Combined standard bypass and parent artery occlusion for management of giant and complex internal carotid artery aneurysms

BackgroundComplex aneurysms do not have a standard protocol for treatment. In this study, we investigate the safety and efficacy of microsurgical revascularization combined with parent artery occlusion (PAO) in giant and complex internal carotid artery (ICA) aneurysms.MethodsBetween 1998 and 2017, 41 patients with 47 giant and complex ICA aneurysms were treated by an a priori planned combined treatment strategy. Clinical and radiological outcomes were stratified according to mRS and Raymond classification. Bypass patency was assessed. Median follow-up time was 3.9 years.ResultsAfter successful STA–MCA bypass, staged endovascular (n=37) or surgical (n=1) PAO was executed in 38 patients following a negative balloon occlusion test. Intolerance to PAO led to stent/coil treatments in two patients. Perioperative bypass patency was confirmed in 100% of completed STA–MCA bypass procedures. Long-term overall bypass patency rate was 99%. Raymond 1 occlusion and good outcome were achieved in 95% and 97% (mRS 0–2) of cases, respectively. No procedure-related mortality was encountered. Eighty-four percent of patients with preoperative cranial nerve compression syndromes improved during follow-up.ConclusionsThe combined approach of STA-MCA bypass surgery followed by parent artery occlusion achieves high aneurysm occlusion and low morbidity rates in the management of giant and complex ICA aneurysms. This combined indirect approach represents a viable alternative to flow diversion in patients with cranial nerve compression syndromes or matricidal aneurysms, and may serve as a backup strategy in cases of peri-interventional complications or lack of suitable endovascular access.

Treatment of Peripheral Nerve Compression Syndromes of the Upper Extremities: a Systematic Review

Background Nerve compression syndromes are referred to as chronic irritation or pressure palsies of peripheral nerves in areas of preformed anatomical constriction. Carpal tunnel syndrome is the most common nerve compression syndrome, followed by cubital tunnel syndrome. In addition, less frequent nerve compression syndromes of the upper extremities that affect the median, ulnar or radial nerves have been described. This review provides an overview of current treatment options for nerve compression syndromes of the upper extremities. Study Design Systematic overview. Methods Based on established national (AWMF) and international guidelines as well as the Cochrane Library, we performed a systematic literature search on PubMed (NLM), focusing on randomised controlled trials. Results Over the research period (2012 – 2020), there were 43 randomised trials that investigated surgical carpal tunnel release methods, 68 that compared different conservative therapies and 12 that compared surgical versus conservative treatments. Furthermore, eight studies analysed surgical techniques and four analysed conservative techniques for cubital tunnel syndrome. No randomised trials were conducted on the less common peripheral nerve compression syndromes, but case reports and observational studies were conducted. Conclusion For carpal and cubital tunnel syndromes, there are evidence-based diagnostic methods as well as therapeutic recommendations based on randomised and controlled trials. When diagnosis is made after clinical examination and supported by radiological and electrophysiological evaluation, surgical treatment is considered superior to conservative treatment. In particular, excellent long-term results can be achieved by surgery for carpal and cubital tunnel syndromes. More controlled studies are needed to establish evidence-based therapeutic recommendations for the less common nerve compression syndromes, which are somewhat controversially and inconsistently defined.

Neurological disorders in pregnancy

Neurological disorders in pregnancy (NDPs) pose challenges to both obstetricians and neurologists. These diseases or their treatment may have adverse effects on the health of the fetus or complicate the course of the pregnancy, delivery, and postpartum period. Vice versa, the metabolic and endocrine changes associated with pregnancy may affect the mother’s neurological health. The care for a patient with an NDP is further complicated by the lack of clinical studies in this population, misinformation of patients regarding the risks associated with pregnancy when suffering from a neurological condition, and insecurity on the part of many physicians confronted with this constellation. Three different scenarios regarding the interdependency of pregnancy and neurological disease are possible. Most patients with NDPs suffer from a pre-existing condition such as epilepsy or multiple sclerosis, whose occurrence is unrelated to the pregnancy per se but nonetheless raises specific pregnancy-related concerns. The second group of NDP patients is afflicted with a neurological disorder observed with increased incidence during pregnancy (e.g. cerebrovascular disease and peripheral nerve compression syndromes). The third category comprises patients suffering from conditions exclusively seen in the pregnant, for example (pre-)eclampsia and amniotic fluid embolism. The subdivisions delineated here are reflected in the organization of this chapter. The aim is to provide a practical overview of the most frequent neurological conditions in childbearing women, highlighting the pregnancy-related issues and focusing on the management of these patients, which requires a highly interdisciplinary approach.