BACKGROUND AND PURPOSE:The very small size of cerebral aneurysms is considered to be one of the limitations for endovascular treatment, with a high risk for intraoperative rupture. We report on treatment of very small saccular ruptured cerebral aneurysms by coil embolization. All the cases were of 2-mm aneurysms with at least 1 of the dimensions being less than 2 mm.
We present our initial experience with the high field (1.5T) intra-operative magnetic resonance imaging, the operating room set-up, our initial cases, the difficulties we faced and how this tool affected a change in the surgical strategy intra-operatively and finally our results. 11 patients were operated on from June 1st to August 1st 2006 of which there were astrocytomas (7), pituitary adenoma (1), craniopharyngioma (1) and meningiomas (2) Localization and lesion targeting were accurate, intra-operative imaging helped to assess the resection volumes, enable corrections for brain shift, perform further tumor resection at the same sitting and help preserve eloquent cortical areas. Gliomas formed 63.6% of the tumors operated on and in 71.4% of these, our surgical strategy changed intra-operatively. Meningiomas formed 9.1% of the tumors operated and image guidance enabled a minimally invasive approach, although no change in our surgical plan was required. One pituitary adenoma and a craniopharyngioma were also operated on with good outcome.
Pediatric intracranial aneurysms are rare with a reported prevalence of 0.5–4.6%. Likewise, anomalous arterial patterns are uncommon in the cerebral circulation. Recognition of these variations and knowledge of vascular territory forms the key to managing pathological conditions associated with these anomalous vessels. Ruptured dissecting aneurysm of type-3 accessory middle cerebral artery (aMCA) has not been reported in the pediatric age group. In addition to type-3 aMCA, the child in this case report had an ipsilateral type-1 aMCA with cortical supply. We describe the patterns of accessory MCA and their vascular territory, state the perplexity involved in deciding the best management strategy, and describe the technical approach we undertook to catheterize this small caliber recurrent artery (type-3 aMCA) originating at an acute angle from the anterior cerebral artery.
We report a prospective investigation of a bedside test to evaluate the role and safety of lumbar puncture in raised intracranial pressure in patients with subarachnoid haemorrhage. Fourteen patients who underwent aneurysm clipping following subarachnoid haemorrhage were studied. All patients had intraventricular drains and needed high volume cerebrospinal fluid (CSF) drainage to maintain the normal intracranial pressure. A lumbar puncture was performed in these patients and the simultaneous opening lumbar and ventricular pressures noted, CSF was then drained via the lumbar puncture, and the simultaneous closing lumbar and ventricular pressures noted. In all patients, the opening lumbar pressure was close to the ventricular pressure. In 13 of 14 patients, CSF drainage resulted in an equivalent and simultaneous fall of ventricular pressure. We concluded that simultaneous measurement of lumbar and ventricular CSF pressure before and after lumbar CSF drainage allows identification of candidates with differential cranial and lumbar pressures and therefore indicates safety or risk of lumbar CSF drainage.
Although intracranial obliteration or detachable balloon occlusion of the proximal artery has been recommended for treatment of unruptured aneurysms of the cavernous sinus, carotid artery ligation continues to be used by many neurosurgeons. This study compares the long term outcome after carotid ligation with that following conservative treatment. Nine of 13 patients treated by common carotid ligation improved, two were unchanged but two patients subsequently needed internal carotid ligation (mean FU 8.2 years). Ten patients were managed conservatively. Three improved, six were unchanged and one patient died following intracranial haemorrhage (mean FU 6.9 years). The authors conclude that carotid ligation remains an acceptable method for treating these difficult lesions.
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