Articles: subarachnoid-hemorrhage.
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Endovascular treatment of acutely ruptured wide-necked aneurysms presents well-known challenges because of the desire to avoid intracranial stenting with attendant dual antiplatelet therapy requirements. Balloon-assisted coiling (BAC) has been well described for this purpose, most commonly using a 2-microcatheter technique, with a balloon microcatheter protecting the aneurysm neck and a coiling microcatheter used to embolize the aneurysm.1,2 However, the availability of advanced double-lumen balloon microcatheters with coiling markers allows for the use of a single-microcatheter technique in select instances.3 We present the case of a patient presenting with a ruptured wide-necked posterior communicating artery aneurysm with a large posterior communicating artery arising from the neck. ⋯ The aneurysm was intentionally subtotally coiled and the patient was retreated with a flow-diverting stent later during the same hospitalization (Video 1). Partial coiling followed by later flow diversion is a pragmatic strategy in wide-necked ruptured aneurysms,4 and use of a single balloon microcatheter for BAC can be useful in certain situations.
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Review Case Reports
Microsurgical Clipping of a Ruptured Wide-Neck Basilar Tip Aneurysm by an Extended Transsylvian Transcavernous Approach: 2-Dimensional Operative Video.
Basilar tip aneurysms are difficult to treat due to their deep location, proximity to cranial nerves and brainstem, and risk of perforator stroke.1-3 A 49-year-old woman presenting to the emergency department with subarachnoid hemorrhage was found to have a wide-neck basilar tip aneurysm measuring 8.6 mm × 5.6 mm × 7.6 mm. The aneurysm had a 4.9-mm wide neck located at the level of the dorsum sellae.4,5 Microsurgical clipping was recommended to the patient due to the complexity of the aneurysm neck, the patient's young age, the expertise of the surgical-anesthetic team, treatment durability, and the low risk of recurrence.2,6-9 We used an extended transsylvian transcavernous approach to expose the aneurysm (Video 1). We preferred this anterolateral approach over the more lateral subtemporal transzygomatic approach because of its versatility in providing better visualization of the bilateral posterior cerebral arteries and superior cerebellar arteries.10 The surgical exposure to the proximal basilar artery was gained by drilling the posterior clinoid process and dorsum sellae. ⋯ The patient tolerated the procedure well with no deficits at the 12-month follow-up. We review the microsurgical nuances of treating complex wide-neck basilar tip aneurysms that are not good candidates for endovascular treatment. Although endovascular tools are favored as the first-line treatment choice for most cerebral aneurysms, microsurgical clipping techniques remain an important tool in the contemporary cerebrovascular neurosurgeon's toolkit.2,6,11-15.
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Subarachnoid hemorrhage (SAH) due to a middle cerebral artery (MCA) aneurysm rupture is often associated with an intracerebral hematoma (ICH) or intrasylvian hematoma (ISH). ⋯ Our study has confirmed that age, Hunt-Hess score, and treatment-related complications influence the outcome of patients with ruptured MCA aneurysms. However, in the subgroup analysis of patients with SAH associated with an ICH or ISH, only the Hunt-Hess score at onset appeared as an independent predictor of the outcome.
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Disturbances in serum sodium concentration (dysnatremia) are common following aneurysmal subarachnoid hemorrhage (aSAH), but its direct impact on outcomes is not well understood. This study aimed to examine the association between dysnatremia following aSAH and patient outcomes. ⋯ Although dysnatremia may not directly impact functional outcome or vasospasm risk, hypernatremia may prolong hospital length of stay. Judicious use of hypertonic saline solutions and avoidance of unnecessary dysnatremia in patients with aSAH should be considered.