Combined Microsurgical, Endovascular, and Endoscopic Approach to the Treatment of a Giant Vertebrobasilar Aneurysm

2018 ◽  
Vol 17 (2) ◽  
pp. 149-156
Author(s):  
Aaron R Plitt ◽  
Ankur R Patel ◽  
Cameron M McDougall ◽  
Ashleigh A Halderman ◽  
Samuel L Barnett ◽  
...  
Keyword(s):  
Multimodal Treatment ◽  
High Rate ◽  
Endoscopic Endonasal ◽  
Lower Cranial Nerve ◽  
Vertebrobasilar System ◽  
Cranial Nerve Dysfunction ◽  
Endoscopic Reconstruction ◽  
Treatment Paradigm ◽  
History Of ◽  
Nerve Dysfunction

Abstract BACKGROUND Dolichoectasia is defined as elongation and dilatation of a blood vessel. In the intracranial circulation, the basilar artery is affected in 80% of cases. These are challenging lesions with an aggressive natural history, and treatment carries a relatively high rate of morbidity and mortality. We describe a case of multimodal treatment including endovascular, open microsurgical, and endoscopic endonasal approach (EEA) for management. OBJECTIVE To describe the technical nuance of the addition of the EEA for management of posterior circulation dolichoectasia METHODS A 44-yr-old Hispanic woman with a 2-mo history of progressive headaches, gait disturbance, and lower cranial nerve dysfunction presented with acute neurologic decline. MRI demonstrated a dolichoectatic vertebrobasilar system with a giant 4.5-cm fusiform basilar aneurysm. RESULTS She underwent concomitant endovascular bilateral vertebral artery sacrifice with suction decompression and trapping by clip ligation distal to the lesion. Postoperatively, she developed symptomatic pontine compression. She was then taken for a transclival EEA for intra-aneurysmal thrombectomy. Thereafter, she made a significant functional recovery. CONCLUSION The addition of endoscopic reconstruction to the treatment of a dolichoectatic basilar aneurysm is an operative nuance that can be employed in treating these highly morbid lesions. This case describing a multimodal treatment paradigm including EEA reconstruction can serve as an example for the future of treatment select cases of dolichoectasia of the vertebrobasilar complex.

scholarly journals Clinical characteristics and long-term outcomes in patients with ruptured posterior inferior cerebellar artery aneurysms: a comparative analysis

2015 ◽  
Vol 123 (2) ◽  
pp. 441-445 ◽  
Author(s):  
Richard W. Williamson ◽  
David A. Wilson ◽  
Adib A. Abla ◽  
Cameron G. McDougall ◽  
Peter Nakaji ◽  
...  
Keyword(s):  
Cranial Nerve ◽  
Posterior Inferior Cerebellar Artery ◽  
High Rate ◽  
Lower Cranial Nerve ◽  
Cranial Nerve Dysfunction ◽  
Fisher Grade ◽  
Nerve Dysfunction ◽  
Pica Aneurysms

OBJECT Subarachnoid hemorrhage (SAH) from ruptured posterior inferior cerebellar artery (PICA) aneurysms is uncommon, and long-term outcome data for patients who have suffered such hemorrhages is lacking. This study investigated in-hospital and long-term clinical data from a prospective cohort of patients with SAH from ruptured PICA aneurysms enrolled in a randomized trial; their outcomes were compared with those of SAH patients who were treated for other types of ruptured intracranial aneurysms. The authors hypothesize that PICA patients fare worse than those with aneurysms in other locations and this difference is related to the high rate of lower cranial nerve dysfunction in PICA patients. METHODS The authors analyzed data for 472 patients enrolled in the Barrow Ruptured Aneurysm Trial (BRAT) and retrospectively reviewed vasospasm data not collected prospectively. In the initial cohort, 57 patients were considered angiographically negative for aneurysmal SAH source and did not receive treatment for aneurysms, leaving 415 patients with aneurysmal SAH. RESULTS Of 415 patients with aneurysmal SAH, 22 (5.3%) harbored a ruptured PICA aneurysm. Eight of them had dissecting/fusiform-type aneurysms while 14 had saccular-type aneurysms. Nineteen PICA patients were treated with clipping (1 crossover from coiling), 2 were treated with coiling, and 1 died before treatment. When comparing PICA patients to all other aneurysm patients in the study cohort, there were no statistically significant differences in age (mean 57.6 ± 11.8 vs 53.9 ± 11.8 years, p = 0.17), Hunt and Hess grade median III [IQR II–IV] vs III [IQR II–III], p = 0.15), Fisher grade median 3 [IQR 3–3] vs 3 [IQR 3–3], p = 0.53), aneurysm size (mean 6.2 ± 3.0 vs 6.7 ± 4.0 mm, p = 0.55), radiographic vasospasm (53% vs 50%, p = 0.88), or clinical vasospasm (12% vs 23%, p = 0.38). PICA patients were more likely to have a fusiform aneurysm (36% vs 12%, p = 0.004) and had a higher incidence of lower cranial nerve dysfunction and higher rate of tracheostomy/percutaneous endoscopic gastrostomy placement compared with non-PICA patients (50% vs 16%, p < 0.001). PICA patients had a significantly higher incidence of poor outcome at discharge (91% vs 67%, p = 0.017), 1-year follow-up (63% vs 29%, p = 0.002), and 3-year follow-up (63% vs 32%, p = 0.006). CONCLUSIONS Patients with ruptured PICA aneurysms had a similar rate of radiographic vasospasm, equivalent admission Fisher grade and Hunt and Hess scores, but poorer clinical outcomes at discharge and at 1- and 3-year follow-up when compared with the rest of the BRAT SAH patients with ruptured aneurysms. The PICA's location at the medulla and the resultant high rate of lower cranial nerve dysfunction may play a role in the poor outcome for these patients. Furthermore, PICA aneurysms were more likely to be fusiform than saccular, compared with non-PICA aneurysms; the complex nature of these aneurysms may also contribute to their poorer outcome.

Endoscopic endonasal resection of the odontoid process: clinical outcomes in 34 adults

2018 ◽  
Vol 128 (3) ◽  
pp. 923-931 ◽  
Author(s):  
Nathan T. Zwagerman ◽  
Matthew J. Tormenti ◽  
Zachary J. Tempel ◽  
Eric W. Wang ◽  
Carl H. Snyderman ◽  
...  
Keyword(s):  
Complication Rate ◽  
Cranial Nerve ◽  
Respiratory Complications ◽  
Postoperative Dysphagia ◽  
Endoscopic Endonasal ◽  
Lower Cranial Nerve ◽  
Cranial Nerve Dysfunction ◽  
Nerve Dysfunction ◽  
The Mean

OBJECTIVETreatment of odontoid disease from a ventral corridor has consisted of a transoral approach. More recently, the endoscopic endonasal approach (EEA) has been used to access odontoid pathology.METHODSA retrospective review was conducted of patients who underwent an EEA for odontoid pathology from 2004 to 2013. During our analysis, the mean follow-up duration was 42.6 months (range 1–80 months). Patient outcomes, complications, and postoperative swallowing function were assessed either by clinic visit or phone contact.RESULTSThirty-four patients underwent an EEA for symptomatic odontoid pathology. The most common pathology treated was basilar invagination (n = 17). Other pathologies included odontoid fractures, os odontoideum, and metastatic carcinoma. The mean patient age was 71.5 years. Thirty-one patients underwent a posterior fusion. All 34 patients experienced stability or improvement in symptoms and all had successful radiographic decompression. The overall complication rate was 76%. Nearly all of these complications were transient (86%) and the overall complication rate excluding mild transient dysphagia was only 44%. Twenty-one patients (62%) suffered from transient postoperative dysphagia: 15 cases were mild, transient subjective dysphagia (6 of whom had documented preoperative dysphagia), whereas 6 other patients required tube feedings for decreased oral intake, malnutrition, and dysphagia in the perioperative setting (5 of these patients had documented preoperative dysphagia). Sixteen patients had documented preoperative dysphagia and 6 of these had lower cranial nerve dysfunction. Postoperatively, 6 (37.5%) of 16 patients with preoperative dysphagia and 4 (67%) of 6 with lower cranial nerve dysfunction had significant dysphagia/respiratory complications. Eighteen patients had no documented preoperative dysphagia and only 2 had significant postoperative dysphagia/respiratory complications (11%). The rates of these complications in patients without preoperative dysphagia were lower than in those with any preoperative dysphagia (p = 0.07) and especially those with preexisting lower cranial neuropathies (p = 0.007). Dysphagia was also significantly more common in patients who underwent occipitocervical fixation (19/26, 73%) than in patients who underwent cervical fusion alone or no fusion (2/8, 25%; p = 0.02). All patients with perioperative dysphagia had improved at follow-up and all patients were tolerating oral diets. No patient suffered from velopalatal insufficiency. Two patients had intraoperative CSF leaks. One of these patients underwent a negative exploratory surgery for a questionable postoperative CSF leak. One patient developed infection in the resection bed requiring debridement and antibiotics. One patient died 8 days following surgery from an unknown cause. The 90-day perioperative mortality rate was 2.9%.CONCLUSIONSA completely EEA can be performed for compressive odontoid disease in all cases of neoplastic, degenerative, or invaginative atlantoaxial disease with satisfactory outcomes and low morbidity. Transient perioperative dysphagia and respiratory complications are common, usually as an exacerbation and reflection of underlying disease or occipitocervical fusion rather than the EEA, emphasizing the importance of avoiding transoral surgery.

scholarly journals Pathological satiety caused by brainstem hemangioblastoma

2008 ◽  
Vol 2 (6) ◽  
pp. 397-401 ◽  
Author(s):  
Debbie K. Song ◽  
Russell R. Lonser
Keyword(s):  
Tumor Resection ◽  
Sensory Impairment ◽  
Rapid Weight Gain ◽  
Lower Cranial Nerve ◽  
Von Hippel Lindau ◽  
Developmental Arrest ◽  
Cranial Nerve Dysfunction ◽  
Nerve Dysfunction ◽  
Gait Abnormalities ◽  
Vhl Disease

Because of the multiplicity and saltatory growth pattern associated with central nervous system hemangioblastomas in von Hippel-Lindau (VHL) disease, resection of individual tumors is usually reserved until symptoms occur, to avoid unnecessary surgery over the lifetime of a patient. Brainstem hemangioblastomas in VHL typically cause lower cranial nerve dysfunction, long-tract signs, sensory impairment, and gait abnormalities. The authors report on a 16-year-old girl with VHL who presented with abnormal early satiety resulting in growth and developmental arrest associated with a growing obex hemangioblastoma. Tumor resection resulted in restoration of appetite, with rapid weight gain, growth in stature, and onset of menses. These findings indicate that caudal brainstem-mediated mechanisms have a profound effect on satiety. Moreover, brainstem hemangioblastomas may present with abnormalities in satiety and feeding that can be effectively reversed with resection.

Rehabilitation of Lower Cranial Nerve Dysfunction

2005 ◽  
Vol 8 (1) ◽  
pp. 50-53
Author(s):  
Timothy D. Anderson ◽  
Eva Michalakis ◽  
Peter Catalano
Keyword(s):  
Cranial Nerve ◽  
Lower Cranial Nerve ◽  
Cranial Nerve Dysfunction ◽  
Nerve Dysfunction

Functional outcome after complete surgical removal of giant vestibular schwannomas

2010 ◽  
Vol 112 (4) ◽  
pp. 860-867 ◽  
Author(s):  
Madjid Samii ◽  
Venelin M. Gerganov ◽  
Amir Samii
Keyword(s):  
Mortality Rate ◽  
Facial Nerve ◽  
Nerve Function ◽  
Facial Nerve Function ◽  
Tumor Removal ◽  
Lower Cranial Nerve ◽  
Cranial Nerve Dysfunction ◽  
Group A ◽  
Nerve Dysfunction ◽  
Group B

Object The authors evaluated the outcome of radical surgery in a consecutive series of patients with giant vestibular schwannomas (VSs). Methods Fifty patients with VSs > 4.0 cm in maximal extrameatal diameter were included in this retrospective study (Group A). The group was compared with a matched group of 167 patients with VSs < 3.9 cm (Group B). In all cases the retrosigmoid approach was used. Outcome measures included completeness of tumor removal, facial nerve function, hearing, and the surgery-related complication rate. Results The mean tumor size in Group A was 4.4 cm and that in Group B was 2.3 cm. Total removal was achieved in all Group A patients and in 97.6% of Group B patients. The anatomical integrity of the facial nerve was preserved in 92% in Group A and in 98.8% in Group B. At last follow-up 75% of the patients with giant VSs had excellent or good facial nerve function, 19% had fair function, and 6% had poor function. In 33% of patients (3 cases) with good preoperative hearing level, it was preserved. Newly developed lower cranial nerve dysfunction occurred in 3 patients but proved to be temporary in 2 of them. A CSF leak developed in 6% of those who not previously undergone surgery. Compared with Group B, a significant difference was found only in the rates of the following parameters: excellent facial nerve function, useful and good hearing, lower cranial nerve dysfunction, and blood collection (p < 0.05). The perioperative mortality rate in both groups was 0%. Conclusions In patients with a giant VS, total tumor removal can be achieved via the retrosigmoid approach with a 0% mortality rate and low morbidity rate, especially with regards to facial nerve function. In selected cases even hearing preservation is possible. Tumor size significantly correlates with postoperative outcome.

Surgical Strategies for Recurrent Craniofacial Meningiomas

Neurosurgery ◽  
2006 ◽  
Vol 58 (5) ◽  
pp. 874-880 ◽  
Author(s):  
Ganesh Rao ◽  
Paul Klimo ◽  
Randy L. Jensen ◽  
Joel D. MacDonald ◽  
William T. Couldwell
Keyword(s):  
Tumor Resection ◽  
Cranial Base ◽  
High Rate ◽  
Surgical Strategies ◽  
University Of Utah ◽  
The Face ◽  
Treatment Paradigm ◽  
History Of ◽  
The Mean ◽  
The University

Abstract OBJECTIVE: Recurrent cranial base meningiomas are among the most difficult tumors to treat surgically. Although they are histologically benign, these tumors often invade through the cranial base into the infratemporal and pterygopalatine fossae. We reviewed our experience with these tumors to describe the natural history of these lesions as well as provide a possible treatment paradigm. METHODS: Between 2000 and 2004, seven patients with meningiomas recurring through the cranial base into facial structures were treated at the University of Utah. Five patients were treated with transcranial approaches only, and two were treated with a combination of transcranial and transfacial approaches. RESULTS: The average age of our patients (6 women, 1 man) was 55 years. The original site of tumor was the sphenoid wing in four patients, the middle fossa in two patients, and the left frontal region in one patient. The average interval between the most recent tumor resection and recurrence into the face was 9.9 years. The mean number of resections a patient underwent before invasion into the face was two. All but one patient had adjunctive therapy (including either radiation or chemotherapy) before recurrence into the face. CONCLUSION: Meningiomas that recur into facial structures present a unique treatment challenge. These lesions have a high rate of recurrence once they have invaded through the cranial base. Although combined approaches may be necessary to achieve a gross total resection, these lesions can often be reached using standard transcranial techniques.

scholarly journals Unruptured intracranial aneurysm presenting with epiletic seizure

2003 ◽  
Vol 61 (3A) ◽  
pp. 663-667 ◽  
Author(s):  
José C. Sena ◽  
Yves Reynier ◽  
Bernard Alliez
Keyword(s):  
Intracranial Aneurysm ◽  
Epileptic Seizure ◽  
Cranial Nerve ◽  
Intracranial Aneurysms ◽  
Intracranial Tumor ◽  
Unruptured Aneurysm ◽  
Unruptured Intracranial Aneurysm ◽  
Cranial Nerve Dysfunction ◽  
History Of ◽  
Nerve Dysfunction

Intracranial aneurysms are frequently present with subarachnoid hemorrhage.Less often they produce suggestive symptoms of cranial nerve dysfunction or intracranial tumor when very large. Their association with epilepsy has rarely been reported; such concurrence may not be a coincidence. When the patient presents with epileptiforme attacks the presence of an intracranial aneurysm is rarely considered. In this paper we report the case of a 45-years-old patient with an unruptured aneurysm of the middle cerebral artery with a 10 years history of epileptic seizure.

Basilar Invagination and Cranial Settling

2018 ◽  
pp. 49-62
Author(s):  
Benjamin D. Elder ◽  
Jean-Paul Wolinsky
Keyword(s):  
Magnetic Resonance Imaging ◽  
Computed Tomography ◽  
Skull Base ◽  
Basilar Invagination ◽  
Basilar Impression ◽  
Anterior Decompression ◽  
Upward Migration ◽  
Lower Cranial Nerve ◽  
Cranial Nerve Dysfunction ◽  
Nerve Dysfunction

Basilar impression represents the broader category of occipitocervical junction pathologies, including basilar impression, basilar invagination, and cranial settling. Basilar invagination results from migration of the entire spine into the skull base. Cranial settling is caused by C1–C2 instability, leading to upward migration and/or rotation of the C2 complex into the cranial vault. Platybasia results from deformation and flattening of the skull base. Many patients present with a combination of neck pain, myelopathy, and potentially lower cranial nerve dysfunction. Computed tomography and magnetic resonance imaging are used to clarify the complex osseous anatomy and compression of neural elements,. Patients with a reducible basilar invagination may be treated with posterior decompression and stabilization alone, while non-reducible or partially reducible invagination must be treated with anterior decompression and posterior stabilization. The goal of treatment is to prevent further neurological decline and provide adequate stabilization of the O-C junction.

scholarly journals Endoscopic Endonasal Transodontoid Approach for Degenerative Pseudotumor of the Craniocervical Junction

2019 ◽  
Vol 80 (S 04) ◽  
pp. S368-S369
Author(s):  
Andrew S. Venteicher ◽  
Ezequiel Goldschmidt ◽  
Michael M. McDowell ◽  
Eric W. Wang ◽  
Carl H. Snyderman ◽  
...  
Keyword(s):  
Odontoid Process ◽  
Mass Effect ◽  
Synovial Cyst ◽  
Craniocervical Junction ◽  
Posterior Fixation ◽  
Endoscopic Endonasal ◽  
Lower Cranial Nerve ◽  
Inferior Aspect ◽  
Cranial Nerve Dysfunction ◽  
Lower Clivus

AbstractVentral masses of the craniocervical junction threaten the medulla and upper spinal cord leading to lower cranial nerve dysfunction and myelopathy. Traditional transoral and newer endonasal approaches can access ventral pathology in this region, though both remain challenging due to the competing goals of achieving sufficient decompression, yet mitigating risk to nearby critical neurovascular structures. Transoral approaches have traditionally been avoided for degenerative pseudotumor which generally slowly regresses following posterior fixation. Here, we present two cases of patients with significant retroodontoid degenerative pseudotumor and pannus causing dysphagia and myelopathy. The first patient was found with a large broad pannus requiring a wide decompression extending from lower clivus to inferior aspect of the C1 arch and odontoid process. The second patient had a more focal mass effect due to pannus and synovial cyst at the level of the inferior half of C1 and midodontoid. Both patients underwent an endoscopic endonasal transodontoid approach for immediate decompression followed by a posterior C1–C2 fusion. In these surgical videos, we highlight anatomic considerations in this critical area, demonstrate nuances of technique, and outline strategies to avoid complications and maximize exposure.The link to the video can be found at: https://youtu.be/19I-GQYGIr4.

Presentation of Type I Chiari Malformation after Head Trauma

Neurosurgery ◽  
1988 ◽  
Vol 23 (6) ◽  
pp. 760-762 ◽  
Author(s):  
Thomas J. Mampalam ◽  
Brian T. Andrews ◽  
Douglas Gelb ◽  
Donna Ferriero ◽  
Lawrence H. Pitts
Keyword(s):  
Upper Extremity ◽  
Cranial Nerve ◽  
Chiari Malformation ◽  
Closed Head Injury ◽  
Magnetic Resonance Images ◽  
Type I ◽  
Lower Cranial Nerve ◽  
Cranial Nerve Dysfunction ◽  
Cranial Nerve Palsies ◽  
Nerve Dysfunction

Abstract An unusual case of Type I Chiari malformation that became symptomatic after closed head injury is reported. The patient manifested transient upper extremity weakness, persistent lower cranial nerve dysfunction, and cerebellar signs that slowly resolved. Magnetic resonance images showed tonsillar ectopia but no displacement of the brain stem or syringomyelia. Type I Chiari malformation should be included in the differential diagnosis of patients who present with upper extremity weakness, lower cranial nerve palsies, or cerebellar signs after trauma.

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