Cavernous malformations (CMs) arising in the cranial nerves are rare. Only a few cases of facial ... more Cavernous malformations (CMs) arising in the cranial nerves are rare. Only a few cases of facial nerve CMs have been reported in literature. case report and review of literature. A 52-year old lady presented with headache, unilateral worsening facial weakness and hearing loss. Imaging was suggestive of a CM of the cerebello-pontine angle. Intraoperatively, a mulberry shaped lesion was seen arising entirely within the seventh nerve. She underwent complete resection with sural nerve interposition graft. CM are very rare but should be included in the differential diagnosis of cerebello-pontine angle masses.
Background: Extracranial-Intracranial (EC-IC) bypass is increasingly used for treatment of hemody... more Background: Extracranial-Intracranial (EC-IC) bypass is increasingly used for treatment of hemodynamic failure in Moya-Moya disease (MMD) or syndrome (MMS). No specific imaging parameter has been established to determine bypass patency in these patients. We sought to determine if vasomotor reactivity (VMR) testing could be correlated with pre-operative angiographic data and predict bypass patency. Methods: All available pre-operative VMRs and diagnostic angiograms (DSA) in patients with EC-IC direct bypass surgeries performed at our institution from 2007-2019 were reviewed to determine the degree of pre-procedural hemispheric failure (by VMR to the inhalation of carbon dioxide and hyperventilation, abnormal defined by less than 70%) and collateral compensation (categorized as complete vs. incomplete collaterals by DSA). Bypass patency was assessed on follow-up imaging (either immediate in post-op angiogram and delayed subsequent CTA or DSA). Results: Of the 113 bypass surgeries perf...
Rotational vertebral artery (VA) occlusion syndrome, also known as bow hunter's syndrome, is ... more Rotational vertebral artery (VA) occlusion syndrome, also known as bow hunter's syndrome, is an uncommon variant of vertebrobasilar insufficiency typically occurring with head rotation.1-3 The most common presenting symptom is dizziness (76.8%), followed by visual abnormalities and syncope (50.4% and 40.4%, respectively).2 Osteophytic compression due to spinal spondylosis has been shown to be the most common etiology (46.2%), with other factors, such as a fibrous band, muscular compression, or spinal instability, being documented.1,2 Treatment is dependent on the level and site of VA compression with anterior, anterolateral, or posterior approaches being described.1,4 We present the case of a 72-yr-old male with osteophytic compression of the V3 segment of the vertebral artery at the occipital-cervical junction. The patient underwent a C1 hemilaminectomy and removal of osteophytic compression from the occipital-cervical joint. The patient had complete resolution of compression of his vertebral artery on postoperative imaging and remained neurologically intact following the procedure. We review the literature on this topic, the technical nuances of the procedure performed, and review the different treatment modalities available for this rare condition.1-11 The patient consented to the procedure and to publication of their image.
Fusiform middle cerebral artery (MCA) aneurysms that require treatment can often necessitate comp... more Fusiform middle cerebral artery (MCA) aneurysms that require treatment can often necessitate complex endovascular or microsurgical treatment. We present a case of a 25-yr-old female with an incidentally discovered left 14-mm fusiform MCA aneurysm incorporating the frontal MCA trunk origin in its dome. The location and anatomy were not favorable for endovascular treatment with flow diversion. The patient was offered continued observation or microsurgical treatment. Direct clipping of this aneurysm was not possible. After a thorough discussion of the risks, benefits, indications, and natural history of the lesion, the patient desired to have the aneurysm treated given her young age, location, size of the aneurysm, and the significant clinical experience of the treating team in bypass surgery. The patient underwent superficial temporal artery to frontal M2 (STA-FM2) direct bypass for flow replacement followed by microsurgical trapping and clip ligation. The patient was maintained on ...
In this 3D video we review the case of a pontomesencephalic cavernous malformation in a 27-year-o... more In this 3D video we review the case of a pontomesencephalic cavernous malformation in a 27-year-old woman who presented with hemiparesis and diplopia. The cavernous malformation was completely resected through a subtemporal transtentorial approach and an epitrigeminal brainstem entry zone, with a significant improvement in the patient’s hemiparesis. The relevant anatomy is reviewed in detail through multiple anatomical brainstem dissection specimens, as well as high-definition fiber tractography images. The rationale for the approach is analyzed relative to other possible options, and a number of technical pearls are provided.The video can be found here: https://youtu.be/8EoIWL7XqAc.
BACKGROUND Trigeminal neuralgia (TN), hemifacial spasm (HFS), and glossopharyngeal neuralgia (GPN... more BACKGROUND Trigeminal neuralgia (TN), hemifacial spasm (HFS), and glossopharyngeal neuralgia (GPN) are hyperactive dysfunction syndromes (HDS) commonly caused by microvascular compression of their root entry zone. Cases of combined HDS involving 2 or more of these entities are extremely rare. Although microvascular decompression is the surgical treatment of choice, there are additional techniques that have been described as efficient methods to accomplish vessel transposition. OBJECTIVE To our knowledge, we present the first reported case of triple simultaneous HDS successfully treated using the clip-sling technique to achieve microvascular decompression. We discuss several technical pearls and pitfalls relevant to the use of the sling suspension technique. METHODS We report the rare case of a 66-yr-old male with combined simultaneous unilateral right-sided TN, HFS, and GPN because of a dolichoectatic vertebrobasilar system compressing the exit zones of the right trigeminal, facial,...
The authors present a 3D surgical video of a direct occipital to angular artery bypass for cerebr... more The authors present a 3D surgical video of a direct occipital to angular artery bypass for cerebral revascularization in the setting of Post-irradiation middle cerebral artery stenosis and symptomatic hypoperfusion. The case refers to a 50-yr-old woman with a history of an unresectable residual skull base meningioma, previously approached through a left frontotemporal craniotomy, and treated with radiation 5 yr prior to presentation. She now presented with right-sided limb shaking transient ischemic attacks and aphasia, along with evidence of left middle cerebral artery territory ischemia. Her symptoms were progressive, despite extensive external carotid collateral blood supply through the prior craniotomy. The video analyzes the surgical steps of the procedure, emphasizing multiple surgical pearls. After positioning, an incision is designed to expose the full course of the occipital artery. After dissection of the donor vessel, a craniotomy is performed to expose the distal sylvian fissure. The donor and recipient vessels are prepared, and the anastomosis is performed with interrupted sutures given the sub-millimeter diameter of the recipient vessel (suture used: 10-0 Ethilon BV75-3 Taper, Ethicon, Johnson & Johnson). Every step of the closure is modified to avoid any constriction of the donor vessel. The patient tolerated the procedure well, and multiple modalities, both intra- and post operatively confirmed patency of, and robust flow within the bypass. No identifying patient information is included. However, the patient's consent was obtained for this publication.
BACKGROUND: Optimal postoperative management paradigm for brain metastases remains controversial.... more BACKGROUND: Optimal postoperative management paradigm for brain metastases remains controversial. OBJECTIVE: To conduct a systematic review of the literature to understand the role of postoperative stereotactic radiosurgery after resection of brain metastases. METHODS: We performed a MEDLINE search of the literature to identify series of patients with brain metastases treated with stereotactic radiosurgery after surgical resection. Outcomes including overall survival, local control, distant intracranial failure, and salvage therapy use were recorded. Patient, tumor, and treatment factors were correlated with outcomes through the use of the Pearson correlation and 2-way Student t test as appropriate. RESULTS: Fourteen studies involving 629 patients were included. Median survival for all studies was 14 months. Local control was correlated with the median volume treated with radiosurgery (r = −0.766, P < .05) and with the rate of gross total resection (r = .728, P < .03). Mean cr...
We present the case of a 34-yr-old male who suffered repeated ischemic events resulting in right-... more We present the case of a 34-yr-old male who suffered repeated ischemic events resulting in right-sided weakness. He was found to have left M1 segment near occlusion on angiography with a large area of uncompensated hypoperfusion. The patient underwent a direct superficial temporal artery-middle cerebral artery (STA-MCA) bypass. Direct bypass in the acute setting of ischemia has been previously described.1-5 Moyamoya ischemic disease can be treated with either direct or indirect surgical revascularization. There have been several techniques developed for direct bypasses in moyamoya ischemic disease. These include the standard 1-donor 1-recipient (1D1R) end-to-side (ES) bypass, the “double-barrel” 2-donor 2-recipient (2D2R) ES bypass, and the more recently developed 1-donor 2-recipient (1D2R)6,7 utilizing both an ES and a side-to-side (SS) bypass with a 1-donor vessel. The case presentation, surgical anatomy, decision-making, operative nuances, and postoperative course and outcome are...
Cavernous malformations (CMs) arising in the cranial nerves are rare. Only a few cases of facial ... more Cavernous malformations (CMs) arising in the cranial nerves are rare. Only a few cases of facial nerve CMs have been reported in literature. case report and review of literature. A 52-year old lady presented with headache, unilateral worsening facial weakness and hearing loss. Imaging was suggestive of a CM of the cerebello-pontine angle. Intraoperatively, a mulberry shaped lesion was seen arising entirely within the seventh nerve. She underwent complete resection with sural nerve interposition graft. CM are very rare but should be included in the differential diagnosis of cerebello-pontine angle masses.
Background: Extracranial-Intracranial (EC-IC) bypass is increasingly used for treatment of hemody... more Background: Extracranial-Intracranial (EC-IC) bypass is increasingly used for treatment of hemodynamic failure in Moya-Moya disease (MMD) or syndrome (MMS). No specific imaging parameter has been established to determine bypass patency in these patients. We sought to determine if vasomotor reactivity (VMR) testing could be correlated with pre-operative angiographic data and predict bypass patency. Methods: All available pre-operative VMRs and diagnostic angiograms (DSA) in patients with EC-IC direct bypass surgeries performed at our institution from 2007-2019 were reviewed to determine the degree of pre-procedural hemispheric failure (by VMR to the inhalation of carbon dioxide and hyperventilation, abnormal defined by less than 70%) and collateral compensation (categorized as complete vs. incomplete collaterals by DSA). Bypass patency was assessed on follow-up imaging (either immediate in post-op angiogram and delayed subsequent CTA or DSA). Results: Of the 113 bypass surgeries perf...
Rotational vertebral artery (VA) occlusion syndrome, also known as bow hunter's syndrome, is ... more Rotational vertebral artery (VA) occlusion syndrome, also known as bow hunter's syndrome, is an uncommon variant of vertebrobasilar insufficiency typically occurring with head rotation.1-3 The most common presenting symptom is dizziness (76.8%), followed by visual abnormalities and syncope (50.4% and 40.4%, respectively).2 Osteophytic compression due to spinal spondylosis has been shown to be the most common etiology (46.2%), with other factors, such as a fibrous band, muscular compression, or spinal instability, being documented.1,2 Treatment is dependent on the level and site of VA compression with anterior, anterolateral, or posterior approaches being described.1,4 We present the case of a 72-yr-old male with osteophytic compression of the V3 segment of the vertebral artery at the occipital-cervical junction. The patient underwent a C1 hemilaminectomy and removal of osteophytic compression from the occipital-cervical joint. The patient had complete resolution of compression of his vertebral artery on postoperative imaging and remained neurologically intact following the procedure. We review the literature on this topic, the technical nuances of the procedure performed, and review the different treatment modalities available for this rare condition.1-11 The patient consented to the procedure and to publication of their image.
Fusiform middle cerebral artery (MCA) aneurysms that require treatment can often necessitate comp... more Fusiform middle cerebral artery (MCA) aneurysms that require treatment can often necessitate complex endovascular or microsurgical treatment. We present a case of a 25-yr-old female with an incidentally discovered left 14-mm fusiform MCA aneurysm incorporating the frontal MCA trunk origin in its dome. The location and anatomy were not favorable for endovascular treatment with flow diversion. The patient was offered continued observation or microsurgical treatment. Direct clipping of this aneurysm was not possible. After a thorough discussion of the risks, benefits, indications, and natural history of the lesion, the patient desired to have the aneurysm treated given her young age, location, size of the aneurysm, and the significant clinical experience of the treating team in bypass surgery. The patient underwent superficial temporal artery to frontal M2 (STA-FM2) direct bypass for flow replacement followed by microsurgical trapping and clip ligation. The patient was maintained on ...
In this 3D video we review the case of a pontomesencephalic cavernous malformation in a 27-year-o... more In this 3D video we review the case of a pontomesencephalic cavernous malformation in a 27-year-old woman who presented with hemiparesis and diplopia. The cavernous malformation was completely resected through a subtemporal transtentorial approach and an epitrigeminal brainstem entry zone, with a significant improvement in the patient’s hemiparesis. The relevant anatomy is reviewed in detail through multiple anatomical brainstem dissection specimens, as well as high-definition fiber tractography images. The rationale for the approach is analyzed relative to other possible options, and a number of technical pearls are provided.The video can be found here: https://youtu.be/8EoIWL7XqAc.
BACKGROUND Trigeminal neuralgia (TN), hemifacial spasm (HFS), and glossopharyngeal neuralgia (GPN... more BACKGROUND Trigeminal neuralgia (TN), hemifacial spasm (HFS), and glossopharyngeal neuralgia (GPN) are hyperactive dysfunction syndromes (HDS) commonly caused by microvascular compression of their root entry zone. Cases of combined HDS involving 2 or more of these entities are extremely rare. Although microvascular decompression is the surgical treatment of choice, there are additional techniques that have been described as efficient methods to accomplish vessel transposition. OBJECTIVE To our knowledge, we present the first reported case of triple simultaneous HDS successfully treated using the clip-sling technique to achieve microvascular decompression. We discuss several technical pearls and pitfalls relevant to the use of the sling suspension technique. METHODS We report the rare case of a 66-yr-old male with combined simultaneous unilateral right-sided TN, HFS, and GPN because of a dolichoectatic vertebrobasilar system compressing the exit zones of the right trigeminal, facial,...
The authors present a 3D surgical video of a direct occipital to angular artery bypass for cerebr... more The authors present a 3D surgical video of a direct occipital to angular artery bypass for cerebral revascularization in the setting of Post-irradiation middle cerebral artery stenosis and symptomatic hypoperfusion. The case refers to a 50-yr-old woman with a history of an unresectable residual skull base meningioma, previously approached through a left frontotemporal craniotomy, and treated with radiation 5 yr prior to presentation. She now presented with right-sided limb shaking transient ischemic attacks and aphasia, along with evidence of left middle cerebral artery territory ischemia. Her symptoms were progressive, despite extensive external carotid collateral blood supply through the prior craniotomy. The video analyzes the surgical steps of the procedure, emphasizing multiple surgical pearls. After positioning, an incision is designed to expose the full course of the occipital artery. After dissection of the donor vessel, a craniotomy is performed to expose the distal sylvian fissure. The donor and recipient vessels are prepared, and the anastomosis is performed with interrupted sutures given the sub-millimeter diameter of the recipient vessel (suture used: 10-0 Ethilon BV75-3 Taper, Ethicon, Johnson & Johnson). Every step of the closure is modified to avoid any constriction of the donor vessel. The patient tolerated the procedure well, and multiple modalities, both intra- and post operatively confirmed patency of, and robust flow within the bypass. No identifying patient information is included. However, the patient's consent was obtained for this publication.
BACKGROUND: Optimal postoperative management paradigm for brain metastases remains controversial.... more BACKGROUND: Optimal postoperative management paradigm for brain metastases remains controversial. OBJECTIVE: To conduct a systematic review of the literature to understand the role of postoperative stereotactic radiosurgery after resection of brain metastases. METHODS: We performed a MEDLINE search of the literature to identify series of patients with brain metastases treated with stereotactic radiosurgery after surgical resection. Outcomes including overall survival, local control, distant intracranial failure, and salvage therapy use were recorded. Patient, tumor, and treatment factors were correlated with outcomes through the use of the Pearson correlation and 2-way Student t test as appropriate. RESULTS: Fourteen studies involving 629 patients were included. Median survival for all studies was 14 months. Local control was correlated with the median volume treated with radiosurgery (r = −0.766, P < .05) and with the rate of gross total resection (r = .728, P < .03). Mean cr...
We present the case of a 34-yr-old male who suffered repeated ischemic events resulting in right-... more We present the case of a 34-yr-old male who suffered repeated ischemic events resulting in right-sided weakness. He was found to have left M1 segment near occlusion on angiography with a large area of uncompensated hypoperfusion. The patient underwent a direct superficial temporal artery-middle cerebral artery (STA-MCA) bypass. Direct bypass in the acute setting of ischemia has been previously described.1-5 Moyamoya ischemic disease can be treated with either direct or indirect surgical revascularization. There have been several techniques developed for direct bypasses in moyamoya ischemic disease. These include the standard 1-donor 1-recipient (1D1R) end-to-side (ES) bypass, the “double-barrel” 2-donor 2-recipient (2D2R) ES bypass, and the more recently developed 1-donor 2-recipient (1D2R)6,7 utilizing both an ES and a side-to-side (SS) bypass with a 1-donor vessel. The case presentation, surgical anatomy, decision-making, operative nuances, and postoperative course and outcome are...
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