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Object: Preoperative embolization is viewed by the authors as a useful adjunct in the surgical management of cerebral arteriovenous malformations (AVMs). This study was performed to determine the rate of significant complication in patients undergoing this procedure., Methods: Demographic, anatomical, and procedure data were collected prospectively. The treating physician reported complications. In addition, a review of medical records including procedure reports, operative reports, and discharge summaries was performed. Univariate statistical analysis was performed to determine if any of the variables was predictive of a poor outcome of embolization (death or permanent neurological deficit). Endovascular procedures for embolization were performed 339 times in 201 patients during an 11-year period. Female patients comprised 53.7% of the study group and 85.6% of the AVMs were supratentorial. Embolization was performed using polyvinyl alcohol particles, N-butyl cyanoacrylate, detachable coils, and/or the liquid polymer Onyx. Analyzed by procedure, a poor result of embolization occurred in 7.7%. Analyzed by patient, 11% died or had a permanent neurological deficit as a result of the embolization. None of the demographic, anatomical, or procedure variables identified were predictive of a poor outcome., Conclusions: Preoperative embolization may gradually reduce flow to an AVM, reduce intraoperative blood loss, and reduce operative time. The risks of this procedure, however, are not insignificant and must be considered in planning treatment for patients with AVMs.

Object: A case-control analysis of patients with SAH was performed to compare risk factors and outcomes at 6 months posthemorrhage in patients with a very small aneurysm compared with those with a larger aneurysm., Methods: All patients with SAH who were treated between January 1998 and December 1999 were studied. A very small aneurysm was defined as "equal to or less than 5 mm in diameter." Clinical data and treatment summaries were maintained in an electronic database. The Glasgow Outcome Scale (GOS) score was determined by an independent registrar. One hundred twenty-seven patients were treated. A very small aneurysm was the cause of SAH in 42 patients (33%), whereas 85 (67%) had aneurysms larger than 5 mm (mean diameter 11 mm). There were no differences in demographic variables or medical comorbidities between the two groups. Thick SAH (Fisher Grade 3 or 4) was more common in patients with a very small aneurysm than in those with a larger aneurysm (p = 0.028). One hundred eight patients underwent microsurgery (85%), 15 underwent coil embolization (12%), and four (3%) required both procedures. Vasospasm occurred in nine patients (21%) with very small aneurysms compared with 14 (16%) with larger aneurysms (p = 0.62). Shunt-dependent hydrocephalus occurred in nine patients (21%) with very small aneurysms and in 19 (22%) with larger aneurysms (p = 1). The mean GOS score for both groups was 4 (moderately disabled) at 6 months., Conclusions: Small aneurysms produce thick SAH more often than larger aneurysms. There is no difference in outcome after SAH between patients with a very small aneurysm and those with a larger aneurysm.

Object: The records of 30 patients with posterior cerebral artery (PCA) aneurysms treated during a 12-year period were reviewed to determine outcome and the risk of visual field deficit associated with PCA sacrifice., Methods: Clinical data and treatment summaries for all patients were maintained in an electronic database. The Glasgow Outcome Scale (GOS) and modified Rankin Scale (mRS) scores were determined by an independent registrar. Visual field changes were determined by review of medical records. Twenty-eight patients were treated with open surgery, one of them after an attempt at detachable coil embolization failed. Two patients underwent successful endovascular PCA sacrifice. The mean GOS and mRS scores in 18 patients with unruptured aneurysms were 4 and 2, respectively, at discharge. Subarachnoid hemorrhage (SAH) from other aneurysms and neurological deficits caused by the PCA lesion or underlying disease contributed to poor outcomes in this group. The mean GOS and mRS scores in 12 patients with ruptured aneurysms were 4 and 4, respectively, at discharge. One patient died of severe vasospasm. Neurological deficits secondary to SAH and, in one patient, treatment of a concomitant arteriovenous malformation contributed to poor outcomes in the patients with ruptured aneurysms. Seven patients with normal visual function preoperatively underwent PCA occlusion. One patient (14%) developed a new visual field deficit., Conclusions: Optimal treatment of PCA aneurysms is performed via one of several surgical approaches or by endovascular therapy. The approach is determined, in part, by the anatomical location and size of the aneurysm and the presence of underlying disease and neurological deficits.

Objective: To provide current information regarding the expected clinical outcomes and sources of morbidity and mortality in the modern surgical management of basilar apex aneurysms., Method: A retrospective review was conducted of 303 cases of such aneurysms that were treated surgically during 18 years at one institution. Postoperative angiography was performed in 81% of the cases. Clinical grading using the Glasgow Outcome Scale was conducted at the time of hospital discharge and for 91% of the surviving patients at 6 months after surgery. The preoperative parameters that were linked statistically to poor clinical outcome were identified through the use of single and multivariate analyses., Results: More than 80% of the patients were operated on using some modification of the trans-sylvian exposure, and temporary arterial occlusion was used routinely. Good outcomes (Glasgow Outcome Scale scores of 4 or 5) were achieved in 76% of the patients at the time of discharge and in 81% of the patients at 6 months after surgery. There was no incidence of postoperative subarachnoid hemorrhage. Residual aneurysm was revealed by postoperative angiography in 6% of the cases. Factors found to be statistically linked to poor outcome included poor admission grade (Hunt and Hess Grades IV and V), patient age older than 65 years, computed tomographic demonstration of thick basal cistern clot, aneurysm size greater than 20 mm, and symptoms attributable to brain stem compression., Conclusion: Direct microsurgical repair of basilar apex aneurysms should result in good clinical outcomes in 80 to 85% of cases, with reliable prevention of subarachnoid bleeding and routine elimination/reduction of symptoms secondary to mass effect. Those patients who are at high risk for poor outcomes can be identified by the presence of certain clinical, radiographic, and demographic features before undergoing surgery and can be considered for alternative or adjunctive modes of therapy if long-term efficacy of such treatment is demonstrated.

Patients with penetrating carotid injuries above C2 present special challenges to the cerebrovascular surgeon. A subgroup of patients may lack the vascular collaterals necessary to tolerate carotid sacrifice or prolonged ischemia during direct carotid repair. We present a technique of extracranial-intracranial (EC-IC) saphenous vein bypass in two patients with high cervical and skull base carotid injuries and poor vascular collaterals. This technique allows preservation of internal carotid flow during the proximal anastomosis. Interruption of cerebral blood flow is limited to the duration required for a distal intracranial anastomosis and is confined to the territory supplied by a single middle cerebral branch. The procedure eliminates systemic anticoagulation, includes trapping of the injured segment of the internal carotid artery, and restores a volume of flow similar to that of the internal carotid artery. It is a valuable adjunct in this specific population of patients with high carotid injuries who cannot tolerate even brief periods of temporary occlusion or in whom clinical urgency precludes an endovascular trial occlusion.

Background: Global orbital infarction results from ischemia of the intraocular and intraorbital structures due to hypoperfusion of the ophthalmic artery and its branches., Patients: The authors describe six patients in whom acute proptosis, ophthalmoplegia, and blindness developed immediately after surgery for intracranial aneurysms., Results: All patients underwent standard frontotemporal craniotomies to clip their aneurysms. In all patients, proptosis, ophthalmoplegia, and blindness developed in the immediate postoperative period; fundus abnormalities included retinal edema, retinal arteriolar narrowing and other vascular abnormalities, and pale optic disc swelling. Some patients had facial and corneal anesthesia. Ophthalmoplegia and facial anesthesia improved in most patients, but none regained any vision in the affected eye., Conclusion: Orbital infarction syndrome is a rare complication of neurosurgical procedures. Increased orbital pressure probably reduced ophthalmic artery and collateral arterial perfusion, resulting in ischemia of the intraocular and intraorbital structures. There may be multiple factors that compound the risk for orbital infarction, and patients with subarachnoid hemorrhage, increased intracranial pressure, anomalous arterial or venous circulation, or impaired orbital venous outflow seem particularly vulnerable.

Aggressive surgical as well as medical management strategies have had limited success with improving outcomes from spontaneous intracerebral hematomas. Future prospects of treatment will undoubtedly focus on less invasive, better tolerated procedures to remove hematomas in select patients. Some success has been achieved with a coupling of stereotactic technology, fibrinolytic agents, and mechanical devices, which can remove solid portions of hematoma through narrow probes. Newer technology also has involved laser endoscopic and small ultrasonic probes to facilitate morcellation and subsequent aspiration without the problems associated with a major intracranial procedure.

We report a technique for insertion of a distal shunt catheter into the peritoneal cavity through a posterior incision. This has been helpful in patients with impaired access anteriorly. It may also be useful in elective situations. We have performed this procedure on 3 infants where the traditional anterior approaches would have been difficult due to subcutaneous scar tissue, ostomy sites and anterior intra-abdominal adhesions. This technique was safe and provided easy access to the peritoneal cavity. Complications would be similar to those for the standard ventriculoperitoneal shunts including bowel perforation, damage to the kidney or liver, infection and occasionally posterior cervical webbing that may cause pain locally or pull the head into an extended position.

Spontaneous intracranial hemorrhage is not an infrequent complication of systemic anticoagulation, as occurs in hemodialysis. The neurological symptoms of subdural hematoma may be similar to those of dialysis disequilibrium. The pressure within a subdural fluid collection was monitored in a patient undergoing hemodialysis. The patient was known to become unresponsive during previous dialysis treatments. The initial pressure within the subdural cavity was measured to be -10.0 cm H2O prior to dialysis. The pressure within the collection decreased to a minimum value of -19.4 cm H2O during dialysis and stabilized at -16.4 cm H2O at the termination of dialysis. The neurological status changed subjectively during the procedure, with the patient becoming unresponsive to verbal stimuli as the intracranial pressure reached a minimum. These findings represent a syndrome similar to aliquorrhea, or low cerebrospinal fluid pressure within an otherwise asymptomatic subdural hematoma. Previously only increased intracranial pressure has been reported with hemodialysis.

A 'spherical coordinate system' has been developed to allow either stereotactic biopsy of two intracranial lesions using a single predetermined trajectory or biopsy of a single lesion through an existing burr hole. By means of the Gildenberg technique, the CT coordinates of the targets (or target and burr hole) are obtained. These are employed in three simple trigonometric equations to give three coordinates-two angles for the probe carrier (theta and alpha) and the radius (T) of a sphere, defined by one target as the center and the other target on the surface. These can be utilized in the Todd-Wells stereotactic frame. This system was evaluated using hollow skulls and crossed 30-gauge wire for phantom targets. The system was tried on ten different target combinations, and eight successful trajectories were obtained to within 3 mm. Two target combinations were inaccessible because of technical limitations of the Todd-Wells frame. This 'spherical coordinate system' can decrease the time to localize multiple targets as well as minimize the number of passes.