Piepgras, David G.

Background and Purpose— Chronic inflammation is postulated as an important phenomenon in intracranial aneurysm wall pathophysiology. This study was conducted to determine if aspirin use impacts the occurrence of intracranial aneurysm rupture. Methods— Subjects enrolled in the International Study of Unruptured Intracranial Aneurysms (ISUIA) were selected from the prospective untreated cohort (n=1691) in a nested case–control study. Cases were subjects who subsequently had a proven aneurysmal subarachnoid hemorrhage during a 5-year follow-up period. Four control subjects were matched to each case by site and size of aneurysm (58 cases, 213 control subjects). Frequency of aspirin use was determined at baseline interview. Aspirin frequency groups were analyzed for risk of aneurysmal hemorrhage. Bivariable and multivariable analyses were performed using conditional logistic regression. Results— A trend of a protective effect for risk of unruptured intracranial aneurysm rupture was observed. Patients who used aspirin 3× weekly to daily had an OR for hemorrhage of 0.40 (95% CI, 0.18–0.87); reference group, no use of aspirin), patients in the “< once a month” group had an OR of 0.80 (95% CI, 0.31–2.05), and patients in the “> once a month to 2×/week” group had an OR of 0.87 (95% CI, 0.27–2.81; P =0.025). In multivariable risk factor analyses, patients who used aspirin 3 times weekly to daily had a significantly lower odds of hemorrhage (adjusted OR, 0.27; 95% CI, 0.11–0.67; P =0.03) compared with those who never take aspirin. Conclusions— Frequent aspirin use may confer a protective effect for risk of intracranial aneurysm rupture. Future investigation in animal models and clinical studies is needed.

Abstract BACKGROUND: Ventral spinal epidural meningeal cysts are rare entities for which the pathogenesis is poorly understood. OBJECTIVE: We present the clinical, radiographic, surgical, and pathologic findings of 4 patients with extensive ventral spinal epidural meningeal cysts and review the relevant literature. In addition, we discuss a suspected mechanism for pathogenesis. METHODS: Four patients with anterior spinal epidural meningeal cysts are retrospectively reviewed. RESULTS: Ventral spinal epidural meningeal cysts are often large, extending on average from C2 to L1 in our series. Patients typically present with a prolonged course of symptoms and signs, including segmental muscle weakness and atrophy, subtle myelopathy, mild to moderate spinal pain, and headache. Histopathologic analysis of the cyst wall demonstrates collagenous tissue consistent with dura but without arachnoid features. Dynamic computed tomographic myelography is the study of choice for localization of the primary dural defect. Patient symptoms and neurological deficits routinely improve after appropriate surgical intervention. CONCLUSION: Diverse signs and symptoms herald the presentation of ventral spinal meningoceles. Intraoperative, radiographic, and pathological findings are all suggestive of an intradural dissection as the etiology. Hence, they may be more appropriately named “ventral spinal intradural dissecting meningoceles.” Definitive treatment involves identification and obliteration of the dural defect.

Background and Purpose Among patients with spontaneous cervical artery dissections, the risk of recurrent arterial dissection is relatively low at 1% per year, but this risk may be higher for patients with a family history of arterial dissections. We compared the risk of a recurrent arterial dissection in patients with familial versus nonfamilial disease. Methods Long-term follow-up was established in 200 patients (104 women and 96 men with a mean age of 44.9 years) with spontaneous cervical artery dissections evaluated at a single institution between 1970 and 1990. Results Among the 200 patients, 10 (5%) were identified who had a family history of spontaneous arterial dissections. In a multivariate analysis, family history was the only significant variable associated with the risk of recurrent dissection (χ 2 =15.51; P =.0001). A recurrent arterial dissection was identified in 5 (50%) of the 10 patients with familial disease compared with 11 (5.8%) of the 190 patients with nonfamilial disease, with an estimated relative risk of 6.3 (95% confidence interval, 2.2 to 18.3; P =.0007). Conclusions Among patients with spontaneous cervical artery dissections, a family history of arterial dissection is an important risk factor for the development of a recurrent arterial dissection.

Background and Purpose —Patients with hereditary hemorrhagic telangiectasia (HHT) are at risk for developing cerebral vascular malformations and pulmonary arteriovenous fistulae. We assessed the risk of neurological dysfunction from these malformations and fistulae. Methods —Three hundred twenty-one consecutive patients with HHT seen at a single institution over a 20-year period were studied. Any evidence of prior neurological symptoms or presence of an intracranial vascular malformation was recorded. All cases of possible cerebral arteriovenous malformation were confirmed by conventional arteriography. Results —Twelve patients (3.7%) had a history of cerebral vascular malformations. Ten patients had arteriovenous malformations, 1 had a dural arteriovenous fistula, and 1 had a cavernous malformation. Seven patients (2.1%) presented with intracranial hemorrhage, 2 presented with seizures alone, and 3 were discovered incidentally. The average age at the time of symptomatic intracranial hemorrhage was 25.4 years. All patients with a history of intracranial hemorrhage were classified as Rankin grade I or II at a mean follow-up interval of 6.0 years. A history of cerebral infarction or transient ischemic attack was found in 29.6% of patients with HHT and a pulmonary arteriovenous fistula. Conclusions —The risk of intracranial hemorrhage is low among people with HHT. Furthermore, a majority of these patients have a good functional outcome after hemorrhage. The data do not suggest a compelling indication for routine screening of patients with HHT for asymptomatic cerebral vascular malformations. By comparison, pulmonary arteriovenous fistulae are a much more frequent cause of neurological symptoms in this population.

Abstract Modern aneurysm clips with newer metallurgic properties and state-of-the-art designs have evolved through the years. Regretfully, manufacturers are still not required to provide product information regarding clip strength, and when such information is supplied, there is no interbrand consistency to how it is obtained. This experiment compares the closing pressures of 5 commonly used brands of aneurysm clips: Yasargil, Sugita, Sundt-Kees, Vari-Angle McFadden, and Heifetz. Interclip comparison is also made of opening pressures, that is, the arterial pressure required to open an aneurysm clip. Findings show a distinct difference in closing forces among these brands of aneurysm clips. The study of opening forces indicates that the important factors determining clip release or displacement were the failure of the clip to cross the vessel completely and intrinsic characteristics of the vascular wall. (Neurosurgery 26:80-85, 1990)

Abstract Neurofibromatosis is of particular interest to neurosurgeons because of the various central and peripheral nervous system tumors and, more rarely, cervicocerebral arterial lesions associated with the disease. In the present paper, we report two patients with neurofibromatosis Type 1 (von Recklinghausen's disease) who had anomalies of the extracranial vertebral arteries. A large extracranial vertebral artery' aneurysm was incidentally discovered in the first patient, a 43-year-old woman, after rupture of a subclavian artery aneurysm. The second patient, a 28-year-old woman, had an enlarging neck mass and was found to have an extensive extracranial vertebral artery arteriovenous fistula. The vascular lesions associated with neurofibromatosis Type 1 in general and those arising from the extracranial vertebral artery in particular are reviewed.

Background and Purpose— The purpose of this study was to determine and compare the rate of stroke, myocardial infarction, and death in patients undergoing early and late carotid endarterectomy (CEA) after a symptomatic event and in asymptomatic patients. Methods— We conducted a retrospective analysis of all CEAs performed in the Department of Neurosurgery between January 2004 and May 2009. Patients were divided into 3 groups: Group 1, asymptomatic patients; Group 2, symptomatic patients operated on >2 weeks after their transient ischemic attack or stroke; and Group 3, symptomatic patients operated on ≤2 weeks of their transient ischemic attack or stroke. Primary outcomes were any myocardial infarction, stroke, or death occurring within 30 days postoperatively. The secondary end point was transient ischemic attack within 30 days postoperatively. Results— Five hundred thirty-two CEAs were performed on 507 patients during the study period. Thirty-day follow-up was available for 500 patients with 525 CEAs. Groups 1, 2, and 3 consisted of 278, 105, and 142 CEAs, respectively. In total, 12 patients had primary outcomes. In Group 1, 5 patients had primary outcomes of stroke, myocardial infarction, or death (1.8%); in Group 2, 1 patient had primary outcomes (1.0%); and in Group 3, 6 patients had primary outcomes (4.2%). There was no significant difference in the rate of primary outcomes among the 3 groups ( P =0.17) or when Groups 2 and 3 were compared ( P =0.24). Conclusions— Although the perioperative risk of transient ischemic attacks, stroke, death, and myocardial infarction is slightly higher in symptomatic patients operated on early, CEA can be done with an acceptable risk in properly selected symptomatic patients within 2 weeks of their transient ischemic attack or stroke.