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Background Cerebral bypass procedures are complex and require substantial experience and skills and thorough preoperative planning. Cerebrovascular surgeons face increasingly complex bypass cases because most routine cases are managed by endovascular means, and because increasing numbers of patients have complex medical problems that affect available and suitable bypass conduit options. We report the cases of several patients undergoing cerebral bypass with limited bypass conduit alternatives, in whom there were unexpected intraoperative difficulties requiring complex solutions. Methods The neurological surgery department database was reviewed to identify patients who had undergone cerebral bypass procedures during a 13-year period in whom there were limited available bypass conduits, and in whom unexpected intraoperative difficulties were encountered during cerebral bypass. Results Patient outcomes and graft patency were evaluated for 13 patients including 6 with ischemia, 3 with giant aneurysms, 2 with mycotic aneurysms, 1 with dissecting aneurysm, and 1 with gunshot-induced pseudoaneurysm. Median duration of follow-up was 43 months. In 12 of 13 patients, bypass graft/grafts were patent on the last computed tomography angiogram. In 1 patient, a prophylactic bypass procedure, the graft was not filling, probably because of lack of demand. Two patients died during follow-up of unrelated causes. Conclusions Cerebrovascular surgeons should be versatile in dealing with patients with complex bypass. When there are limited available conduit options, we find that collaboration with other surgical specialties (e.g., plastics and vascular) is helpful. In patients in whom extreme intraoperative difficulties are expected, thorough preoperative planning with multiple backup plans should be exercised, as described in this report.

Background It can sometimes be challenging to find a suitable clip to treat an unusual aneurysm, or when the surrounding anatomy is unusual, especially in resource-limited environments. We describe a method to modify aneurysm clips based on the method originated by Sugita et al in 1985. Herein clip modification (Clip-Mod) is used to treat anatomically difficult anterior communicating artery aneurysms. Methods The Department of Neurological Surgery database was reviewed to find aneurysm patients treated using modified aneurysm clips. Clip-Mod was performed during surgery by shortening the tines of titanium aneurysm clips by abrasion applied from the side of a standard 3-mm surgical diamond drill bit under constant irrigation. Note that the thickness of the tines and the clip spring were not modified or contacted by the drill. Results Four cases used modified aneurysm clips, from 648 total clip-treated aneurysms (0.6%) by 2 surgeons over a 14-year period. Three patients presented with subarachnoid hemorrhages that were determined to be due to anterior communicating artery aneurysms. One patient presented with an incidental unruptured anterior communicating artery aneurysm. All 4 patients were treated with 3-mm titanium clips shortened intraoperatively to 1- to 2-mm lengths, to achieve aneurysm obliteration without stenosing parent or perforating vessels. Conclusions All 4 patients have done well clinically with no reoccurrences after 2–6 years' follow-up, which included angiographic evaluation. The use of this “Clip-Mod” technique thus appears useful for anterior communicating artery aneurysms. Clip-Mod could also be considered for treating other aneurysms when the “perfect” length clip is not available.

Simulation models enable trainees to master microsurgical skills before performing surgeries. Vascular bypass is a critical component of cerebrovascular and many nonneurologic procedures. However, most available bypass training models lack important spatial, tactile, and physiologic aspects of real surgery. Animal and placental models provide true physiology but are expensive. While some models adequately simulate superficial temporal artery-middle cerebral artery bypass, there is no model for side-to-side distal anterior cerebral artery bypass. The objective is to create a realistic and inexpensive training model for this important procedure.The depth of interhemispheric fissures in cadaver brains was compared with the grapefruit radii. Grapefruits were dissected to simulate the operative field within the deep and narrow interhemispheric fissure. Pericallosal arteries were mimicked with chicken wing vessels or synthetic tubing, with an aquarium pump providing closed circulation. Twelve board-certified neurosurgeons who were given bypass training using the grapefruit model were blindly surveyed on model realism and training suitability.Grapefruit depths from pith to central column were comparable with interhemispheric cadaveric fissure depths. Approximate preparation time of grapefruit training models was 5-10 minutes. Surveyed neurosurgeons rated the model a better replicate for cerebral artery bypass (P 0.02) and more challenging than common training models (P0.01). They also rated the grapefruit model as likely to be superior for improving surgical skills before surgery (P0.05).This grapefruit model provides a realistic simulation of side-to-side distal anterior cerebral artery bypass procedure that can be inexpensively and easily implemented in nearly any resource environment.

OBJECTIVEIn daily practice, neurosurgeons face increasing numbers of patients using aspirin (acetylsalicylic acid, ASA). While many of these patients discontinue ASA 7–10 days prior to elective intracranial surgery, there are limited data to support whether or not perioperative ASA use heightens the risk of hemorrhagic complications. In this study the authors retrospectively evaluated the safety of perioperative ASA use in patients undergoing craniotomy for brain tumors in the largest elective cranial surgery cohort reported to date.METHODSThe authors retrospectively analyzed the medical records of 1291 patients who underwent elective intracranial tumor surgery by a single surgeon from 2007 to 2017. The patients were divided into three groups based on their perioperative ASA status: 1) group 1, no ASA; 2) group 2, stopped ASA (low cardiovascular risk); and 3) group 3, continued ASA (high cardiovascular risk). Data collected included demographic information, perioperative ASA status, tumor characteristics, extent of resection (EOR), operative blood loss, any hemorrhagic and thromboembolic complications, and any other complications.RESULTSA total of 1291 patients underwent 1346 operations. The no-ASA group included 1068 patients (1112 operations), the stopped-ASA group had 104 patients (108 operations), and the continued-ASA group had 119 patients (126 operations). The no-ASA patients were significantly younger (mean age 53.3 years) than those in the stopped- and continued-ASA groups (mean 64.8 and 64.0 years, respectively; p < 0.001). Sex distribution was similar across all groups (p = 0.272). Tumor locations and pathologies were also similar across the groups, except for deep tumors and schwannomas that were relatively less frequent in the continued-ASA group. There were no differences in the EOR between groups. Operative blood loss was not significantly different between the stopped- (186 ml) and continued- (220 ml) ASA groups (p = 0.183). Most importantly, neither hemorrhagic (0.6%, 0.9%, and 0.8%, respectively; p = 0.921) nor thromboembolic (1.3%, 1.9%, and 0.8%; p = 0.779) complication rates were significantly different between the groups, respectively. In addition, the multivariate model revealed no statistically significant predictor of hemorrhagic complications, whereas male sex (odds ratio [OR] 5.9, 95% confidence interval [CI] 1.7–20.5, p = 0.005) and deep-extraaxial-benign (“skull base”) tumors (OR 3.6, 95% CI 1.3–9.7, p = 0.011) were found to be independent predictors of thromboembolic complications.CONCLUSIONSIn this cohort, perioperative ASA use was not associated with the increased rate of hemorrhagic complications following intracranial tumor surgery. In patients at high cardiovascular risk, ASA can safely be continued during elective brain tumor surgery to prevent potential life-threatening thromboembolic complications. Randomized clinical trials with larger sample sizes are warranted to achieve a greater statistical power.

Objective To investigate if the implementation of white matter (WM) fiber tractography by diffusion tensor imaging in presurgical planning for supratentorial tumors proximal to eloquent WM tracts can alter a neurosurgeon's operative strategy. Methods A retrospective review was conducted of patients with supratentorial brain tumors within eloquent WM tracts who underwent diffusion tensor imaging (DTI) tractography as part of their preoperative assessment. These patients were classified into 3 different DTI groups per the radiology reports: group 1, intact WM tracts; group 2, deviated and/or displaced WM bundles; and group 3, patients with an established WM injury (interrupted and/or destroyed tracts). A blinded prospective behavioral study followed, in which 4 neurosurgeons reviewed the preoperative images at 2 different times (magnetic resonance imaging without DTI, followed by a review of the DTI). They provided estimations about the DTI group of each individual eloquent WM category in every patient, and their planned surgical approach. Results Fifteen patients (mean age, 58.3 years) were included in the study. The neurosurgeons provided a correct DTI group estimation in 53%, 60%, and 57% of the cases that involved motor/sensory pathway tracts, optic tracts, and language tracts, respectively. The neurosurgeons underestimated DTI group 3 in the motor category and in the optic category 75% of the time. DTI did not alter the planned surgical approach. Conclusions DTI WM tractography helped neurosurgeons to correctly identify patients with interrupted motor and optic pathway tracts so they could be more aggressive with the extent of tumor resection, despite its inability to alter the operative approach.

Introduction Meningiomas are among the most common primary intracranial tumors. While well-described, there is limited information on the outcomes and consequences following treatment of giant-sized vertex-based meningiomas. These meningiomas have specific risks and potential complications due to their size, location, and involvement with extracalvarial soft tissue and dural sinuses. Herein, we present four giant-sized vertex transosseous meningioma cases with involvement and occlusion of the sagittal sinus, that postoperatively developed external hydrocephalus and ultimately required shunting. Methods A retrospective chart review identified patients with large vertex meningiomas that were: (1) large (>6 cm) with hemispheric (no skull base) location, (2) involvement of the superior sagittal sinus resulting in complete sinus occlusion, (3) involvement of dura resulting in a large duraplasty area, (4) transosseous involvement requiring a 5 cm or larger craniectomy for resection of invaded calvarial bone. Results Tumors were resected in all four cases, with all patients subsequently developing external hydrocephalus which required shunting within 2 weeks to 6 months postsurgery. Conclusion We believe this may be the first report of the development of hydrocephalus following surgical resection of these large lesions. Based on our observations, we propose that a combination of superior sagittal sinus occlusion and changes in brain elasticity and compliance affect the brain's CSF absorptive capacity, which ultimately lead to hydrocephalus development. We suggest that neurosurgeons be aware that postoperative hydrocephalus can quickly develop following treatment of giant-sized vertex-based meningiomas, and that correction of hydrocephalus with shunting can readily be achieved.

A significant proportion of children that survive hypoxic-ischemic encephalopathy (HIE) develop visual impairment. These visual deficits are generally attributed to injuries that occur in the primary visual cortex and other visual processing systems. Recent studies suggested that neuronal damage might also occur in the retina. An important structure affecting the viability of retinal neurons is the vasculature. However, the effects of HIE on the retinal neurovasculature have not been systemically evaluated. Here we investigated whether exposure of postnatal day 9 (P9) neonatal mice to HIE is sufficient to induce neurovascular damage in the retina. We demonstrate that the blood vessels on the surface of the retina, from mice subjected to HIE, were abnormally enlarged with signs of degeneration. The intermediate and deep vascular layers in these retinas failed to form normally, particularly in the periphery. All the vascular damages observed here were irreversible in nature up to 100 days post HIE. We also observed loss of retinal neurons, together with changes in both astrocytes and Müller cells mainly in the inner retina at the periphery. Collectively, our findings suggest that HIE results in profound alterations in the retinal vasculature, indicating the importance of developing therapeutic strategies to protect neurovascular dysfunction not only in the brain but also in the retina for infants exposed to HIE.

Brainstem cavernous malformations (CMs) pose significant challenges to neurosurgeons because of their deep locations and high surgical risks. Most patients with brainstem CMs present with sudden-onset cranial nerve deficits or ataxia, but uncommonly patients can present in extremis from an acute hemorrhage, requiring surgical intervention. However, the timing of surgery for brainstem CMs has been a controversial topic. Although many authors propose delaying surgery into the subacute phase, some patients may not tolerate waiting until surgery. To the best of the authors’ knowledge, emergency surgery after a brainstem CM hemorrhage has not been described. In cases of rapidly progressive neurological deterioration, emergency resection may often be the only option. In this retrospectively reviewed small series of patients, the authors report favorable outcomes after emergency surgery for resection of brainstem CMs.

Background Hypertrophic olivary degeneration (HOD) occurs because of posterior fossa or brainstem lesions that disrupt the dentato-rubro-olivary tract, well known as the Guillain-Mollaret triangle. Clinical and radiologic hallmarks of this condition are palatal myoclonus and T2 hyperintensity of the inferior olivary complex on magnetic resonance imaging (MRI), respectively. Because symptomatic HOD can complicate the recovery of patients with posterior fossa or brainstem lesions, the purpose of this study is to evaluate clinical and imaging findings of patients with HOD. Methods Sixteen patients (8 female and 8 male) with a mean age of 40.7 years, (range, 5–83 years) years were included in this study based on clinical symptoms and MRI findings. Results We reviewed the clinical and imaging findings in 16 cases of HOD at our institution. Seven patients (43.7%) had posterior fossa tumors, 6 patients (37.5%) had cavernoma, 2 patients (12.5%) sustained traumatic brain injury, and only 1 patient (6.2%) had cerebellar infarction. Posterior fossa surgery was performed in 13 (81.2%) of these patients. HOD was detected a mean of 7.2 months (range, 0.5–18 months) after surgery or primary neurologic insult. Unilateral HOD was observed in 10 patients (62.5%), while bilateral HOD was observed in only 6 patients (37.5%). Seven patients (43.7%) were asymptomatic for HOD, whereas 5 patients (31.2%) had symptoms attributable to HOD. Two patients died because of primary tumors, although mean follow-up after detection of HOD on MRI was 52.2 months (range, 1–120 months) in the remaining 14 patients. In these cases, no change in clinical symptoms or imaging findings was detected during follow-up. Conclusions In this series, posterior fossa tumors and cavernomas were the most common causes of HOD. Although most of the patients with HOD remained asymptomatic, HOD complicated the course of recovery in almost one quarter of the patients included in this study. Neurosurgeons should be aware of HOD, which has characteristic clinical and imaging findings. In addition, HOD can complicate the recovery of patients with disruption to the dentato-rubro-olivary tract.

In the case of elective clipping of unruptured aneurysms, the surgeon has the luxuries of time and careful planning, which he or she should leverage fully to ensure a fully optimized case. Prior to entering the operating theater, it is important to reassess the patient’s history, specifically reviewing their history for any prior subarachnoid hemorrhage (SAH) or cranial trauma, cranial surgery, endovascular therapy – both neurosurgical and otherwise – and medications, including antiplatelets, anticoagulation, and antiepileptics. Next, review all imaging modalities obtained in the workup of their lesion, including catheter-based angiogram, computed tomography angiography, and magnetic resonance angiography. These images should be reviewed with careful attention paid to any vascular variants or anomalies, aneurysm dome projection and configuration, distance from the Sylvian fissure to the aneurysm when applicable, presence of multiple aneurysms, estimating the skull thickness, anterior clinoid process (ACP) anatomy, frontal sinus size and configuration, and cortical veins. Finally, the patient should be asked for any changes in their medical history since their last office visit, and a brief physical examination should be performed.

Complex intracranial aneurysms are rare cerebrovascular lesions that pose significant management challenges. Their microsurgical interventions often require complex reconstruction or bypass procedures to achieve the goal of aneurysmal obliteration and vascular preservation.

Tumors of the lateral and third ventricles are cradled on all sides by vital vascular and eloquent neural structures. Microsurgical resection, which always requires attentive planning, plays a critical role in the contemporary management of these lesions. This article provides an overview of the open microsurgical approaches to the region highlighting key clinical perspectives. Electronic supplementary material The online version of this article (doi:10.1007/s11060-016-2126-9) contains supplementary material, which is available to authorized users.

The superficial temporal artery (STA) to the middle cerebral artery (MCA) bypass is the most common bypass type for revascularization to treat cerebral ischemia. If the ipsilateral STA is not available for anastomosis, various options for bypass conduits can be exercised. When the entire ipsilateral external carotid and its branches are not available, the contralateral STA may be used as a donor artery through an interposition graft. This technique is known as a "bonnet bypass." In this video, we demonstrate the utilization of a bonnet bypass in a 48-yr-old man with protein S deficiency, and right carotid artery occlusion with recurrent strokes and transient ischemic attacks (TIA). After exhausting nonsurgical options by treating with 2 antiplatelet drugs and supportive lifestyle changes, the patient continued to experience TIAs and watershed strokes in the right hemisphere. Angiography showed that the right anterior artery and the MCA were filled through the Circle of Willis, but the ipsilateral STA and entire external and common carotid arteries were not patent for potential use as a bypass donor. Since the ipsilateral bypass options were not available, we elected to perform a bypass from the contralateral STA trunk to the ipsilateral M2 with a saphenous vein interposition graft, for a so-called bonnet bypass. The patient did well after surgery and has remained symptom-free for 19 mo post bypass. The surgical technique and each step in performing this bonnet bypass are demonstrated in this 3-dimensional video. The patient consented to the publication of his operative video.

Operative management of intrinsic brainstem lesions remains challenging despite advances in electrophysiological monitoring, neuroimaging, and neuroanatomical knowledge. Surgical intervention in this region requires detailed knowledge of adjacent critical white matter tracts, brainstem nuclei, brainstem vessels, and risks associated with each surgical approach. Our aim was to systematically verify internal anatomy associated with each brainstem safety entry zone (BSEZ) via neuroimaging modalities commonly used in pre-operative planning, namely high-resolution magnetic resonance imaging (MRI) and diffusion tensor tractography (DTT). Twelve BSEZs were simulated in eight, formalin-fixed, cadaveric brains. Specimens then underwent radiological investigation including T2-weighted imaging and DTT using 4.7 T MRI to verify internal anatomic relationships between simulated BSEZs and adjacent critical white matter tracts and nuclei. The distance between simulated BSEZs and pre-defined, adjacent critical structures was systemically recorded. Entry points and anatomic limits on the surface of the brainstem are described for each BSEZ, along with description of potential neurological sequelae if such limits are violated. With high-resolution imaging, we verified a maximal depth for each BSEZ. The relationship between proposed safe entry corridors and adjacent critical structures within the brainstem is quantified. In combination with tissue dissection, high-resolution MR diffusion tensor imaging allows the surgeon to develop a better understanding of the internal architecture of the brainstem, particularly as related to BSEZs, prior to surgical intervention. Through a careful study of such imaging and use of optimal surgical corridors, a more accurate and safe surgery of brainstem lesions may be achieved.

Cerebral revascularization procedures, such as the external carotid-internal carotid bypass, have been used in the clinical management of cerebral ischemic states. Among the most commonly performed bypasses is the superficial temporal artery-middle cerebral artery (STA-MCA) bypass to restore cerebral blood flow. In cases of a foreshortened STA donor vessel, a radial artery (RA) graft is often used as an interposition graft between the STA and MCA. However, addressing the vessel size mismatch between the radial artery and donor can be problematic and challenging. We present the case of an 80-year-old male presenting with positional-onset expressive aphasia and right-sided hemiparesis. Computed tomography perfusion demonstrated a diffusion-perfusion mismatch in a left MCA distribution. Angiography showed a complete left internal cerebral artery occlusion and poor distal filling of the STA. We performed an external carotid artery-to-internal carotid artery bypass through interposing an RA graft to the STA proximally with an end-to-end anastomosis and to the MCA distally using an end-to-side anastomosis. The mismatch between 2 bypass vessel sizes was corrected by removing a small piece from the RA graft at 1 margin and suturing it to itself to reduce the size of the RA vessel diameter opening on the side used to sew to the STA. The patient did well clinically with improved right-sided strength, a patent graft, and no postoperative complications. Addressing vessel mismatch when using RA interposition grafts for bypass is challenging. Various operative approaches to address mismatch should be individualized on the basis of the particular vascular anatomy and needs of the case. Nevertheless, our method of cutting and suturing 1 side of the RA graft into a semiblind end to match donor vessel diameter may be of use to cerebrovascular surgeons in select cases.

The aim of this study was to analyze the topographical anatomy of the dorsal spinal cord (SC) in relation to the posterior median septum (PMS). This included the course and variations in the PMS, and its relationship to and distance from other dorsal spinal landmarks. Microsurgical anatomy of the PMS was examined in 12 formalin-fixed adult cadaveric SCs. Surface landmarks such as the dorsal root entry zone (DREZ), the denticulate ligament, the architecture of the leptomeninges and pial vascular distribution were noted. The PMS was examined histologically in all spinal segments. The PMS extended most deeply at spinal segments C7 and S4. This was statistically significant for all spinal segments except C5. The PMS was shallowest at segments T4 and T6, where it was statistically significantly thinner than at any other segment. In 80% of the SCs, small blood vessels were identified that traveled in a rostrocaudal direction in the PMS. The longest distance between the PMS and the DREZ was at the C1–C4 vertebral levels and the shortest distance was at the S5 level. Prevention of deficits following a dorsal midline neurosurgical approach to deep-seated SC lesions requires careful identification of the midline of the cord. The PMS and septum define the midline on the dorsum of the SC and their accurate identification is essential for a safe midline surgical approach. In this anatomical study, we describe the surface anatomy of the dorsal SC and its relationship with the PMS, which can be used to determine a safe entry zone into the SC. Clin. Anat. 28:45–51, 2015. © 2014 Wiley Periodicals, Inc.

Intradural metastatic tumors are rarely reported in foramen magnum (FM), including cases of melanoma, pituitary carcinoma, thyroid carcinoma, and prostate carcinoma metastases. We report a 68-year-old male who presented with right-sided headache, progressive swallowing difficulty requiring gastrostomy tube and hoarseness over the course of 1 year. Images revealed a heterogeneous, contrast-enhancing lesion in the FM that compressed the anterior aspect of the medulla and upper spinal cord. Although metastatic tumor was considered in differential diagnosis, presumptive diagnosis was FM meningioma due to lack of bone destruction or sclerosis on CT and T2W isointense and T1W hypointense appearance on MRI. The patient underwent gross total resection via right far-lateral transcondylar approach. Histopathological examination revealed prostate carcinoma metastasis. To the best of our knowledge this is the second case report of an intradural prostate carcinoma metastasis in the FM.

The complexity of arteriovenous malformations (AVMs) does not necessarily preclude surgical resection. In this video the authors present a 72-year-old male who was known to have an occipital AVM with a large draining varix for the previous 10 years. The patient had progressively worsening visual and cognitive deficits over several years. Total surgical resection was achieved following single stage preoperative embolization. Although resection of the AVMs is challenging, even in experienced hands, it offers a cure and may improve patient clinical outcome.The video can be found here: https://youtu.be/YI1AwGjJdvo.

Aneurysms of the distal anterior cerebral artery (dACA) are rare, consisting only 2-6% of all intracranial aneurysms. dACA aneurysms are often associated with anomalies such as azygous, bihemispheric and triplication of ACA. Among these anomalies accessory anterior cerebral artery (accACA) is an anatomical variant found in 3.3% to 15% of the population. Here we report a case of a 60-year-old female who presented with a Hunt and Hess grade II, Fisher grade III subarachnoid hemorrhage secondary to a ruptured saccular aneurysm originating from the pericallosal-callosomarginal artery bifurcation at the A3 segment of the accessory ACA and underwent an uncomplicated microsurgical clipping.

Spinal Cord Injury Without Radiographic Abnormality defines the clinical symptoms of traumatic myelopathy with no radiographic or computed tomographic features of spinal fracture or instability. This condition mostly affects the children below 8-years old and a rare phenomenon in adults. We aimed to report an adult patient with spinal cord injury without radiographic abnormality after a heavy fall of truck holder to his head and neck regions., et Radyografik anormalliğin eşlik etmediği spinal kord hasarı; radyografik olarak veya bilgisayarlı tomografide omurga kırığı ya da instabilitesinin saptanmadığı travmatik myelopatiyi tarif etmektedir. Bu durum çoğunlukla 8 yaş altı çocukları etkilemekte, erişkinde ise nadiren görülmektedir. Biz de baş ve boyun bölgesine kamyon kasası çarpması sonrası radyografik anormalliğin eşlik etmediği spinal kord hasarı bulguları gösteren erişkin hastanın sunumunu amaçladık

BACKGROUND In contemporary microneurosurgery reducing retraction-induced injury to the brain is essential. Self-retaining retractor systems are commonly used to improve visualization and decrease the repetitive microtrauma, but sometimes self-retaining retractor systems can be cumbersome and the force applied can cause focal ischemia or contusions. This may increase the morbidity and mortality. Here, we describe a technique of retraction using 10-0 sutures in the arachnoid. OBJECTIVE To evaluate the imaging and clinical results in patients where 10-0 suture retraction was used to aid the surgical procedure. METHODS Adjacent cortex was retracted by placing 10-0 nylon suture in the arachnoid of the bank or banks of the sulcus. The suture was secured to the adjacent dural edge by using aneurysm clips, allowing for easy adjustability of the amount of retraction. We retrospectively analyzed the neurological outcome, signal changes in postoperative imaging, and ease of performing surgery in 31 patients with various intracranial lesions including intracranial aneurysms, intra- and extra-axial tumors, and cerebral ischemia requiring arterial bypass. RESULTS Clinically, there were no injuries, vascular events, or neurological deficits referable to the relevant cortex. Postoperative imaging did not show changes consistent with ischemia or contusion due to the retraction. This technique improved the visualization and illumination of the surgical field in all cases. CONCLUSION Retraction of the arachnoid can be used safely in cases where trans-sulcal dissection is required. This technique may improve initial visualization and decrease the need for dynamic or static retraction.

A 44-year-old male with Aarskog syndrome (AS) presented with subarachnoid hemorrhage secondary to ruptured posterior communicating artery aneurysm. AS, also known as faciogenital dysplasia, is an X-linked, autosomal dominant or autosomal recessive congenital developmental disorder. This syndrome is characterized by short stature in association with a variety of multiple anomalies in musculoskeletal, neurological, and urogenital systems. Cerebrovascular abnormalities such as anomalous cerebral venous drainage, dysplastic internal carotid artery, and basilar artery malformation have been reported to be associated with AS. To our knowledge this represents the first case of a ruptured intracranial aneurysm in a patient with AS.

We previously found increased microglial proliferation and pro-inflammatory cytokine release in infant mice compared to juvenile mice after hypoxia-ischemia (HI). The aim of the current study was to assess for differences in the effect of microglial suppression on HI-induced brain injury in infant and juvenile mice. HI was induced in neonatal (P9) and juvenile (P30) mice and minocycline or vehicle was administered at 2 hours and 24 hours post-HI. P9 minocycline-treated mice demonstrated early but transient improvements in neurologic injury, while P30 minocycline-treated mice demonstrated sustained improvements in cerebral atrophy and Morris Water Maze performance at 60 days post-HI.

Giant posterior circulation aneurysms pose a significant challenge to neurovascular surgeons. Among various treatment methods that have been applied individually or in combination, clipping under hypothermic circulatory arrest (HCA) is rarely used. We present a 62-year-old man who initially underwent coil occlusion of the right vertebral artery (VA) for a 2.5 cm giant vertebrobasilar junction (VBJ) aneurysm. His neurological condition had declined gradually and the aneurysm grew to 4 cm in size. The patient underwent clip reconstruction of giant VBJ aneurysm under HCA. His postoperative course was prolonged due to his preexisting neurological deficits. His preoperative Modified Rankin Score was 5, and improved postoperatively to 3 at three and six months, and to 2 at one year.The video can be found here: http://youtu.be/L53SiLV8eJY.

Intracranial pseudoaneurysms (IP) represent about 1% of all patients presenting with an intracranial aneurysm. In true intracranial aneurysms, the intima, internal elastic lamina, and media are disrupted, but the adventitia is intact. In pseudoaneurysms, there is disruption of all three layers of the arterial wall, thus resulting in higher rates of re-hemorrhage and thrombus formation. Patients with IP commonly present with subarachnoid hemorrhage or thromboembolic complications. Until now, no specific guidelines have been established for the ideal treatment of pseudoaneurysms. Although IP have higher rates of morbidity and mortality compared to true intracranial aneurysms, surgical treatment can prevent catastrophic hemorrhagic and thrombotic complications. Despite recent advances in endovascular techniques that allow safe approaches to complicated intracranial vascular pathologies, vascular trapping and bypass remains the definitive and safe treatment for IP. Based on our experience and related literature, we consider the latter treatment in experienced hands as an effective and decisive treatment modality to prevent the devastating complications of IP. In this article, we discuss the surgical management of iatrogenic intracranial internal carotid artery pseudoaneurysms by trapping, and extracranial-intracranial bypass through a case illustration in which the technique is demonstrated via a video presentation.

Introduction Klippel-Trenaunay-Weber syndrome (KTWS) is a rare syndrome in which patients usually present with cutaneous hemangiomas, venous varicosities, and bone and soft tissue hypertrophy of the affected limb. Intracranial lesions in patients with KTWS are extremely rare, and are generally reported as single cases in the literature. We describe a rare case, where a patient with KTWS was found with a hemorrhagic grade IV astrocytoma. Although central nervous system abnormalities such as intracranial aneurysms and cerebral and spinal cord cavernomas have been described in patients with KTWS, to the best of our knowledge, this is the first report of an association between glioblastoma multiforme (grade IV astrocytoma) and KTWS in the English-language medical literature. Case presentation A 61-year-old white Caucasian man with a history of KTWS presented with seizures. Left upper and lower extremity hypertrophy, left foot, leg and ear gigantism and left-sided abdominal capillary hemangiomas were noted in the physical examination. Cranial computed tomography (CT) and magnetic resonance imaging (MRI) were obtained, showing a heterogeneous lesion in the cingulate gyrus, with peripheral and central areas of T1 hyperintensity and layering T2 hypointensity consistent with a hemorrhage. A right parasagittal frontal craniotomy was performed with an interhemispheric approach. We had difficulty controlling the bleeding with bipolar electrocautery during surgery and finally were able to stop the bleeding using surgicel and gelfoam. Postoperative cranial CT and MRI scans showed intraparenchymal hemorrhage centered within the medial right frontal lobe. There was no increase in hematoma size in consecutive CT scans. Conclusions Co-occurrence of vascular abnormalities with KWTS should be taken into consideration to avoid perilous preoperative and postoperative complications.

AIM We have applied diffusion tensor imaging (DTI) to interrogate microstructural changes in white matter integrity in a widely used middle cerebral artery occlusion (MCAO) model of cerebral ischemia. MATERIAL AND METHODS We performed ex vivo DTI 35 days after 60 minutes transient focal ischemia in male spontaneously hypertensive rats and generated fractional anisotropy (FA), mean, axial and radial diffusivity maps. Regions of interest corresponding to external capsule (EC), corpus callosum (CC) and internal capsule (IC) were compared among sham and stroked rats. We compared tractographic projections of white matter fiber patterns and examined white matter integrity by Luxol fast blue histological analysis. We also determined infarct lesion volumes at 24 hours post-ischemia by T2-weighted magnetic resonance imaging (MRI) or at 35 days by histological staining with cresyl violet. RESULTS We found alterations in EC and IC, but not CC, as represented by decreased FA and increased mean, axial and radial diffusivities. The size of the ischemic lesion detected subacutely by T2-weighted MRI or at 35 days by histological staining correlated with the decline in FA in the affected structures. Tractography revealed disruption of fiber trajectories through the EC and reorientation of fibers within the caudate/putamen of rats subjected to MCAO. Similarly, loss of white matter integrity in the EC and increased white matter density in the caudate/putamen along the infarct border zone was evidenced by Luxol fast blue staining. CONCLUSION Diffusion tensor imaging therefore allows for monitoring of white matter injury and reorganization in hypertensive rats.

Objective To illustrate a unique instance of Ehlers-Danlos syndrome type VIII (EDS VIII) with blood blister–like aneurysm of the middle cerebral artery. Design This is a single patient case report. Setting University of Wisconsin-Madison Hospital. Participants A 42-year-old woman with diagnosis of EDS VIII presented with a sudden onset severe headache and altered mental status. She was diagnosed with Hunt and Hess grade IV subarachnoid hemorrhage. Angiography demonstrated a blood blister–like aneurysm of the left middle cerebral artery. After an unsuccessful coiling attempt in another facility, the patient was operated on with the intention to perform extracranial to intracranial bypass and trapping of the diseased segment of the artery. Results The patient's neurologic condition remained poor after surgery. On postoperative day 2, her neurologic examination unchanged, and care was withdrawn per the family's request. Conclusions Individuals with EDS VIII may be at risk for catastrophic vascular events.

Blood blister-like aneurysms (BBAs) pose a significant challenge to neurosurgeons and neuro-interventionalists. These fragile broad-based aneurysms have a propensity to rupture with minimal manipulation during surgical or endovascular explorations because, unlike saccular aneurysms, they lack all layers of the arterial wall. Aneurysm trapping with extracranial-intracranial (EC-IC) bypass is a safe and durable treatment for BBAs. We describe our technique and the guiding principles for surgical bypass and trapping of BBAs of the supraclinoid internal carotid artery (ICA). Treatment of BBAs of the supraclinoid ICA remains difficult. Aneurysm trapping with EC-IC bypass treats BBAs definitively by eliminating the diseased segment of the ICA. We have found the technique and principles described here to be safe and durable in our hands.

The natural history of Moyamoya disease (MD) is variable. Moyamoya disease in children mostly presents with progressive ischemic complications and in adulthood it tends to present with hemorrhage. Surgical strategies depend on augmenting cerebral blood flow to the anterior cerebral circulation. Revascularization is the mainstay treatment for MD. We introduce a 31 year old female with a history of MD and leftsided revascularization as a child, who presented with headache, confusion, and worsening left sided weakness. Cranial computed tomography (CT) showed a right sided putaminal hemorrhage. Cerebral angiogram with selective external runs revealed MD, hypoplastic parietal branch of the superficial temporal artery (STA) on the right side and previous revascularization on the left side. Thus, our decision was made to perform a bypass with the frontal branch of the STA to an M3-M4 segment of the middle cerebral artery and an encephaloduroarteriomyosynangiosis with the parietal branch of the STA. The patient's postoperative course was uneventful. Postoperative CT angiogram confirmed patency of bypass. This technique provides immediate revascularization and seems to provide risk reduction for ischemic and hemorrhagic stroke. We review the natural history and surgical treatment of MD along with a case presentation in which surgical technique is demonstrated in video.

In adolescents and young adults, ependymomas are the most common intramedullary tumors in the spinal cord.These tumors arise from ependymal cell lining the ventricles and spinal canal. The clinical presentation of intramedullary ependymomas are variable and nonspecific. They usually present with diffuse back or neck pain as a chief complaint. Upper and lower motor neuron deficits, numbness which typically progresses from distal to proximal, are other common symptoms. Gross total resection of ependymomas can achieve long-term tumor control with preservation of function. Here we present a 29-year old man who presented with progressive weakness of the left leg, bowel and bladder incontinence. During surgery, somatosensory evoked potentials (SSEPs) and motor evoked potentials (MEPs) were used and we achieved gross total resection while preserving the spinal cord. The patient made excellent recovery and all of his preoperative deficitis improved completely. He returned to work on postoperative 2-month.

Background True hemodynamic assessment of the posterior communicating artery (PComA) by preoperative angiography in terms of its perforators and configuration (adult vs. fetal vs. transitional) can be challenging in the surgical treatment of aneurysms involving the PComA, posterior cerebral artery, and basilar artery. Indocyanine green videoangiography (ICG-VA) is a widely accepted new technique in the surgical treatment of intracranial aneurysms to assess the patency of the parent artery, branches, and residual flow within the aneurysm after clipping. Case description Here we report two cases in which ICG-VA was utilized to assess either the direction of flow in the PComA or preservation of the PComA perforators with temporary clip application before dividing the PComA. Conclusions Our experience is that ICG-VA can be used to assess the main trunk, and perforating branches of the PComA providing real-time, dynamic intraoperative information of the surgical field. Therefore we suggest that ICG-VA may increase the safety of surgical treatment of aneurysm involving PComA.

Male neonate brains are more susceptible to the effects of perinatal asphyxia resulting in hypoxia and ischemia (HI)-related brain injury. The relative resistance of female neonatal brains to adverse consequences of HI suggests that there are sex-specific mechanisms that afford females greater neuroprotection and/or facilitates recovery post-HI. We hypothesized that HI preferentially induces estrogen receptor α (ERα) expression in female neonatal hippocampi and that ERα is coupled to Src family kinase (SFK) activation that in turn augments phosphorylation of the TrkB and thereby results in decreased apoptosis. After inducing the Vannucci's HI model on P9 (C57BL/6J) mice, female and male ERα wild-type (ERα(+/+)) or ERα null mutant (ERα(-/-)) mice received vehicle control or the selective TrkB agonist 7,8-dihydroxyflavone (7,8-DHF). Hippocampi were collected for analysis of mRNA of ERα and BDNF, protein levels of ERα, p-TrkB, p-src, and cleaved caspase 3 (c-caspase-3) post-HI. Our results demonstrate that: (1) HI differentially induces ERα expression in the hippocampus of the female versus male neonate, (2) src and TrkB phosphorylation post-HI is greater in females than in males after 7,8-DHF therapy, (3) src and TrkB phosphorylation post-HI depend on the presence of ERα, and (4) TrkB agonist therapy decreases the c-caspase-3 only in ERα(+/+) female mice hippocampus. Together, these observations provide evidence that female-specific induction of ERα expression confers neuroprotection with TrkB agonist therapy via SFK activation and account for improved functional outcomes in female neonates post-HI.

Osteopetrosis (OP) is hereditary X-linked, autosomal recessive (ARO), or autosomal dominant (ADO) skeletal disease. ARO has two subtypes, which are infantile malignant and intermediate type. ARO and X-linked OP have poor clinical outcome. ADO is called adult benign type because of the normal life expectancy, which has type I and type II. Here, the authors present an ADO patient with Chiari type I. Concomitant ADO with Chiari type I malformation is an extremely rare condition. Literature research yielded only one case report to date.

Thrombosed giant intracranial aneurysms usually present with symptoms and signs from their mass effect. Although multiple treatment options are available, direct clip reconstruction with thromboendarterectomy remains the gold standard. Here we present a 66-year-old man with seizure, aphasia and hemiparesis. Work-up revealed a giant partially thrombosed aneurysm of the internal carotid artery bifurcation with surrounding vasogenic edema. He underwent clip reconstruction of the aneurysm via a cranio-orbital approach. Although we prepared for bypass with the radial artery and/or the superficial temporal artery, we were able to clip-reconstruct the aneurysm without bypass. The patient improved upon his pre-morbid state after surgery and made an excellent recovery.The video can be found here: http://youtu.be/P_10hRQFuPo.

The retrosigmoid approach is a work-horse approach to the cerebellopontine angle (CPA), providing access from the foremen magnum to the tentorium. Indications for this approach are variable such as resection of meningiomas, acoustic neuromas and epidermoid tumors, treatment of vascular lesions of vertebrobasilar system, vascular decompression of cranial nerves (V, VII, IX, X), cranial nerve neurectomies, and intrinsic lesions of the cerebellum and brainstem. In this video, we demonstrate the use of retrosigmoid craniotomy for resection of a large CPA meningioma, delineating all steps including positioning, mapping.The video can be found here: http://youtu.be/kISkYS16Brk.