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The insular cortex is an uncommon epileptogenic location from which complex partial seizures may arise. Seizure activity in insular epilepsy may mimic temporal, parietal, or other cortical areas. Semiology, electroencephalography, and even surface electrocorticography recordings may falsely localize other cortical foci, leading to inaccurate diagnosis and treatment. The use of insular depth electrodes allows more precise localization of seizure foci. The authors describe the case of a young girl with seizures falsely localized to the cortex, with foci arising from the insula, as proven by depth electrode recordings. Resection of the insula yielded seizure control.

BackgroundThe effect of dural venous sinus stenting has been investigated for the treatment of idiopathic intracranial hypertension (IIH) but the effect of stenting on the long-term patency of the cortical draining veins, especially the vein of Labbé (VOL), remains unknown.MethodsWe reviewed our database of 38 patients with IIH with 41 stented dural venous sinuses between October 2006 and December 2014. Demographic, clinical, and radiological data were reviewed. Follow-up catheter angiographic data were included when available.ResultsStent placement spanned the ostium of the VOL in 35 patients (92.1%), with no immediate effect on the drainage of the VOL. Follow-up angiography (mean 35.1 months, range 1.7–80.7 months) was available in 24 patients, 21 of whom had stents spanning the VOL ostium. The VOL remained patent without occlusion or drainage alteration in all 21 patients. There were no immediate or long-term intracranial complications.ConclusionsDural venous sinus stenting for patients with IIH does not affect the immediate or long-term patency of the VOL and is not associated with intracranial complications.

BACKGROUND AND PURPOSE: Computational fluid dynamics modeling is useful in the study of the hemodynamic environment of cerebral aneurysms, but patient-specific measurements of boundary conditions, such as blood flow velocity and pressure, have not been previously applied to the study of flow-diverting stents. We integrated patient-specific intravascular blood flow velocity and pressure measurements into computational models of aneurysms before and after treatment with flow-diverting stents to determine stent effects on aneurysm hemodynamics. MATERIALS AND METHODS: Blood flow velocity and pressure were measured in peri-aneurysmal locations by use of an intravascular dual-sensor pressure and Doppler velocity guidewire before and after flow-diverting stent treatment of 4 unruptured cerebral aneurysms. These measurements defined inflow and outflow boundary conditions for computational models. Intra-aneurysmal flow rates, wall shear stress, and wall shear stress gradient were calculated. RESULTS: Measurements of inflow velocity and outflow pressure were successful in all 4 patients. Computational models incorporating these measurements demonstrated significant reductions in intra-aneurysmal wall shear stress and wall shear stress gradient and a trend in reduced intra-aneurysmal blood flow. CONCLUSIONS: Integration of intravascular dual-sensor guidewire measurements of blood flow velocity and blood pressure provided patient-specific computational models of cerebral aneurysms. Aneurysm treatment with flow-diverting stents reduces blood flow and hemodynamic shear stress in the aneurysm dome.

The hemodynamic environment of intracranial aneurysms is considered an important promoter of aneurysmal formation, growth and rupture [1]. Flow-diverting stent technology [2] has been developed to reduce blood flow (and hence hemodynamic stress) inside the aneurysm, potentially lowering the rupture risk. Computational fluid dynamics (CFD) modeling of aneurysms and the surrounding cerebral vasculature allows investigators to calculate important hemodynamic characteristics such as wall shear stress (WSS), which have been implicated in aneurysm growth and rupture.Copyright © 2013 by ASME

Background Spinal epidural arteriovenous fistulas (SEDAVF) are rare and poorly understood clinical entities. Materials and methods We report a series of five (three men, two women) consecutive cases treated at our center to analyze their characteristic and treatment strategies in their management. We report a successful technique of percutaneous embolization of fistulas in a patient with failed previous attempts. Results All five patients were symptomatic; three patients presented with a history of back pain, which progressed to myelopathic symptoms, one patient had symptoms of persistent back pain, and one patient had intermittent numbness of the left arm and thigh. Of the three patients who had myelopathic symptoms, two were successfully treated with transarterial embolizations with Onyx copolymer. The third patient who had a prominent epidural venous pouch with numerous arterial feeders was embolized percutaneously with a flat detector CT guided navigation (XperCT) and real time fluoroscopic monitoring of the injected n-butyl cyanoacrylate glue, after previous unsuccessful attempts with surgery and arterial embolizations. All three myelopathic treated patients had complete angiographic remission of the fistulas and symptoms on follow-up (mean 7.2 months). Conclusions The diagnosis and treatment of SEDAVF can be challenging due to their rarity and intricate pathomechanics. Patients with severe pain or progression of symptoms or myelopathic symptoms need to be treated at the earliest opportunity, while asymptomatic patients can be closely monitored. Percutaneous embolization is an effective strategy to embolize SEDAVF associated venous pouch.

Cerebral perfusion analysis is useful in the diagnosis and treatment of cerebral vasospasm. A new modality of real-time cerebral perfusion imaging and analysis has been developed using standard 2-dimensional angiography. We report our initial experience with this technique to assess response to therapy during endovascular vasospasm procedures.Colorized angiographic perfusion maps were obtained immediately before and after endovascular vasospasm treatment. Semiquantitative perfusion parameters (cerebral blood flow, cerebral blood volume, mean transit time, and time to peak) were calculated from time-density curves obtained from intraarterial contrast injection. The effects of intraarterial vasospasm therapy were assessed.Eight vascular territories in 4 patients with vasospasm underwent interventional angiography and angiographic perfusion analysis. Pretreatment perfusion maps demonstrated variable perfusion deficits in specific vascular territories. After endovascular treatment in 6 vessels, improvement was seen to varying degrees in both angiographic appearance and perfusion parameters. Clinical improvement and reduction in transcranial Doppler velocity was also observed.Real-time angiographic perfusion imaging is feasible during endovascular procedures for vasospasm. Perfusion analysis may aid in assessment of efficacy of the intervention. Comparison with traditional perfusion imaging is needed to validate this technique.

Cerebrospinal fluid shunt placement has a high failure rate, especially in patients with small ventricles. Frameless stereotactic electromagnetic image guidance can assist ventricular catheter placement. The authors studied the effects of image guidance on catheter accuracy and shunt survival in children.Pediatric patients who underwent placement or revision of a frontal ventricular CSF shunt were retrospectively evaluated. Catheters were placed using either anatomical landmarks or image guidance. Preoperative ventricular size and postoperative catheter accuracy were quantified. Outcomes of standard and image-guided groups were compared.Eighty-nine patients underwent 102 shunt surgeries (58 initial, 44 revision). Image guidance was used in the placement of 56 shunts and the standard technique in 46. Shunt failure rates were not significantly different between the standard (22%) and image-guided (25%) techniques (p = 0.21, log-rank test). Ventricular size was significantly smaller in patients in the image-guided group (p0.02, Student t-test) and in the surgery revision group (p0.01). Small ventricular size did not affect shunt failure rate, even when controlling for shunt insertion technique. Despite smaller average ventricular size, the accuracy of catheter placement was significantly improved with image guidance (p0.01). Shunt accuracy did not affect shunt survival.The use of image guidance improved catheter tip accuracy compared with a standard technique, despite smaller ventricular size. Failure rates were not dependent on shunt insertion technique, but an observed selection bias toward using image guidance for more at-risk catheter placements showed failure rates similar to initial surgeries.

Background Loeys–Dietz syndrome (LDS) is an autosomal dominant connective tissue disorder characterized by extensive arterial aneurysms. The successful clipping of intracranial aneurysms in patients with LDS has been reported in a limited number of patients but endovascular treatment of intracranial aneurysms in LDS has never before been described. The first successful cases of endovascular management of five intracranial aneurysms in two patients with LDS are reported. Clinical presentation The first patient was an asymptomatic 45-year-old woman with LDS and two incidentally discovered, unruptured wide necked aneurysms (6×5 mm and 4×2 mm) arising from the ophthalmic segment of the left internal carotid artery. Both aneurysms were successfully embolized via Neuroform stent assisted coiling. The second patient was an asymptomatic middle 40s woman with LDS found to have an unruptured anterior communicating artery aneurysm (7×4 mm) as well as two ophthalmic segment aneurysms (2.5×3.7 mm and 2.9×3.5 mm). All three aneurysms were successfully embolized via Neuroform stent assisted coiling in two staged procedures. There were no periprocedural complications in either patient. Long term follow-up imaging demonstrated durable embolization in all aneurysms in both patients. Conclusion This is the first reported case series of endovascular management of intracranial aneurysms in the setting of LDS. The endovascular approach was safe, effective and durable in all aneurysms in both patients, and should be considered when treating patients with LDS and intracranial aneurysms.

Objective Accurate image guidance is an essential component of percutaneous procedures in the head and neck. The combination of preprocedural magnetic resonance imaging (MRI) with cone-beam computed tomography (CBCT) and real-time fluoroscopy (the “triple-overlay” technique) could be useful in image-guided targeting of lesions in the head and neck. Methods Three patients underwent percutaneous diagnostic or therapeutic procedures of head and neck lesions (mean, 2.3 ± 2.4 cm). One patient presented for biopsy of a small lesion in the infratemporal fossa only visible on MRI, one presented for preoperative embolization of a nasal tumor, and one presented for sclerotherapy of a parotid hemangioma. Preprocedural MRI for each case was merged with CBCT to create a three-dimensional volume for procedural planning. This was then combined with real-time fluoroscopy to create a triple-overlay for needle trajectory and real-time guidance. Results The registration of MRI, CBCT, and fluoroscopy was successful for all three procedures, allowing 3D manipulation of the combined images. Percutaneous procedures were successful in all patients without complications. Conclusions The combination of MRI, CBCT, and real-time fluoroscopy provides detailed anatomical information for 3D image-guided percutaneous procedures of the head and neck, especially for small lesions or lesions with features visible only by MRI.

Transcranial Doppler ultrasonography is the most commonly used method of cerebrovascular blood flow velocity measurement, but it is subject to certain technical and anatomic limitations. The Doppler velocity guidewire measures blood flow velocity within any vessel during cerebral angiography, overcoming these limitations. We report the first use of this guidewire in the measurement of blood flow velocity during balloon test occlusion, with results similar to simultaneously measured transcranial Doppler ultrasonography. Velocity measurement by Doppler guidewire could be useful in balloon test occlusion for vertebrobasilar circulation, where transcranial Doppler ultrasonography is limited, and provide anatomically specific blood flow velocity measurements in the diagnosis and treatment of stroke and other cerebrovascular diseases.

Dural arteriovenous fistulas (dAVFs) are a complex family of vascular malformations. Most series discuss features in isolation of other vascular pathologies, despite evidence that dAVFs may arise in a setting of elevated angiogenic growth factors related to regional hypoxia. We describe a 72-year-old man with ischemic symptoms secondary to middle cerebral artery stenosis and an incidental ipsilateral Borden I dAVF. Balloon-occlusion single photon emission computed tomography demonstrated reversible ischemia within the basal ganglia consistent with fistula-related "steal" phenomenon. This case supports the hypothesis that dAVFs may arise secondary to angiogenic growth factors related to regional tissue hypoxia.

BACKGROUND AND IMPORTANCE Propionibacterium acnes is an uncommon pathogen in delayed surgical site infection, and its indolent course can complicate diagnosis and treatment. We report the longest delay between neurosurgery and P acnes infection reported. CLINICAL PRESENTATION Asymptomatic postoperative P acnes osteomyelitis and tumor recurrence occurring 23 years after initial craniotomy. Initial presentation was of tumor recurrence only, without signs or symptoms of infection. Calvarial osteomyelitis was unexpectedly discovered intraoperatively. Craniectomy and debridement were performed, and there was prolonged antibiotic therapy. CONCLUSION The longest delay between neurosurgery and asymptomatic P acnes infection is reported. We review the literature for P acnes infection and discuss biofilm formation and its role in delayed surgical infection.

Carotid-cavernous fistulas (CCFs) are anomalous connections between the carotid circulation and the cavernous sinus, and may cause significant morbidity. Endovascular treatment of these lesions can be challenging if typical transvenous routes are inaccessible. We describe a case of a Barrow type D carotid-cavernous fistula in which transvenous embolization was attempted via the inferior petrosal sinus (IPS). No connection was found to the fistula, and the superior ophthalmic vein (SOV) was thrombosed. A novel direct percutaneous puncture of the IOV was performed with ultrasound guidance showing that this is a safe alternative route of CCF access and embolization when the IPS and SOV are inaccessible.

Human posttraumatic epilepsy (PTE) is highly heterogeneous, ranging from mild remitting to progressive disabling forms. PTE results in simple partial, complex partial, and secondarily generalized seizures with a wide spectrum of durations and semiologies. PTE variability is thought to depend on the heterogeneity of head injury and patient's age, gender, and genetic background. To better understand the role of these factors, we investigated the seizures resulting from calibrated fluid percussion injury (FPI) to adolescent male Sprague–Dawley rats with video electrocorticography. We show that PTE incidence and the frequency and severity of chronic seizures depend on the location and severity of FPI. The frontal neocortex was more prone to epileptogenesis than the parietal and occipital, generating earlier, longer, and more frequent partial seizures. A prominent limbic focus developed in most animals, regardless of parameters of injury. Remarkably, even with carefully controlled injury parameters, including type, severity, and location, the duration of posttraumatic apnea and the age and gender of outbred rats, there was great subject-to-subject variability in frequency, duration, and rate of progression of seizures, indicating that other factors, likely the subjects' genetic background and physiological states, have critical roles in determining the characteristics of PTE.

The insular cortex is an uncommon epileptogenic location from which complex partial seizures may arise. Seizure activity in insular epilepsy may mimic temporal, parietal, or other cortical areas. Semiology, electroencephalography, and even surface electrocorticography recordings may falsely localize other cortical foci, leading to inaccurate diagnosis and treatment. The use of insular depth electrodes allows more precise localization of seizure foci. The authors describe the case of a young girl with seizures falsely localized to the cortex, with foci arising from the insula, as proven by depth electrode recordings. Resection of the insula yielded seizure control.

FPCT and navigation software on contemporary fluoroscopic units perform imaging of a quality comparable with conventional CT. They can accurately guide percutaneous procedures, providing live instrument visualization and the capability to re-image without patient transfer. FPCT navigation was used in the placement of a ventricular drain in a 62-year-old woman for subarachnoid-related hydrocephalus by using an otherwise standard bedside technique. Ventriculostomy catheter placement was technically successful without complication with a catheter at the foramen of Monro.

The ability to expand and innovate on current practices, such as genetic subtyping of gliomas, personalized medicine, and stem cell research, may be impacted. On one hand, greater global access to genetic knowledge could help to disseminate neurosurgical expertise across nations. On the other hand, would these innovations continue to enjoy intellectual property protection, and if not, how would that affect progress on Parkinson disease or knowledge of central nervous system tumor biology?

The aim of this report is to describe the management of scalp toxic epidermal necrolysis (TEN) and cranial osteomyelitis complicating malignant glioma therapy. A 21-year-old man developed TEN while being radiated and receiving antineoplastic and anticonvulsant therapies for a malignant intracranial glioma. The strategy used to manage the above situation included withdrawal of the medications causing TEN, meticulous dermatological wound care, resection of residual glioma, debridement of scalp and bone, and reconstruction of the scalp and calvarial defect with a myocutaneous vascularized free flap. The scalp wounds have healed completely in a cosmetically acceptable fashion and the patient remains free of tumor recurrence approximately 18 months after surgery, having completed a course of systemic chemotherapy. TEN may complicate the use of anticonvulsant and antineoplastic medications in malignant glioma patients. Withdrawal of the offending agent and immune suppressant medications, skin care and infection control, tumor resection to diminish steroid use, and reconstruction of scalp and calvarial defects with a vascularized myocutaneous flap facilitate wound healing and permit resumption of antineoplastic therapies.

High-stoma output is a common problem that can lead to dehydration and electrolyte disturbance. The following report describes three patients with end ileostomy who had high-stoma outputs where conventional medical management was unsuccessful in controlling stoma output. All three patients responded to high-dose loperamide, resulting in significant clinical improvement. High-dose loperamide therapy should be considered in patients with high-stoma output who have failed conventional medical management.

Cerebral aneurysm formation, growth and rupture are thought to be the result of a complex interaction between cerebrovascular hemodynamics and pathobiology. Recently, new evidence has emerged regarding the role of inflammation in the walls of cerebral aneurysms. Noninvasive methods to characterize the degree of inflammation in aneurysms could enable clinicians to estimate the risk of future aneurysm growth and rupture, influencing treatment. This review examines emerging techniques of imaging inflammatory biomarkers in cerebral aneurysms.