Posterior Interhemispheric Transfalcine Transprecuneus Approach for Microsurgical Resection of Peri-Atrial Lesions: Indications, Technique, and Outcomes

OBJECT Surgical exposure of the peritrigonal or periatrial region has been challenging due to the depth of the region and overlying important functional cortices and white matter tracts. The authors demonstrate the operative feasibility of a contralateral posterior interhemispheric transfalcine transprecuneus approach (PITTA) to this region and present a series of patients treated via this operative route. METHODS Fourteen consecutive patients underwent the PITTA and were included in this study. Pre- and postoperative clinical and radiological data points were retrospectively collected. Complications and extent of resection were reviewed. RESULTS The mean age of patients at the time of surgery was 39 years (range 11–64 years). Six of the 14 patients were female. The mean duration of follow-up was 4.6 months (range 0.5–19.6 months). Pathology included 6 arteriovenous malformations, 4 gliomas, 2 meningiomas, 1 metastatic lesion, and 1 gray matter heterotopia. Based on the results shown on postoperative MRI, 1 lesion (7%) was intentionally subtotally resected, but ≥ 95% resection was achieved in all others (93%) and gross-total resection was accomplished in 7 (54%) of 13. One patient (7%) experienced a temporary approach-related complication. At last follow-up, 1 patient (7%) had died due to complications of his underlying malignancy unrelated to his cranial surgery, 2 (14%) demonstrated a Glasgow Outcome Scale (GOS) score of 4, and 11 (79%) manifested a GOS score of 5. CONCLUSIONS Based on this patient series, the contralateral PITTA potentially offers numerous advantages, including a wider, safer operative corridor, minimal need for ipsilateral brain manipulation, and better intraoperative navigation and working angles

Anterior communicating artery complex aneurysms: anatomic characteristics as predictors of surgical outcome in 300 cases

OBJECTIVE Anterior communicating artery (ACoA) complex aneurysms are challenging to treat microsurgically. The authors report their experience with microsurgical treatment of ACoA aneurysms and examine the anatomic characteristics of these aneurysms as predictors of outcome. METHODS The authors queried their institution’s aneurysm database for records of consecutive patients treated for ACoA aneurysms via microsurgical clip ligation. Data included patient demographics and clinical/radiographic presentation characteristics as well as operative techniques. Glasgow outcome scores (GOS) at hospital discharge and 6-month as well as 1-year follow-up were analyzed. RESULTS Of 319 ACoA aneurysms that underwent treatment, 259 were ruptured and 60 were unruptured. Average GOS at 1-year follow-up for all patients was 4.6. Average GOS for patients with ruptured aneurysms correlated with Hunt and Hess grade at presentation, presence of frontal hemorrhages, and need for multiple clips during surgery. Notably, 142 (44.5%) of aneurysms originated mainly from the ACoA artery; 12 (3.8%) primarily from the A1 branch; 3 (0.9%) from the A2 branch; and 162 (50.8%) from the A1/A2 junction. Aneurysm projection was superior in 118 (37%), inferior in 106 (33.2%), anterior in 88 (27.6%), and posterior in 7 (2.2%). Patients with aneurysms originating from the A1 segment had worse outcomes. Posteriorly-projecting aneurysms were more likely to be unruptured and larger than other aneurysm configurations. CONCLUSIONS The aneurysm’s exact location in relation to the adjacent neurovascular structures is potentially predictive of outcomes in the microsurgical treatment of ACoA aneurysms

Intracranial chordoma presenting as acute hemorrhage in a child: Case report and literature review

BACKGROUND: Chordomas are rare, slow-growing malignant neoplasms derived from remnants of the embryological notochord. Pediatric cases comprise only 5% of all chordomas, but more than half of the reported pediatric chordomas are intracranial. For patients of all ages, intracranial chordomas typically present with symptoms such as headaches and progressive neurological deficits occurring over several weeks to many years as they compress or invade local structures. There are only reports of these tumors presenting acutely with intracranial hemorrhage in adult patients. CASE DESCRIPTION: A 10-year-old boy presented with acute onset of headache, emesis, and diplopia. Head computed tomography and magnetic resonance imaging of brain were suspicious for a hemorrhagic mass located in the left petroclival region, compressing the ventral pons. The mass was surgically resected and demonstrated acute intratumoral hemorrhage. Pathologic examination was consistent with chordoma. CONCLUSION: There are few previous reports of petroclival chordomas causing acute intracranial hemorrhage. To the authors' knowledge, this is the first case of a petroclival chordoma presenting as acute intracranial hemorrhage in a pediatric patient. Although uncommon, it is important to consider chordoma when evaluating a patient of any age presenting with a hemorrhagic lesion of the clivus

Thermomechanical data of polyurethane shape memory polymer: Considering varying compositions

This article presents data from the investigation of the thermal characteristics and mechanical behaviors of twelve different compositions of a polyurethane shape memory polymer (SMP). Each of the SMP compositions has a unique molar ratio of three monomers: (i) hexamethylene diisocyanate (HDI), (ii) N,N,N′,N′-Tetrakis(2-Hydroxypropyl)ethylenediamine (HPED), and (iii) Triethanolamine (TEA). The thermal characteristic datasets for each composition include the glass transition temperatures, as obtained from differential scanning calorimetry (DSC) and dynamic mechanical analysis (DMA), and the thermal degradation thresholds, as found from thermogravimetric analysis (TGA). The mechanical behaviors of the SMPs are represented by the failure stresses and strains, as obtained by cyclic tensile testing and failure testing, respectively. The interpretation of these measurements as well as a discussion of the potential usage of candidate SMP compositions for medical devices can be found in the companion article by Kunkel et al. (2018) [1], “Synthesis and characterization of bio-compatible shape memory polymers with potential applications to endovascular embolization of intracranial aneurysms.”Funding from the Oklahoma Center for the Advancement of Science and Technology (OCAST, HR18-002) and the Oklahoma Shared Clinical and Translational Resources (OSCTR, NIGMS U54GM104938) are gratefully acknowledged. CHL was also supported by the institutional start-up funds from the School of Aerospace and Mechanical Engineering, the IBEST SEED Funding for Interdisciplinary Research, and the Faculty Investment Program from the Research Council at the University of Oklahoma (OU). Open Access fees paid for in whole or in part by the University of Oklahoma Libraries.Ye

Blood Supply to the Human Spinal Cord. II. Imaging and Pathology

The blood supply of the spinal cord is a complex system based on multilevel sources and anastomoses. Diseases often affect this vascular supply and imaging has been developed that better investigates these structures. The authors review the literature regarding pathology and imaging modalities for the blood supply of the spinal cord. Knowledge of the disease processes and imaging modalities used to investigate these arterial lesions of the spinal cord will assist the clinician when treating patients with spinal cord lesions

Shape Memory Polyurethane with Porous Architectures for Potential Applications in Intracranial Aneurysm Treatment

Conventional endovascular embolization of intracranial (or brain) aneurysms using helical detachable platinum coils can be time-consuming and occasionally requires retreatment due to incomplete coil packing. These shortcomings create a need for new biomedical devices and methods of achieving brain aneurysm occlusion. This paper presents a biocompatible and highly porous shape memory polymer (SMP) material with potential applications in the development of novel endovascular devices for treating complex intracranial aneurysms. The novel highly porous polyurethane SMP is synthesized as an open cell foam material with a glass transition temperature (Tg) of 39 °C using a sugar particle leaching method. Once heated above the Tg, the compressed SMP foam is able to quickly return to its original shape. An electrical resistance heating method is also employed to demonstrate a potential triggering design for the shape recovery process in future medical applications. The mechanical properties of the developed SMP foam are characterized at temperatures up to 10 °C above the respective Tg. The results from this work demonstrate that the porous SMP material developed in this study and the electrical resistance heating trigger mechanism provide a solid foundation for future design of biomedical devices to enhance the long-term therapeutic outcomes of endovascular intracranial aneurysm treatments.Open access fees fees for this article provided whole or in part by OU Libraries Open Access Fund.Ye

A pilot study on biaxial mechanical, collagen microstructural, and morphological characterizations of a resected human intracranial aneurysm tissue

Intracranial aneurysms (ICAs) are focal dilatations that imply a weakening of the brain artery. Incidental rupture of an ICA is increasingly responsible for significant mortality and morbidity in the American’s aging population. Previous studies have quantified the pressure-volume characteristics, uniaxial mechanical properties, and morphological features of human aneurysms. In this pilot study, for the first time, we comprehensively quantified the mechanical, collagen fiber microstructural, and morphological properties of one resected human posterior inferior cerebellar artery aneurysm. The tissue from the dome of a right posterior inferior cerebral aneurysm was first mechanically characterized using biaxial tension and stress relaxation tests. Then, the load-dependent collagen fiber architecture of the aneurysm tissue was quantified using an in-house polarized spatial frequency domain imaging system. Finally, optical coherence tomography and histological procedures were used to quantify the tissue’s microstructural morphology. Mechanically, the tissue was shown to exhibit hysteresis, a nonlinear stress-strain response, and material anisotropy. Moreover, the unloaded collagen fiber architecture of the tissue was predominantly aligned with the testing Y-direction and rotated towards the X-direction under increasing equibiaxial loading. Furthermore, our histological analysis showed a considerable damage to the morphological integrity of the tissue, including lack of elastin, intimal thickening, and calcium deposition. This new unified characterization framework can be extended to better understand the mechanics-microstructure interrelationship of aneurysm tissues at different time points of the formation or growth. Such specimen-specific information is anticipated to provide valuable insight that may improve our current understanding of aneurysm growth and rupture potential

Synthesis and characterization of bio-compatible shape memory polymers with potential applications to endovascular embolization of intracranial aneurysms

This is the post print for the version of record: Kunkel, Robert, Devin Laurence, Jingyu Wang, Donnie Robinson, Joshua Scherrer, Yi Wu, Bradley N. Bohnstedt, Aichi Chien, Yingtao Liu, and Chung-Hao Lee. "Synthesis and characterization of bio-compatible shape memory polymers with potential applications to endovascular embolization of intracranial aneurysms." Journal of the mechanical behavior of biomedical materials (2018). This post print is licensed CC BY-NC-ND and was retrieved from http://www.ou.edu/coe/ame/bbdl/publications.Intracranial aneurysms (ICAs) are focal dilations in the brain's arteries. When left untreated, ICAs can grow to the point of rupture, accounting for 50–80% of subarachnoid hemorrhage cases. Current treatments include surgical clipping and endovascular coil embolization to block circulation into the aneurysmal space for preventing aneurysm rupture. As for endovascular embolization, patients could experience aneurysm recurrence due to an incomplete coil filling or compaction over time. The use of shape memory polymers (SMPs) in place of conventional platinum coils could provide more control and predictability for mitigating these complications. This study was focused on characterization of an aliphatic urethane-based SMP to evaluate its potential as a novel biomaterial for endovascular embolization. Twelve compositions of the SMP were synthesized and their thermomechanical properties together with the shape recovery behavior were comprehensively investigated. Our results showed that the SMPs experienced a significant decrease in storage and loss moduli as heated above their glass transition temperatures (32.3–83.2 °C), and that all SMPs were thermally stable up to 265 °C. Moreover, the SMPs exhibited both composition-dependent stress relaxation and a decrease in elastic modulus during cyclic loading. The shape recovery time was less than 11 s for all SMP compositions, which is sufficiently short for shape changing during embolization procedures. Several candidate compositions were identified, which possess a glass transition temperature above body temperature (37 °C) and below the threshold of causing tissue damage (45 °C). They also exhibit high material strength and low stress relaxation behavior, suggesting their potential applicability to endovascular embolization of ICAs. This is the post print for the version of record: Kunkel, Robert, Devin Laurence, Jingyu Wang, Donnie Robinson, Joshua Scherrer, Yi Wu, Bradley N. Bohnstedt, Aichi Chien, Yingtao Liu, and Chung-Hao Lee. "Synthesis and characterization of bio-compatible shape memory polymers with potential applications to endovascular embolization of intracranial aneurysms." Journal of the mechanical behavior of biomedical materials (2018). This post print is licensed CC BY-NC-ND and was retrieved from http://www.ou.edu/coe/ame/bbdl/publications.Ye

Load-dependent collagen fiber architecture data of representative bovine tendon and mitral valve anterior leaflet tissues as quantified by an integrated opto-mechanical system

The data presented in this article provide load-dependent collagen fiber architecture (CFA) of one representative bovine tendon tissue sample and two representative porcine mitral valve anterior leaflet tissues, and they are stored in a MATLAB MAT-file format. Each dataset contains: (i) the number of pixel points, (ii) the array of pixel's x- and y-coordinates, (iii) the three acquired pixel intensity arrays, and (iv) the Delaunay triangulation for visualization purpose. This dataset is associated with a companion journal article, which can be consulted for further information about the methodology, results, and discussion of the opto-mechanical characterization of the tissue's CFA's (Jett et al. [1]).Supports from the American Heart Association Scientist Development Grant (SDG) Award (16SDG27760143), the Presbyterian Health Foundation Team Science Grants (C5122401), and the Oklahoma Center for the Advancement of Science and Technology (OCAST) Health Research program (HR-18-002) are gratefully acknowledged. CHL was in part supported by the institutional start-up funds from the School of Aerospace and Mechanical Engineering (AME) and the institutional research funding through the Faculty Investment Program from the Research Council and IBEST-OUHSC Interdisciplinary Funding at the University of Oklahoma. Open Access fees paid for in whole or in part by the University of Oklahoma Libraries.Ye

Warfarin versus factor Xa inhibitors in the long-term treatment of cerebral venous sinus thrombosis a single-center retrospective analysis

Long-term anticoagulation in the treatment of Cerebral Venous Sinus Thrombosis (CVST) has revolved around the use of warfarin. The relatively recent introduction of Direct Oral Anticoagulants (DOACs), such as Factor Xa inhibitors, in treating CVSTs promises to offer numerous patient benefits. We aimed to examine the efficacy of Factor Xa inhibitors in comparison to warfarin in the long-term treatment of CVSTs. A single-center retrospective analysis was conducted in which 49 eligible patients having presented with a first-time CVST were identified. Long-term anticoagulation was achieved with Warfarin (n = 23) or Factor Xa Inhibitors (n = 26; Apixaban or Rivaroxaban). Outcomes of interest were improvements in patient functional status, modified Ranking Scores (mRS), and radiographic improvement/resolution in sinus thromboses. Secondary comparisons included complication rates, particularly recurring venous thrombotic events. Patient mRS scores by 7-to-18-month follow-up all fell within the extremely favorable range of 0-1 regardless of the long-term anticoagulant (P-value = 0.3591). Proportion of patients with radiographic improvement/resolution of thrombosed sinuses trended towards being higher in the Factor Xa Inhibitor group at the 12-month follow-up period, Warfarin and Factor Xa inhibitor groups had similar rates of radiographic sinus improvement - 76.9% versus 71.4%, respectively (P-value = 0.6298). No statistically significant differences were documented between groups regarding complications. Factor Xa inhibitors are equally as effective as Warfarin in the long-term treatment of CVSTs, whether it be restoring patient functional status, sinus thrombus burden reduction, or minimizing bleeding complications whilst preventing recurrent venous thrombosis