Eosinophilic meningitis following suboccipital craniotomy without bovine dural graft: illustrative case

BACKGROUND Eosinophilic meningitis is a rare known complication after brain surgery associated with duraplasty using artificial bovine graft. However, eosinophilic meningitis after craniotomy without bovine dural graft has not been reported. OBSERVATIONS A 48-year-old female presented with lateral medullary infarction caused by a vertebral artery dissecting aneurysm incorporating the posterior inferior cerebellar artery (PICA). The authors performed occipital artery–PICA anastomosis and repaired the dura by primary suture without bovine graft. Thereafter, endovascular internal trapping using coils was conducted. Severe headache developed at postoperative day 17, and the patient was diagnosed with eosinophilic meningitis. After administration of a high-dose corticosteroid for 2 weeks, her symptoms and laboratory findings were improved. LESSONS Postoperative eosinophilic meningitis is rarely related to craniotomy without using bovine graft. Neurosurgeons should consider the possibility of eosinophilic meningitis after craniotomy without a xenogeneic dural material.

Internal carotid artery anatomy – not always straightforward

Objectives To present a rare variant of internal carotid artery anatomy. Methods Case report presenting CT angiography finding of internal carotid anatomy variant. Results We present the case of an unusual origin of the occipital artery from cervical portion of the internal carotid artery as an incidental finding during CT angiography of the carotid arteries. In discussion, we discuss the possible embryological basis, incidence and prevalence of such finding and its possible clinical implications. Conclusion One of the specific aspects of carotid arteries is their straightforward anatomy – the cervical portion of internal carotid artery, unlike the external carotid, does not give origin to any branches – this aspect is even used as a highlight for orientation, e.g. during ultrasound examination. However, although rare, variants exist, and sometimes can have clinical importance – in the endovascular access or surgical treatment.

Preoperative Endovascular Embolization of Glomus Jugulare Tumors: A Retrospective Case Series of 22 Embolizations in 20 Patients and Literature Review

Objective Glomus jugulare tumors, or tympanojugular paragangliomas, are rare, highly vascularized skull base tumors originated from paraganglion cells of the neural crest. With nonabsorbable embolic agents, embolization combined with surgery has become the norm. The authors assess the profile and outcomes of patients submitted to preoperative embolization in a Brazilian tertiary care hospital. Methods The present study is a single-center, retrospective analysis; between January 2008 and December 2019, 22 embolizations were performed in 20 patients in a preoperative character, and their medical records were analyzed for the present case series. Results Hearing loss was the most common symptom, present in 50% of the patients, while 40% had tinnitus, 30% had dysphagia, 25% had facial paralysis, 20% had hoarseness, and 10% had diplopia. In 7 out of 22 embolization procedures (31%) more than a single embolic agent was used; Gelfoam (Pfizer, New York, NY, USA) was used in 18 procedures (81%), in 12 of which as the single agent, followed by Embosphere (Merit Medical, South Jordan, UT, USA) (31%), Onyx (Medtronic, Minneapolis, MN, USA) (9%), and polyvynil alcohol (PVA) and Bead Block (Boston Scientific, Marlborough, MA, USA) in 4,5% each. The most common vessel involved was the ascending pharyngeal artery, involved in 90% of the patients, followed by the posterior auricular artery in 15%, the internal maxillary artery or the occipital artery in 10% each, and the superficial temporal or the lingual arteries, with 6% each. Only one patient had involvement of the internal carotid artery. No complications from embolization were recorded. Conclusions Preoperative embolization of glomus tumors is safe and reduces surgical time and complications, due to the decrease in size and bleeding.

Sternocleidomastoid flap for pedicled reconstruction in head & neck surgery- revisiting the anatomy and technique

Background Previous studies on sternocleidomastoid flaps, have defined the importance of preserving sternocleidomastoid (SCM) branch of superior thyroid artery (STA). This theory drew criticism, as this muscle is known to be a type II muscle, i.e., the muscle has one dominant pedicle (branches from the occipital artery at the superior pole) and smaller vascular pedicles entering the belly of muscle (branches from STA and thyrocervical trunk) at the middle and lower pole respectively. It was unlikely for the SCM branch of STA to supply the upper and lower thirds of the muscle. We undertook a cadaveric angiographic study to investigate distribution of STA supply to SCM muscle. Methods It is a cross-sectional descriptive study on 10 cadaveric SCM muscles along with ipsilateral STA which were evaluated with angiography using diatrizoate (urograffin) dye. Radiographic films were interpreted looking at the opacification of the muscle. Results were analyzed using frequency distribution and percentage. Results Out of ten specimens, near complete opacification was observed in eight SCM muscle specimens. While one showed poor uptake in the lower third of the muscle, the other showed poor uptake in the upper third segment of muscle. Conclusion Based on the above findings we suggest to further investigate sternocleidomastoid muscle as a type III flap, as the STA branch also supplies the whole muscle along with previously described pedicle from occipital artery. However, this needs to be further corroborated intra-operatively using scanning laser doppler. This also explains better survival rates of superior thyroid artery based sternomastoid flaps.

Abstract 1122‐000124: Dural Arteriovenous Fistula and Implications in Aneurysmal Genesis

Introduction : There is a reported association of cerebral arteriovenous malformations and aneurysms, however, data regarding patients presenting with dural arteriovenous fistulas (dAVF) and aneurysms is limited. Here, we present a patient who was incidentally diagnosed with 2 aneurysms in addition to a dAVF; and her treatment course. Previous to her diagnosis, she denied any and all symptomatology that would prompt further evaluation. Methods : Case description: 60‐year‐old female with history of hypertension, hypothyroidism and gastroesophageal reflux disease who initially presented to an outside hospital after a motor vehicle collision in 2016, at that time she reports being diagnosed with multiple aneurysms; but was lost to follow up. In 2020 she was referred to interventional neuroradiology and underwent diagnostic digital cerebral angiogram. Which reported a 13 × 12 × 13.3 mm left para‐ophthalmic internal carotid artery (ICA) aneurysm with a 7 mm neck. A 5.7 × 7.7 × 6.1 mm basilar tip artery aneurysm with a 5.6 mm neck and a right Cognard type four occipital dAVF, with feeding vessels from the right posterior cerebral artery and right occipital artery and anterograde drainage to the dural sinuses. From the time of diagnosis to the initiation of interventions, patient denied any concerning symptomatology. Treatment was initiated 4 months after diagnostic angiogram. She received 5 days of Dual Antiplatelet therapy (DAPT) with aspirin and Plavix previous to the deployment of a woven endobridge device (WEB™ 8‐3mm) into the basilar tip aneurysm; as this was felt to be the aneurysm with highest probability of rupture. Post‐operative course was unremarkable and DAPT was discontinued. Three months after WEB™ deployment, the patient underwent embolization of the right occipital dAVF with a liquid embolic agent (onyx™). Post operatively, she developed decreased peripheral vision in her left eye, though the rest of her hospitalization was unremarkable. 3 months after embolization, she underwent left para‐ophthalmic artery aneurysm flow diversion with a pipeline™ (4‐18mm) flow diverter, with an uncomplicated admission. She was subsequently evaluated by neuro‐ophthalmology who has reported a stable peripheral left eye left inferior quadrantic defect along with a supertemporal defect in her right eye. Results : Discussion: Interestingly, the patient presented 2 aneurysms, one in the anterior circulation and the most concerning, located in the posterior circulation. One could draw conclusions that the dAVF was associated with the basilar aneurysm. As dAVFs are acquired lesions, it is feasible to assume that there may be an association between both types of lesions, perhaps due to flow or pressure being exerted on weakened vessel walls, thus leading to aneurysmal formation. Conclusions : Conclusion: Because a potential for implication in the flow dynamics of the dAVF in aneurysmal formation. We have opted to use computational fluid dynamics to analyze said flow within the dAVF to better understand the causal relationship between aneurysms and dural fistulae. In the long run research into genesis of aneurysms secondary to coexisting vascular lesions could further elucidate the mechanisms by which aneurysms develop.

Successful shrinkage of anterior communicating artery aneurysm after ACA–ACA bypass with interposed occipital artery graft in pediatric moyamoya disease: illustrative case

BACKGROUND Selecting therapeutic options for moyamoya disease (MMD)-associated anterior communicating artery (ACoA) aneurysm, a rare pathology in children, is challenging because its natural course remains unclear. OBSERVATIONS A 4-year-old boy exhibiting transient ischemic attacks was diagnosed with unilateral MMD accompanied by an unruptured ACoA aneurysm. Although superficial temporal artery to middle cerebral artery anastomosis eliminated his symptoms, the aneurysm continued to grow after surgery. Since a previous craniotomy and narrow endovascular access at the ACoA precluded both aneurysmal clipping and coil embolization, the patient underwent a surgical anastomosis incorporating an occipital artery graft between the bilateral cortical anterior cerebral arteries (ACAs). This was intended to augment blood flow in the ipsilateral ACA territory and to reduce the hemodynamic burden on the ACoA complex. The postoperative course was uneventful, and radiological images obtained 12 months after surgery revealed good patency of the bypass and marked shrinkage of the aneurysm in spite of the intact contralateral internal carotid artery. LESSONS Various clinical scenarios should be assessed carefully with regard to this pathology. Bypass surgery aimed at reducing flow to the aneurysm might be an alternative therapeutic option when neither coiling nor clipping is feasible.

Methods of carotid endarterectomy

This literature review is devoted to various carotid endarterectomy (CE) methods that exist today in Russia. The pros and cons of conventional and eversion technique of the operation are given. It is indicated that the former is associated with higher long-term rate of restenosis, aneurysm and patch infection. The second is associated with higher prevalence of intraoperative internal carotid artery (ICA) thrombosis due to intimal detachment distal to endarterectomy area. The following CE methods for patients with prolonged ICA involvement are described: neo bifurcation formation, autoarterial reconstruction, ICA autotransplantation, plastic using an occipital artery flap. The methods of CE with carotid body saving have been demonstrated: 1. Swallow tail type patch repair proposed by R.I. Izhbuldin; 2. S-shaped arteriotomy proposed by K. A. Antsupov; 3. Two types of operations proposed by R. А. Vinogradov; 4. Сutting off the ICA with sections of common and external carotid artery proposed by A. N. Kazantsev; 5. Glomus-saving ICA autotransplantation in patients with prolonged atherosclerotic involvement. The role of ICA transposition over the hypoglossal nerve in eversion CE is presented. The glomus-saving CE with ICA transposition, called Chik-Chirik CE, is described. Conclusions are drawn on the need to demonstrate all CE types in the novel Russian guidelines for the management of patients with of head and neck arterial diseases.

Magnetic resonance angiographic study of the variations in the branching pattern of external carotid artery

Knowledge of anatomy of the branching pattern of external carotid artery (ECA) is needed for head and neck surgeries and diagnostic purposes. Previously knowledge regarding this was obtained from dissecting specimens. But with magnetic resonance angiograms being done widely, data from these may be taken for a better understanding of the branching pattern of ECA. To study the branching pattern of external carotid artery using MR angiograms taken for other purposes. A cross-sectional study was carried out in our institution, which is a tertiary care centre, between September 2013 and September 2015 in which we studied the MR angiograms of 50 patients. Out of the 50 MR angiograms studied, variations were seen in 5 cases. In two cases, the ascending pharyngeal artery was seen to arise from the lateral side instead of the medial side on the left side. In another two, the ascending pharyngeal artery was seen to arise from the occipital artery on the left side. In one case the superior laryngeal artery arose from the external carotid artery. MR angiogram taken for other purposes is an inexpensive, ionizing radiation free method which can be used to study the branching pattern of external carotid artery.