Endoscopic Intraventricular Biopsy of Infundibular Langerhans Cell Histiocytosis: Case Report

OBJECTIVE: Surgical biopsy of isolated infundibular lesions is indicated in patients who are symptomatic or whose imaging suggests a treatable lesion. Early therapy can prevent irreversible neurological or endocrinological damage and, potentially, metastasis. These considerations justify the small risk associated with surgery. CLINICAL PRESENTATION: A 5-year-old boy presented with diabetes insipidus and an enhancing lesion of the pituitary stalk without evidence of extracranial disease. INTERVENTION: The lesion was biopsied via an endoscopic intraventricular approach without complications. Pathological examination revealed Langerhans cell histiocytosis. CONCLUSION: Endoscopic intraventricular biopsy can be considered as a less invasive alternative to craniotomy in patients with infundibular lesions protruding superiorly into the third ventricle. Copyright © by the Congress of Neurological Surgeons

Anterior Cerebral Artery Amputation and Salvage Repair of Internal Carotid Artery Tear: Technical Case Report

OBJECTIVE: We describe a novel technique used to repair an unanticipated tear of the internal carotid artery (ICA) requiring anterior cerebral artery (ACA) amputation to allow primary repair of the arteriotomy. CLINICAL PRESENTATION: A 59-year-old woman underwent an orbitozygomatic craniotomy to treat a large, suprasellar, thyroid-stimulating hormone-secreting adenoma. During resection, an incidental ICA tear occurred opposite the exit of the middle cerebral artery. TECHNIQUE: After an ICA tear on the wall opposite the middle cerebral artery occurred, clips were placed on the ICA, middle cerebral artery, and ACA. Primary closure was not feasible without critically stenosing the ICA. The ipsilateral ACA was clipped and amputated just distal to its origin. The relaxation afforded by amputating the ACA allowed primary suture repair of the arteriotomy. A clip was placed on the proximal ACA stump. The distal ACA stump revealed good backflow and was also clipped. CONCLUSION: When an arteriotomy of a large intracranial artery cannot be repaired primarily, creative alternatives must be considered. Amputation of a branch artery with sufficient collateral flow is a method to afford adequate relaxation for primary repair of an arteriotomy. This novel method should be considered in the armamentarium of neurosurgeons to minimize the impact of potentially disastrous vascular complications. Copyright © by the Congress of Neurological Surgeons

Safety of Carotid Endarterectomy While on Clopidogrel (Plavix): Clinical Article

Object. Many patients undergoing carotid endarterectomy (CEA) regularly take clopidogrel, a permanent platelet inhibitor. The authors sought to determine whether taking clopidogrel in the period before CEA leads to more bleeding or other complications. Methods. The authors performed a retrospective, institutional review board - approved review of 182 consecutive patients who underwent CEA. Clinical, radiographic, and surgical data were gleaned from hospital and clinic records. Analysis was based on the presence or absence of clopidogrel in patients undergoing CEA and was performed twice by considering clopidogrel use within 8 days and within 5 days of surgery to define the groups. Results. Taking clopidogrel within 8 days before surgery resulted in no statistical increase in any measure of morbidity or death. Taking clopidogrel within 5 days was associated with a small but significant increase in operative blood loss and conservatively managed postoperative neck swelling. No measure of permanent morbidity or death was increased in either clopidogrel group. Conclusions. Findings in this study support the safety of preoperative clopidogrel in patients undergoing CEA

Prospective Evaluation of Surgical Microscope-Integrated Intraoperative Near-Infrared Indocyanine Green Angiography During Cerebral Arteriovenous Malformation Surgery

OBJECTIVE: Microscope-integrated indocyanine green (ICG) fluorescence angiography is a novel technique in vascular neurosurgery with potential utility in treating arteriovenous malformations (AVMs). METHODS: We analyzed the application of intraoperative ICG in 10 consecutive AVM surgeries for which surgical video was available. The ability to distinguish AVM vessels (draining veins, feeding and nidal arteries) from each other and from normal vessel was evaluated, and ICG angiographic findings were correlated with intra- and postoperative findings on digital subtraction angiography (DSA). RESULTS: ICG angiography was found to be useful by the surgeon in 9 of 10 patients. In 8 patients, it helped to distinguish AVM vessels. In 3 of 4 patients undergoing a postresection injection, it demonstrated that there was no residual arteriovenous shunting. In 1 patient, it helped to identify a small AVM nidus that was otherwise inapparent within a hematoma. Intraoperative DSA showed residual AVM in 2 of 10 patients requiring further resection of AVM not visualized during surgery. CONCLUSION: Microscope-integrated ICG angiography is a useful tool in AVM surgery. It can be used to distinguish AVM vessels from normal vessels and arteries from veins based on the timing of fluorescence with the dye. Our experience suggests that it is less useful with deep-seated lesions or when AVM vessels are not on the surface. ICG angiography complements rather than replaces DSA. Copyright © by the Congress of Neurological Surgeons