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Intracranial aneurysms (IA) occur in 3–5% of the general population and may require surgical or endovascular obliteration if the patient is symptomatic or has an increased risk of rupture. These procedures carry an inherent risk of neurological complications, and the outcome can be influenced by the physiological and pharmacological effects of the administered anesthetics. Despite the critical role of anesthetic agents, however, there are no current studies to systematically assess the intraoperative anesthetic risks, benefits, and outcome effects in this population. In this systematic review of the literature, we carefully examine the existing evidence on the risks and benefits of common anesthetic agents during IA obliteration, their physiological and clinical characteristics, and effects on neurological outcome. The initial search strategy captured a total of 287 published studies. Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, 28 studies were included in the final report. Our data showed that both volatile and intravenous anesthetics are commonly employed, without evidence that either is superior. Although no specific anesthetic regimens are promoted, their unique neurological, cardiovascular, and physiological properties may be critical to the outcome in vulnerable patients. In particular, patients at risk for perioperative ischemia may benefit from timely administration of anesthetic agents with neuroprotective properties and optimization of their physiological parameters. Further studies are warranted to examine if these anesthetic regimens can reduce the risk of neurological injury and improve the overall outcome in these patients.

In the current dynamic health environment, increasing number of procedures are being completed by advanced practitioners (nurse practitioners and physician assistants). This is the first study to assess the clinical outcomes and safety of external ventricular drain (EVD) placements by specially trained advanced practitioners. Compare the safety and outcomes of EVD placement by advanced practitioners in patients with subarachnoid hemorrhage (SAH). A cohort comparison study was performed from an aneurysmal SAH database selecting patients treated with EVD from a single major academic institution in the USA between June 2007 and June 2017. Safety, accuracy, and complications of EVD placement were compared between advanced practitioners and neurosurgical physicians (attending neurosurgeon and subspecialty clinical fellow). Statistical analysis was performed using the Mann–Whitney test for continuous variables and χ2 test for categorical variables, with p values set at

Dementia places a large burden on the economy, with financial and emotional costs incurred by patients, caregivers and the health sector. We report the first published case series of giant basilar aneurysm leading to progressive cognitive and functional decline. We review the literature regarding giant aneurysms and their association with dementia and the possible underlying pathophysiological mechanism. This report highlights a number of therapeutic considerations when determining the best management strategy for these difficult lesions.

To investigate the frequency, predictors, and clinical impact of electrographic seizures in patients with high clinical or radiologic grade non-traumatic subarachnoid hemorrhage (SAH), independent of referral bias.We compared rates of electrographic seizures and associated clinical variables and outcomes in patients with high clinical or radiologic grade non-traumatic SAH. Rates of electrographic seizure detection before and after institution of a guideline which made continuous EEG monitoring routine in this population were compared.Electrographic seizures occurred in 17.6 % of patients monitored expressly because of clinically suspected subclinical seizures. In unselected patients, seizures still occurred in 9.6 % of all cases, and in 8.6 % of cases in which there was no a priori suspicion of seizures. The first seizure detected occurred 5.4 (IQR 2.9-7.3) days after onset of subarachnoid hemorrhage with three of eight patients (37.5 %) having the first recorded seizure more than 48 h following EEG initiation, and 2/8 (25 %) at more than 72 h following EEG initiation. High clinical grade was associated with poor outcome at time of hospital discharge; electrographic seizures were not associated with poor outcome.Electrographic seizures occur at a relatively high rate in patients with non-traumatic SAH even after accounting for referral bias. The prolonged time to the first detected seizure in this cohort may reflect dynamic clinical features unique to the SAH population.

The purpose of this study was to present a meta-analysis on the safety and efficacy of different endovascular modalities when treating vertebral artery dissections, since ideal treatment remains controversial. We performed a meta-analysis of 39 retrospective studies involving different treatment modalities for vertebral artery dissections in adults and obtained weighted pooled proportional outcome and mortality ratios with a random effects model. Overall, 75.11 % (confidence interval (CI) 68.89-80.84, I (2) 66.89 %) had excellent outcomes, 10.10 % (CI 6.83-15.56, I (2) 65.64 %) had good outcomes, and 13.70 % (CI 9.64-18.35, I (2) 60.33 %) had poor outcomes. Postoperative complications occurred in 10.52 % (CI 6.87-14.84, I (2) 62.48 %), with 2.73 % (CI 1.64-4.10, I (2) 0.0 %) exhibiting vasospasm, 3.03 % (CI 1.88-4.46, I (2) 0.0 %) experiencing postoperative rebleeding, and 6.31 % (CI 3.57-9.76, I (2) 60.92 %) showing ischemia. Overall mortality was 8.69 % (CI 6.13-11.64, I (2) 33.76 %). When compared to these overall ratios, different treatment modality subgroups did not differ significantly, except for the proximal occlusion group, with poor outcome ratio = 26.96 % (difference 13.26, CI 0.02-30.04, p = 0.0403) and mortality ratio = 21.36 % (difference 12.67, CI 0.94-28.86, p = 0.0189). Different endovascular treatment modalities are comparatively safe and effective in the management of vertebral artery dissection. Their reduced operative time, minimal invasiveness, and overall safety render them a suitable option for intervention-amenable dissections.

The objective of this study is to assess the sensitivity of intracranial aneurysm geometry to the modality of imaging. Four imaging modalities—3D rotational angiography (3DRA), computed tomography angiography (CTA), contrast enhanced magnetic resonance angiography (CE-MRA), and time-of-flight magnetic resonance angiography (TOF-MRA)—were assessed using data from a flow phantom and human subjects. A silicone flow phantom of the head and neck arteries with a 10 mm ACOM aneurysm was imaged using all four modalities under steady flow conditions. Three human subjects with mid to large sized intracranial aneurysm who had a 3DRA scan and one of CTA, CE-MRA, or TOF-MRA performed within a day were also studied. The aneurysm and contiguous vasculature were segmented for all available scans and geometric measures of their size (5 indices) and shape (6 indices) were estimated and compared. Visually, the size and shape of segmented 3D models of the aneurysms were similar across scan modalities for both the human subjects and the flow phantom. Consequently, the computed indices were consistent across modalities in the key morphometric indices. In conclusion, quantified indices of 3D geometry of the mid to large sized intracranial aneurysms investigated in this small study population are not sensitive to scanning modality.

The true incidence of residual lesions after surgical resection of AVMs is not well documented in the literature. Partial surgical resection is thought to not confer any improvement over the natural history risk of hemorrhage of AVMs, and in certain cases may actually increase the risk of hemorrhage. Over the past 11 years, we have adopted a policy of immediate postoperative angiography with immediate surgical re-exploration if a residual lesion is seen. The purpose of the present study was to review our experience to determine the incidence of residual lesions and subsequent outcome.From June 1991 to June 2002, 324 patients underwent craniotomy and surgical AVM resection. As per protocol, all patients underwent immediate postoperative angiography. We have a protocol for immediate surgical re-exploration if a residual lesion is seen on postoperative angiographic exam.There were total six patients (1.8% of patients operated with intracranial AVMs) with residual lesions on postoperative angiography. All six patients underwent immediate surgical re-exploration with complete 100% obliteration; two patients required two re-exploration procedures. There was one operative complication: posterior cerebral artery and superior cerebellar artery infarcts after re-exploration of residual lesion after surgical resection of a large occipito-temperal-parietal AVM. There were no other morbidities and no mortalities.The incidence of residual lesions seen on postoperative angiography after AVM surgery at an experienced center is 1.8%. Because of the potential imminent danger of hemorrhage from a residual lesion, we recommend a policy of immediate postoperative angiography (or intraoperative angiography if image quality is satisfactory) for all AVM surgery and early surgical re-exploration if a residual lesion is seen.

To describe how to differentiate transfusion-related acute lung injury from acute chest syndrome of sickle cell disease. A neurosurgical patient with sickle cell disease received two units of packed red blood cells postoperatively. Four hours later she developed progressive respiratory distress, diffuse geographical airspace disease and bilateral pulmonary edema. The patient recovered sufficiently to be transferred from the intensive care unit within four days. The temporal relationship to transfusion, features on computerized tomographic scan, and the rapid resolution of severe edema point to a diagnosis of transfusion related acute lung injury. Granulocyte or human leukocyte antigen antibodies in donor plasma may confirm a diagnosis of transfusion injury. The clinician should appreciate that erythrocyte transfusion to prevent or treat acute chest syndrome may cause transfusion related acute lung injury, a condition that mimics, exacerbates or possibly triggers the syndrome it was intended to treat.

Cerebral vasospasm and related ischemic stroke continue to be significant complicating factors in the course of many patients with subarachnoid hemorrhage from berry aneurysm rupture. The risk of this well-recognized but poorly understood complication can be estimated on the basis of patient medical history, neurologic examination, and head CT findings. Every patient with possible risk needs specialized neurologic intensive care unit care after aneurysm obliteration. Surgical and pharmacologic wash-out of subarachnoid blood around the basal arteries, proper management of intracranial pressure and fluid status, hyponatremia, hypomagnesemia, and fever, as well as use of calcium channel blockers, have been considered helpful in patient management prior to and with the symptomatic vasospasm development. Transcranial Doppler (TCD) ultrasound is important in detecting vasospasm before the patient suffers ischemic neurologic deficit or infarct. Elevated TCD velocities often initiate the use of triple-H (HHH: hypertension, hemodilution, and hypervolemia) therapy and subsequently guide it. Up to the end of the first 3 weeks after subarachnoid hemorrhage and aneurysm obliteration, development of any focal neurologic deficit or mental deterioration, unless convincingly proven otherwise, is assumed to be from cerebral vasospasm. When a hemodynamically significant vasospasm in the arterial segments of clinical concern is suggested, emergency cerebral angiography with balloon dilatation angioplasty or intra-arterial infusion of vasodilating agents may be helpful in relieving ischemic symptoms.

We report the case of an extramedullary pathologically proven hemangioblastoma of the conus medullaris. As spinal dural arteriovenous fistulas most commonly present with a conus medullaris syndrome, our presentation of the MRI, myelographic, and angiographic findings of this unique lesion may be useful in differentiating these two entities.We report the case of a 57 year old woman with a two year history of progressive low back and right lower extremity pain and weakness. Spinal MRI and myelography demonstrated serpiginous vasculature on the dorsum of the spinal cord consistent with either a vascular tumor or malformation. Selective spinal angiography was thus undertaken by the neuroendovascular team which revealed a tumor nodule consistent with vascular tumor. T12-L1 laminectomy was performed and a 6 mm vascularized tumor was found in the intradural extramedullary compartment adjacent to the conus medullaris. The tumor was completely removed and pathological analysis was consistent with hemangioblastoma.This report documents a unique location for extramedullary spinal hemangioblastomas. Although both MRI and myelography are helpful in studying these lesions, angiography remains the gold standard in differentiating between vascular tumor and malformation. We suggest that the angiography be performed by a neurointerventional team to facilitate embolization, should this be warranted.

Background. Treatment of intracranial aneurysms is evolving with the development of novel therapies. It is important to have an animal model which simulates human aneurysms. We describe a new modified technique to the elastase aneurysm model which creates aneurysms that histologically and hemodynamically resemble human aneurysms. Methods. Twelve New Zealand white rabbits underwent the aneurysm creation procedure, and 2 underwent a control procedure. In the aneurysm creation procedure, the right common carotid artery (RCCA) origin is surgically exposed and temporarily occluded with a temporary aneurysm clip. The RCCA is ligated distally, and the trapped segment is infused with elastase for 20 minutes, afterwhich the clip is removed. In the control procedure, the RCCA is ligated distally with no elastase. Animals were assessed neurologically using a previously described rabbit neurologic grading scale and food intake scale. Intravenous digital subtraction angiography (IVDSA) was performed 21 days after the procedure. Aneurysms were harvested and stained with H&E and Verhoeff’s stain. Findings. All 14 rabbits had normal neurologic and food intake assessments. All 12 rabbits that underwent aneurysm creation procedures demonstrated saccular aneurysms on IVDSA. Mean aneurysm size was 5.9±1.9 mm; range 4.3–10.8 mm. The close proximity of the LCCA to the origin of the RCCA on the aortic arch of the New Zealand white rabbit closely resembles a bifurcation aneurysm. Both rabbits that underwent control procedures showed no aneurysm and retrograde thrombosis of the RCCA. Histologic analysis showed the aneurysms had histology characteristic of true human aneurysms. Conclusion. We have developed a new modified technique to the elastase aneurysm model which creates aneurysms that hemodynamically and histologically resemble human aneurysms. There have been previous elastase models described, however we find our model is easier to perform and highly reproducible. The aneurysms can be accessed transfemorally making the model ideal for testing endovascular therapies.