contributes to the knowledge required to optimize recanalization treatments for posterior circulation strokes and may help to improve future clinical studies.
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Treatment for circumferential vertebral artery dissecting aneurysms (VADAs) remains challenging. Stent-assisted coil embolization is the most common treatment technique. However, this approach presents high rates of incomplete occlusion and recurrence, often requiring the addition of second or third stents for reconstruction. A flow diverter may achieve favorable clinical outcomes, but it cannot result in immediate aneurysm occlusion and is limited by strict antiplatelets and expensive price. We report excellent results of a 1-stage modified balloon-in-stent technique for circumferential VADA. ⋯ We demonstrated an innovative modified BIS technique to treat circumferential VADA by using a coiling basket followed by the deployment of a self-expandable stent and in-stent Scepter balloon angioplasty. This strategy is safe, feasible, and cost effective and was not associated with recurrence or complications over at least 2 years of follow-up.
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Spinal dural arteriovenous fistulas (SDAVFs) are rare vascular malformations. Digital subtraction angiography is the modality of choice to demonstrate the malformation before endovascular embolization or open surgical repair. Angiographically occult SDAVFs have been previously reported. Surgical considerations in SDAVFs with misleading angiography findings have not yet been assessed. ⋯ SDAVFs should be treated promptly after diagnosis. In cases with high suspicion for SDAVF with occult or misleading angiography findings, spinal exploration should be pursued with no delay. Indocyanine green-assisted microscopic angiography may contribute to exploratory spine surgery for SDAVF closure.
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Case Reports
Two-Level Separation Surgery for Thoracic Epidural Metastatic Disease: An Operative Video Demonstration.
The spinal column is one of the most common regions of cancer metastasis. Spinal metastases typically occur in the vertebral body, and due to direct posterior extension or retropulsed pathological fractures, they often present with signs and symptoms of epidural spinal cord compression. This scenario requires surgical management to relieve compression and stabilize the spine. ⋯ In this video, we present the case of a 61-year-old woman with metastatic hepatocellular carcinoma found to have severe spinal cord compression due to pathological vertebral body fractures at T10-T12, and ventral epidural disease at T10 and T12. The patient received T8-L2 posterior instrumented fusion and T10 and T12 separation surgery, with intraoperative cement embolization. We demonstrate the operative steps required to complete this procedure (Video 1).
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Electric cortical stimulation (ECS) has been the gold standard for intraoperative functional mapping in neurosurgery, yet it carries the risk of induced seizures. We assess the safety of focal cortical cooling (CC) as a potential alternative to ECS. ⋯ CC when used as an intraoperative mapping technique is safe and may complement ECS.