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The intravascular use of the rapidly polymerizing acrylic compound isobutyl 2-cyanoacrylate in four patients with carotid-cavernous fistulas is described. The monomer was injected into the cavernous sinus at craniotomy after the intraoperative angiographic identification of the fistula site and the origin of its venous drainage. All patients had postoperative angiographic documentation of fistula closure and confirmed carotid artery patency. There was no operative mortality or permanent neurological morbidity. Two patients (50%) suffered transient dysfunction in the immediate postoperative period of one of the cranial nerves that transit the cavernous sinus.

The intravascular use of the rapidly polymerizing acrylic compound, isobutyl 2-cyanoacrylate (IBC), in 10 patients with intracranial arteriovenous malformations (AVMs) is described. The monomer was introduced into each malformation at craniotomy using angiographic control and microvascular dissection technique to identify, isolate, and inject the major components of each vascular lesion while attempting to preserve normal arterial circulation. Postoperative angiography was used routinely to evaluate the results of IBC embolization. Four patients underwent the injection and immediate surgical excision of an intracranial AVM, and 6 underwent injection alone; 3 of the latter had residual malformation demonstrated on postoperative angiography, and 1 of these patients had the remnants of her malformation occluded by a second embolic procedure. There was no operative mortality nor permanent neurological morbidity. Three patients suffered transient neurological dysfunction in the immediate postoperative period.

Penetrating injuries of the internal carotid artery at the base of the skull often require permanent or transient occlusion of the injured vessel during repair. Extracranial-intracranial bypass (EC-IC) was employed in five patients to insure adequate cerebral perfusion during cervical exploration. Preoperative neurologic deficits were noted in three patients; two demonstrated complete reversal following EC-IC. This experience suggests that EC-IC can maintain adequate cerebral perfusion during repair of internal carotid injuries and allow selective revascularization of patients with neurologic deficit and carotid occlusion.

Recurrent transient neurologic deficits were evaluated clinically in four patients. In three patients, the symptoms included recurrent transient homonymous hemianopia, episodic weakness and numbness of the left arm and leg, and recurrent sudden loss of speech and of strength in the right arm. In these three patients, the episodes were first thought to be transient ischemic attacks (TIAs). A fourth patient had repeated confusional spells, in which a recurrent musical theme excluded other thoughts. This was associated with dizziness and difficulty in naming. A partial complex seizure was thought responsible. In each of the cases the symptoms lasted less than 30 minutes and were not associated with loss of consciousness, headache, or stiff neck. Electroencephalogram (EEG), brain scan, lumbar puncture, and computed tomography (CT) scan were normal. In all patients, cerebral arteriography unexpectedly revealed an unruptured cerebral aneurysm. The locations of the aneurysms were appropriate to the symptoms, which remitted in the three patients treated surgically for the aneurysm. Although the pathophysiology is uncertain, an ischemic process may be implicated.

A case of traumatic middle cerebral artery aneurysm is presented. The case demonstrates some of the difficulties encountered when dealing with this type of aneurysm. The unusual surgical approach required for obliteration is described.

Dorsal root entry zone lesions have been documented as effective for control of intractable pain in patients with brachial plexus avulsion or severe spinal cord injury. These lesions are usually made with the radiofrequency technique. The authors report three cases in which the CO2 laser was used as an alternative means of making the lesions. This latter technique provided effective pain relief in two of the patients and was efficient to use. It was noted that the presence of overlying scar tissue can be deceptive in judging the depth of the lesion made with the laser. The CO2 laser provided a means of producing controlled spinal cord lesions which may be more precise than the radiofrequency method.

Extracranial-intracranial arterial bypass procedures provide important augmentation of collateral circulation to cortical areas rendered potentially ischemic by therapeutic occlusion of major branches of the circle of Willis. Although the case studies reported to date in general reflect positively on this use of the bypass procedure, this report of a patient who failed to tolerate acute middle cerebral artery occlusion despite the presence of a patent superficial temporal-middle cerebral artery branch anastomosis points up several of the practical and theoretical limitations of this therapeutic approach. Certain modifications of the timing of the bypass procedure, the selection of donor and recipient arteries, and the mechanics of intracranial arterial occlusion may allow a wider application of extracranial-intracranial arterial bypass in this therapeutic setting.