Intracranial Aneurysms: Review of Current Treatment Options and Outcomes

Intracranial aneurysms are present in roughly 5% of the population, yet most are often asymptomatic and never detected. Development of an aneurysm typically occurs during adulthood, while formation and growth are associated with risk factors such as age, hypertension, pre-existing familial conditions, and smoking. Subarachnoid hemorrhage, the most common presentation due to aneurysm rupture, represents a serious medical condition often leading to severe neurological deficit or death. Recent technological advances in imaging modalities, along with increased understanding of natural history and prevalence of aneurysms, have increased detection of asymptomatic unruptured intracranial aneurysms (UIA). Studies reporting on the risk of rupture and outcomes have provided much insight, but the debate remains of how and when unruptured aneurysms should be managed. Treatment methods include two major intervention options: clipping of the aneurysm and endovascular methods such as coiling, stent-assisted coiling, and flow diversion stents. The studies reviewed here support the generalized notion that endovascular treatment of UIA provides a safe and effective alternative to surgical treatment. The risks associated with endovascular repair are lower and incur shorter hospital stays for appropriately selected patients. The endovascular treatment option should be considered based on factors such as aneurysm size, location, patient medical history, and operator experience

Neuroprotection in brain and spinal cord trauma

Traumatic brain and spinal cord injuries continue to be a public health problem. These types of injuries often occur in early adulthood and have a major impact for society. This review discusses strategies and therapeutic agents for perioperative neuroprotection in the management of brain and spinal cord trauma. There are no definitive drugs or strategies that can be utilized to provide perioperative neuroprotection in brain and spinal cord trauma patients. Phase III trials of several pharmacologic agents, including inhibitors of oxidative and excitotoxic injury, have been unable to demonstrate clinical efficacy. Although experimental animal data for hypothermia have been promising over the years, clinical application of therapeutic hypothermia cannot be recommended for routine use in neurotrauma patients. Administration of methylprednisolone, which has become common practice in acute spinal cord injury, has come under close scrutiny. Various experimental animal investigations suggest that potential therapeutic agents include estrogen, progesterone, minocycline, erythropoietin, and magnesium. The main priority in the initial treatment of brain and spinal cord trauma is to maintain oxygenation and perfusion in order to avoid aggravating secondary injury. Future progress will depend on the translation of neuroprotective strategies into well designed clinical trials with promising outcomes

Infratemporal Fossa Approaches to the Jugular Foramen

The infratemporal fossa provides access to lesions of the lateral skull base, including the jugular foramen. Variants of the infratemporal fossa approaches are classified as types A, B, C, and D. The Fisch type A approach is most commonly used for glomus jugulare tumors that invade the infralabyrinthine and apical components of the temporal bone or tumors that extend intradurally. Lesions of the jugular foramen, including glomus tumors, meningiomas, and schwannomas, can be resected through this approach. The infratemporal fossa, a cavity with incomplete walls, contains the pterygoid venous plexus, the pterygoid muscles, the maxillary artery, and the mandibular division of the trigeminal nerve. Involvement of the internal carotid artery, combined with preoperative intolerance to balloon occlusion or significant intraoperative blood loss, may preclude complete resection of a glomus jugulare tumor. However, complete resection can be achieved in most cases. Injuries to the lower cranial nerves from tumor resection typically result in transient dysfunction but are expected to improve gradually

Surgical Anatomy of the Jugular Foramen

The complexity of the jugular foramen can be appreciated once its deep location, variability in shape and size, and neurovascular contents are recognized. Safe surgical access to this foramen is hindered by surrounding structures. Structures that traverse the jugular foramen are the sigmoid sinus, inferior petrosal sinus, jugular bulb, glossopharyngeal nerve, vagus nerve, accessory nerve, Jacobson’s nerve, Arnold’s nerve, meningeal branches of the ascending pharyngeal and occipital arteries, and the cochlear aqueduct. The classic description of the jugular foramen divides this structure into two discrete compartments, the pars nervosa and the pars venosa. However, microanatomical studies have demonstrated that this compartmentalization of the jugular foramen is an oversimplification and has no surgical significance. Instead, it is more useful to describe the petrosal, sigmoid, and intrajugular portions of the jugular foramen. The petrosal portion contains the inferior petrosal sinus. The sigmoid portion receives the sigmoid sinus. The intrajugular portion contains cranial nerves IX, X, and XI. All of the surgical approaches to this region require thorough knowledge of the temporal bone, which forms the lateral, posterior, and superior boundaries of the jugular foramen

Cerebral Revascularization in Skull Base Tumors

Skull base tumors involving the carotid artery pose a difficult surgical challenge. The potential for bypass grafting for cerebral revascularization carries inherent risks but may aid in tumor resection and control in those who warrant carotid sacrifice but have inappropriate natural cerebrovascular reserve. We include a review of the literature discussing the indications for carotid resection as part of skull base tumor surgery, indications for cerebral revascularization, balloon test occlusion, graft types and operative technique, complications, and results

Surgical Management of Middle Cerebral Artery Aneurysms: Surgical Anatomy, Approaches, and Pitfalls

Aneurysms of the middle cerebral artery pose a significant challenge to neurosurgeons. The authors describe surgical techniques, clinical features, and different approaches to treat these aneurysms in light of surgical anatomy, lessons learned from complications, and personal experience

Half‐Dose (45 mg Twice Daily) Ticagrelor Versus Clopidogrel in Neuroendovascular Dual Antiplatelet Therapy: A Single‐Center Cohort Study

Background Cardiovascular literature has found aspirin‐based dual antiplatelet therapy using half‐dose ticagrelor (45 mg BID [T45]) to be superior to standard‐dose clopidogrel (75 mg once daily) in achieving lower P2Y12 reaction units without resulting in an increased incidence of intracranial hemorrhage. We present the first neuroendovascular experience based on T45 versus standard‐dose clopidogrel dual antiplatelet therapy in patients undergoing stent‐assist coiling/flow diversion as treatment for unruptured intracranial aneurysms. Methods This was a retrospective cohort study comparing patients receiving dual antiplatelet therapy with T45+aspirin 81 mg daily (group 1) with those receiving standard‐dose clopidogrel+aspirin 325 mg daily (group 2). The primary outcome was ischemic stroke occurring intraoperatively or within 48 hours postoperatively. The secondary outcomes were delayed ischemic stroke, intracranial hemorrhage, and 6‐month angiographic result. Results A total of 111 patients met the final inclusion criteria: group 1/T45 (37.8%, n=42) and group 2/standard‐dose clopidogrel (62.2%, n=69). The median (interquartile range) P2Y12 reaction units was significantly lower in group 1 (69; 37–124) versus group 2 (135; 75.5–175.5; P=0.027). However, there was no significant difference in the number of patients achieving therapeutic preprocedural P2Y12 reaction units (<194 at our institution's laboratory; 85.3% versus 81.2%; P=0.643). Primary outcome was comparable: group 1, 7.1% (n=3) versus group 2, 1.5% (n=1; P=0.149). All secondary outcomes were also comparable: delayed ischemic stroke (9.8% versus 4.4%; P=0.270), intracranial hemorrhage (4.1% versus 0%; P=0.129), access‐site bleeding requiring transfusion (0% versus 2.9%; P=0.526), and 6‐month Raymond–Roy score (P=0.642). Conclusions T45‐based dual antiplatelet therapy may be feasible in neuroendovascular interventions with comparable ischemic and hemorrhagic outcomes. This hypothesis needs to be further explored in larger prospective clinical trials

Scepter-Mini Balloon Assisted Coil Embolization of an Intracranial Arterial Aneurysm in a Child with PHACE Syndrome via a Persistent Trigeminal Artery

Cerebral vascular malformations constitute one of the key abnormalities in children with PHACE syndrome, which is characterized by Plaque like cutaneous hemangiomas, Posterior fossa abnormalities, arterial Cerebrovascular and Eye abnormalities, with or without Sternal clefts (PHACES when sternal clefts are present), and associated midline anomalies. Both moyamoya arteriopathy and intracranial aneurysms have been reported in children with this syndrome. Herein, we report the successful treatment of a growing left posterior-communicating artery aneurysm arising from an aberrant left internal carotid artery (LICA) with balloon assisted coiling (BAC) in a child with PHACE syndrome. We circumvented the limitations posed by the narrow caliber of the proximal LICA, by successfully navigating a coiling microcatheter from the basilar artery into the LICA via a persistent trigeminal artery. BAC was then achieved using a Scepter Mini balloon microcatheter for aneurysm neck remodelling