Rangel Castilla, Leonardo

Abstract Spinal cord meningiomas are rare, benign lesions typically found at the cervical or thoracic spinal region. They can cause symptoms through compression of the spinal cord and nerve roots. These tumors often have a challenging surgical course due to their location in relation to spinal cord and nerve rootlets. We present a 33-yr-old female who presented with cervical radicular and myelopathy symptoms. MRI of the cervical spinal demonstrated an anterolateral, 3 cm intradural, extrameduallary tumor causing significant cord compression at C6-7 level. The patient was taken to surgery for cervical laminoplasty and microsurgical tumor removal. The current 3-dimensional video demonstrates the steps involved during the microsurgical resection of the tumor. In order to facilitate spinal cord rotation without compromising blood supply the dentate ligaments at 3 levels (C5-C7) were identified and transected, the anterolateral-situated tumor was separated from the exiting right C6 and C7 nerve rootlet followed by circumferential dissection, and subsequent en bloc resection. No complications were encountered during the procedure; somatosensory and motor evoked potential registration remained intact. The patient recovered well from the procedure and was discharged on postoperative day three with improvement in her presenting symptoms.

Objectives Remote ischemic preconditioning has been proposed as a possible potential treatment for ischemic stroke. However, neuroprotective benefits of the pre-procedural administration of remote ischemic preconditioning have not been investigated in patients undergoing an elective endovascular intracranial aneurysm repair procedure. This study investigated the safety and feasibility of remote ischemic preconditioning in patients with an unruptured intracranial aneurysm who undergo elective endovascular treatment. Methods In this single-center prospective study, patients with an unruptured intracranial aneurysm undergoing elective endovascular treatment with flow diverters or coiling were recruited. Patients received three intermittent cycles of 5 minutes arm ischemia followed by reperfusion using manual blood cuff inflation/deflation less than 5 hours prior to endovascular treatment. Patients were monitored and followed up for remote ischemic preconditioning-related adverse events and ischemic brain lesions by diffusion -weighted magnetic resonance imaging within 48 hours following endovascular treatment. Results A total of seven patients aged 60 ± 5 years with an unruptured intracranial aneurysm successfully completed a total of 21 sessions of remote ischemic preconditioning and the required procedures. Except for two patients who developed skin petechiae over their arms, no other serious procedure-related adverse events were observed as a result of the remote ischemic preconditioning procedure. On follow-up diffusion -weighted magnetic resonance imaging, a total of 19 ischemic brain lesions with a median (interquartile range) volume of 245 (61–466) mm 3 were found in four out of seven patients. Conclusions The application of remote ischemic preconditioning prior to endovascular intracranial aneurysm repair was well tolerated, safe and clinically feasible. Larger sham-controlled clinical trials are required to determine the safety and efficacy of this therapeutic strategy in mitigating ischemic damage following endovascular treatment of intracranial aneurysms.

Abstract Herein, we demonstrate a case of a large, wide-necked, basilar apex aneurysm (BAA) that was treated with neck reconstruction-assisted coil embolization using the PulseRider device (PulsarVascular, Los Gatos, California), a novel neck-reconstruction device. A 68-yr-old man was found to have large BAA during work-up for sinusitis. Computed tomography angiogram revealed an 11 × 10-mm BAA. Patient has history of coronary artery disease, atrial fibrillation (currently taking Warfarin), recent left hip replacement and right femoral bypass. Treatment of the aneurysm was advised due to its location and size. Microsurgical clip reconstruction was high risk for general anesthesia due to his medical comorbidities and anticoagulation. Wide-necked bifurcation aneurysms are challenging to treat with traditional balloon- or stent-assisted techniques. To mitigate these challenges, novel neck-reconstruction devices have been developed. The Pulsar is one of these neck-reconstruction devices that removes the need to selectively catheterize branch arteries; it is available in a “Y” and “T” configuration. Under conscious sedation and through a radial artery approach, the patient underwent endovascular reconstruction of BAA with Pulsar device and coils. A 6-Fr guide catheter, a 0.021" microcatheter for the Pulsar device and a 0.017" microcatheter for coil delivering were used. A 3 × 8.6 mm Pulsar device was selected based on aneurysm neck and basilar artery measurements. Complete embolization (Raymond-Roy 1 obliteration) of the aneurysm was successfully achieved with no complications. The patient remained neurologically intact and was discharged on postoperative day 1. Parts of this video were published in Intracranial Aneurysms (1st Edition), Ringer (Ed), online companion to chapter 33B, Copyright Elsevier (2018).

Abstract Cavernous malformations (CM) of the anterior midbrain are best reached through an orbitozygomatic (OZ) approach with removal of the orbital rim and wide Sylvian fissure dissection. Our surgical video demonstrates this approach to resect a ruptured CM in a 36-yr-old woman who presented with headaches, left face and left arm paresthesias/weakness, and right-sided partial oculomotor nerve (CN III) palsy. Initial magnetic resonance imaging (MRI) showed a midbrain CM, and the patient was managed conservatively. However, 1 wk later, she presented again with worsened left arm and leg weakness and complete CN III palsy. Seven Tesla MRI demonstrated a larger hematoma, and the CM with new mass effect and upper pons extension. The patient underwent a right modified OZ craniotomy and Sylvian fissure split under guidance of intraoperative neuronavigation and with neuromonitoring. The carotid-oculomotor triangle and the Liliequist membrane were dissected to access the midbrain, and CN III was identified and followed posteriorly to the midbrain. Confirmed with neuronavigation, a longitudinal incision of the midbrain was performed, and the CM was encountered. The hematoma and CM were debulked and removed in a piece-meal fashion, leaving hemosiderin-stained brain intact to prevent unnecessary additional damage to the midbrain. Postoperative MRI confirmed gross-total resection, and the patient's weakness recovered substantially. In this video, we demonstrate that the brainstem is no longer forbidden surgical territory, and show how the use of neuronavigation for surgical planning, positioning, and approach, in addition to the understanding of safe entry zones and meticulous microsurgical technique have made safe and effective surgery on the brainstem possible.

Abstract Middle cerebral artery (MCA) aneurysms often have an irregular morphology that might require creative clipping techniques even in the case of small aneurysms. In this video, we illustrate the case of a patient with an incidental but very irregular MCA aneurysm. The presence of 2 separate, asymmetric lobes was dealt with by utilizing the “interlocking” clip technique in which a regular clip is used to obliterate 1 portion of the aneurysm and a fenestrated clip, with the ring of the fenestration circling the body of the first clip, is used to obtain obliteration of the other lobe. This patient also had a contralateral internal carotid artery occlusion, and we discuss the pitfalls of temporary clipping in such a situation.