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Abstract BACKGROUND: Internal maxillary artery (IMax)–middle cerebral artery (MCA) bypass has been recently described as an alternative to cervical extracranial-intracranial bypass. This technique uses a “keyhole” craniectomy in the temporal fossa that requires a technically challenging end-to-side anastomosis. OBJECTIVE: To describe a lateral subtemporal craniectomy of the middle cranial fossa floor to facilitate wide exposure of the IMax to facilitate bypass. METHODS: Orbitozygomatic osteotomy is used followed by frontotemporal craniotomy and subsequently laterotemporal fossa craniectomy, reaching its medial border at a virtual line connecting the foramen rotundum and foramen ovale. The IMax was identified by using established anatomic landmarks, neuronavigation, and micro Doppler probe (Mizuho Inc. Tokyo, Japan). Additionally, we studied the approach in a cadaveric specimen in preparation for microsurgical bypass. RESULTS: There were 4 cases in which the technique was used. One bypass was performed for flow augmentation in a hypoperfused hemisphere. The other 3 were performed as part of treatment paradigms for giant middle cerebral artery aneurysms. Vein grafts were used in all patients. The proximal anastomosis was performed in an end-to-side fashion in 1 patient and end-to-end in 3 patients. Intraoperative graft flow measured with the Transonic flow probe ranged from 20 to 60 mL/min. Postoperative angiography demonstrated good filling of the graft with robust distal flow in all cases. All patients tolerated the procedure well. CONCLUSION: IMax to middle cerebral artery subcranial-intracranial bypass is safe and efficacious. The laterotemporal fossa craniectomy technique resulted in reliable identification and wide exposure of the IMax, facilitating the proximal anastomosis.

Background. Classification of hemangiopericytoma (HPC) has evolved to a mesenchymal, nonmeningothelial grade two or three neoplasm according to the World Health Organization; however its blood supply has always been defined by dual origin, pial and dural contribution. Case Description. We present the case of a patient with an intracranial HPC with only pial vascular supply. Angiography confirmed the lack of dural supply to this bihemispheric intracranial mass. Subsequent histologic examination confirmed the diagnosis of hemangiopericytoma. Angiographic evidence here is atypical of the natural history of hemangiopericytomas with dual vascular supply and was critical in the decision-making towards surgical resection without tumor embolization. Conclusion. Data presented suggests the lack of dural vascular supply alone does not rule out the diagnosis of hemangiopericytoma.

BackgroundMycotic aneurysms, although well recognized, are relatively rare intracranial vascular pathology. These aneurysms are typically located in distal cortical vessels. When these aneurysms are located in eloquent cerebral territories, they may become challenging to treat. Eloquent location may necessitate intraoperative angiographic evaluation to verify complete aneurysmal occlusion/obliteration and preservation of normal adjacent vasculture. Recently, ICG videoangiography has become a widely used intra-operative adjunct and is an important tool used to assess complete occlusion and vessel patency at the conclusion of clip reconstruction. In this report, we outline the comprehensive and concurrent utilization of both vascular imaging modalities to ensure safe and complete occlusion of a mycotic aneurysm.MethodsWe describe our experience with a patient with left M4, Rolandic, enlarging mycotic aneurysm that was treated in a comprehensive fashion with microsurgery and intra-operative angiography (IA).ConclusionsICG videoangiography, in combination with concurrent intraoperative angiography in the setting of complex vascular lesions, may support intraoperative decision-making and provide demonstration of complete occlusion in an immediate fashion. A hybrid operative suite allows for high-quality imaging confirming complete resection.

BACKGROUND:Internal maxillary artery (IMax)–middle cerebral artery (MCA) bypass has been recently described as an alternative to cervical extracranial-intracranial bypass. This technique uses a “keyhole” craniectomy in the temporal fossa that requires a technically challenging end-to-side anastomosis. OBJECTIVE:To describe a lateral subtemporal craniectomy of the middle cranial fossa floor to facilitate wide exposure of the IMax to facilitate bypass. METHODS:Orbitozygomatic osteotomy is used followed by frontotemporal craniotomy and subsequently laterotemporal fossa craniectomy, reaching its medial border at a virtual line connecting the foramen rotundum and foramen ovale. The IMax was identified by using established anatomic landmarks, neuronavigation, and micro Doppler probe (Mizuho Inc. Tokyo, Japan). Additionally, we studied the approach in a cadaveric specimen in preparation for microsurgical bypass. RESULTS:There were 4 cases in which the technique was used. One bypass was performed for flow augmentation in a hypoperfused hemisphere. The other 3 were performed as part of treatment paradigms for giant middle cerebral artery aneurysms. Vein grafts were used in all patients. The proximal anastomosis was performed in an end-to-side fashion in 1 patient and end-to-end in 3 patients. Intraoperative graft flow measured with the Transonic flow probe ranged from 20 to 60 mL/min. Postoperative angiography demonstrated good filling of the graft with robust distal flow in all cases. All patients tolerated the procedure well. CONCLUSION:IMax to middle cerebral artery subcranial-intracranial bypass is safe and efficacious. The laterotemporal fossa craniectomy technique resulted in reliable identification and wide exposure of the IMax, facilitating the proximal anastomosis. ABBREVIATIONS:EC-IC, extracranial-intracranialIMax, internal maxillary arteryMCA, middle cerebral arterySC-IC, subcranial-intracranialSTA, superficial temporal artery

Background Treatment of selected wide-neck internal carotid artery (ICA) bifurcation aneurysms remains challenging for clip reconstruction and for endovascular options. Objective To describe a new endovascular treatment technique for wide-neck ICA bifurcation (ICAb) aneurysms. Methods We have employed a treatment approach that uses both complete proximal occlusion and reversal of flow in the ipsilateral A1 segment, using different endovascular modalities such as coils, stent-assisted coiling, or flow diverters (FDs) plus coiling concomitantly. This endovascular technique may overcome the challenges of current treatments and high recanalization rates for coiled ICAb aneurysms. Results We treated four patients in whom we redirected the pre-existing flow in the supraclinoid ICA into the ipsilateral A1 and M1 segments, to a new unilateral, linear flow from the supraclinoid ICA solely into the ipsilateral M1 segment. This resulted in the establishment of flow from the contralateral A1 segment into the ipsilateral A1 segment, allowing supply of only demanding perforating arteries on this specific (ipsilateral) segment. This technique was not associated with any new neurological deficits or radiographic ischemia. The four patients reviewed were all treated using coils. One was treated with a standard stent. The other two were treated with a FD. Conclusions We found that the proposed technique of flow modification can allow for hemodynamic conversion of ICAb to ‘side-wall’ aneurysm. In patients with good collateral flow through the anterior communicating complex, this treatment paradigm is safe and effective.

Abstract BACKGROUND: For some posterior inferior cerebellar artery (PICA) aneurysms, there is no constructive endovascular or direct surgical clipping option. Intracranial bypass is an alternative to a deconstructive technique. OBJECTIVE: To evaluate the clinical features, surgical techniques, and outcome of PICA aneurysms treated with bypass and obliteration of the diseased segment. METHODS: Retrospective review of PICA aneurysms treated via intracranial bypass was performed. Outcome measurements included postoperative stroke, cranial nerve deficits, gastrostomy/tracheostomy requirement, bypass patency, modified Rankin scale (mRS) at discharge, and mRS at 6 mo. RESULTS: Seven patients with PICA aneurysms treated with intracranial bypass were identified. Five had fusiform aneurysms (4 ruptured, 1 unruptured), 1 had a giant partially thrombosed saccular aneurysm (unruptured), and 1 had a dissecting traumatic aneurysm (ruptured). Two aneurysms were at the anteromedullary segment, 4 at the lateral medullary segment, and 1 at the tonsillomedullary segment. Three patients underwent PICA-to-PICA side to side anastomoses, 2 PICA-to-PICA reanastomosis, 1 vertebral artery-to-PICA bypass, and 1 occipital artery-PICA bypass. Six out of 7 aneurysms were obliterated surgically and 1 with additional endovascular occlusion after the bypass. All bypasses were patent intraoperatively; 2 were later demonstrated occluded without radiological signs or symptoms of stroke. No patients had new cranial nerve deficit postoperatively. With the exception of 1 death due to pulmonary emboli 3 mo postoperatively, all others remain at a mRS ≤ 2. CONCLUSION: Constructive bypass and aneurysm obliteration remains a viable alternative for treatment of PICA aneurysms not amenable to direct surgical clipping or to a vessel-preserving endovascular option.

Abstract BACKGROUND: Intraoperative angiography is routinely utilized for aneurysms and arteriovenous malformations (AVMs) to verify complete occlusion and resection. Surgery for spinal and posterior fossa neurovascular lesions is usually performed in prone position. Intraoperative angiography in the prone position is challenging and there is no standardized protocol for this procedure. OBJECTIVE: To describe our experience with intraoperative angiography in the prone and lateral positions, using upper extremity arterial access. METHODS: We reviewed our experience with intraoperative angiography in the prone position between 2014 and 2015, where vascular access was obtained via the upper extremity arteries. Patients were treated in a hybrid endovascular operating room. High cervical and intracranial lesions were studied via brachial or radial access. All accesses were obtained using ultrasonographic guidance and a small caliber arterial sheath (4F). RESULTS: Five patients were treated in the prone and lateral positions using brachial/radial artery access. Patients harbored cerebellar AVM, lateral medullary AVM, cervical arteriovenous fistula (AVF), tentorial dural AVF, and tentorial-incisural dural AVF. Patients were positioned prone (n = 2), semiprone (n = 2), and lateral (n = 1) for the surgery. Three patients were treated via right brachial artery access. Two patients were treated via radial arteries access. All patients tolerated the procedures without technical or clinical complications. Intraoperative angiography verified complete occlusion and resection in all cases prior to surgical closure. CONCLUSIONS: Intraoperative angiography in the prone and lateral positions using upper extremity access is an important adjunct. Brachial or radial access can be obtained safely and provides comfortable and quick approaches.

AIMS Orbital arteriovenous malformations (OAVM) are rare, mostly described with high flow characteristics. Two cases are reported with an OAVM of distinct haemodynamic abnormality. The clinical, angiographic features, and the management considerations are discussed. METHODS Case review of two patients with dural AVM (DAVM) who presented to referral neuro-ophthalmology and endovascular services because of clinical symptoms and signs consistent with a cavernous sinus dural AVM. RESULTS In each patient, superselective angiography revealed a small slow flow intraorbital shunt supplied by the ophthalmic artery. The transarterial and transvenous endovascular approaches to treat the malformation were partially successful. Although, the abnormal flow was reduced, complete closure of the DAVM could not be accomplished without significant risk of iatrogenic injury. Neither patient's vision improved after intervention. CONCLUSION A DAVM in the orbit can cause similar clinical symptoms and signs to those associated with a cavernous sinus DAVM. Even with high resolution magnetic resonance imaging, only superselective angiography can identify this small intraorbital slow flow shunt. The location in the orbital apex and the small size precludes a surgical option for treatment. The transarterial and transvenous embolisation options are limited.

This retrospective study evaluates the impact of implementing a standardized scheduled metamizole dosing protocol within a multimodal analgesia approach after cardiac surgery. The results showed that scheduled metamizole administration was associated with lower opioid consumption, while maintaining adequate pain control and safety. Pain scores measured by the Numeric Rating Scale improved from 1.12 pre-protocol to 0.89 post-protocol (p < 0.0001). Mean opioid consumption decreased from 119.51 mg morphine equivalents to 95.91 mg (p < 0.0001). No cases of clinically relevant agranulocytosis or persistent neutropenia were observed. Renal function, assessed by changes in serum creatinine, showed no significant differences between groups, suggesting renal safety. Despite improved analgesia and reduced opioid use, hospital length of stay increased slightly, potentially due to confounding factors. Our findings support scheduled metamizole as a safe and effective opioid-sparing agent in postoperative cardiac surgery pain management. Further prospective randomized trials are warranted to confirm these results and establish optimal protocols.

BackgroundAscites is a common finding in patients with ovarian cancer. Paracentesis is a relatively simple, safe, and effective procedure for draining fluid from the peritoneum, but valid quality-of-life tools are needed to determine its subjective value for alleviating symptoms and improving patient quality of life. The objective of this study was to prospectively evaluate the performance of a novel Ascites Symptom Mini-Scale (ASmS) and compare it with a previously available questionnaire.MethodsPatients with ovarian cancer–related ascites presenting for paracentesis were asked to complete the newly devised ASmS before the procedure and 1 and 24 hours after. Patients also completed a pain assessment scale and a previously validated ascites questionnaire at the same time points.ResultsThe cohort included 28 patients of median age 68 years (range, 51–86 years), 13 (46.4%) with primary ovarian cancer and 15 with recurrent disease. A median of 3300 mL of ascites was drained. The median score on the ASmS decreased significantly from 21.5 before paracentesis to 11.0 at 1 hour after paracentesis (P < 0.001) and remained low at 24 hours. No demographic factor predicted greater benefit from the procedure. Patients with both mild and severe symptoms reported significant relief.ConclusionsThe ASmS is a robust quality-of-life tool for the specific assessment of symptoms of ovarian cancer–related malignant ascites. It can be used in the clinical trial setting assessing interventions aimed at treating ascites and in the clinic to identify those patients with mild symptoms, who may benefit from paracentesis.