Intraoperative Rupture of an Intracranial, Extradural Hydatid Cyst: Case Report and Treatment Options

A 23-year-old woman was presented to the Emergency Unit with intracranial hypertension syndrome and blindness in her left eye which had started recently. A cranial native computed tomography scan and a magnetic resonance imaging (MRI) with contrast examinations revealed a giant intracranial cystic lesion, extending into the left frontal lobe, which was compressing the optic chiasm and eroding the internal plate of the left frontal bone. Surgical craniotomy was performed for evacuation and decompression, but during the craniotomy the cyst ruptured. After assessing the degree of erosion of the internal bone plate, we concluded that the primary origin of the cyst was intraosseous. With the dura mater being intact, abundant lavage with H2O2 was applied and the bone flap was replaced after rigorous bone scraping. Imaging control at six and twelve months identified no recurrence of the cyst. In the literature, hydatid cysts located in the skull bone are very rare and most of them rupture intraoperatively. Given their extremely low incidence in developed countries, any neurosurgeons’ experience with such pathology is limited and in some cases surgery cannot be delayed. In the case of intracerebral hydatid cysts, a neurosurgeon usually has only one shot at surgery, so simple and quick-to-access therapeutic guidelines must be developed in order to inform the choice of surgical technique. We conclude that the most successful surgical approach could be double concentric craniotomy. This surgical technique is used in intracerebral tumors, which also have an important bone invasion.

Rupture of the Pleomorphic Adenoma of the Parotid Gland. What to Know before, during and after Surgery

Background: We assessed the cases of intraoperative spillage of primary pleomorphic adenomas (PPAs) of the parotid gland in the literature, comparing them with our own cases. We aim to explain how the surgeon should manage a spillage during surgery (i.e., how to avoid spreading the contents that are coming out of the tumor). We also aim to investigate whether or not spillage is linked to a higher rate of PPA recurrence. Methods: We collected surgical and pathological reports, taking data on capsular ruptures and the spillage of tumors. Results: Intraoperative tumor spillage and tumor rupture occurred in 34/202 cases. There were three recurrences after a mean of 3.7 years (mean follow-up duration: 10.3 years). One recurrence happened to a patient who had an intraoperative tumor spillage, and two more recurrences happened to patients who did not have spillage. Conclusion: We believe that the real number of the events of spillage is underestimated and underreported by surgeons. Capsular rupture must always be avoided, and secure resection margins must always be pursued, independent of the type of parotidectomy being performed. Features that increase the risk of recurrence are an intraoperative rupture and the presence of satellite nodules (as recorded in the pathologist’s report). In these cases, patients need a longer follow-up period.

126 Neurosurgical Clipping Versus Endovascular Coiling for Unruptured and Ruptured Distal Anterior Cerebral Artery Aneurysms: A Systematic Review and Meta-Analysis

Aim To assess outcomes after clipping or coiling of distal anterior cerebral artery (DACA) aneurysms via a meta-analysis. Method Systematic searches of Medline, Embase and Cochrane Central were undertaken from 1st January 1973 until 1st May 2020 for published studies reporting microsurgical clipping and endovascular coiling of DACA aneurysms. Primary outcome measure was independent functional outcome (modified Rankin scale (mRS) 0–2, or Glasgow Outcome Scale (GOS) 4–5). Secondary outcomes were poor clinical outcome and mortality, perioperative complications, aneurysm occlusion rates, rebleeding and recurrence. Results 938 and 223 patients with ruptured and unruptured DACA aneurysms, respectively, were reported across 28 studies. Pooled rate of procedure-related morbidity was 6.8% (95%CI: 3.2 – 11.2) and 1.3% (95%CI: 0.0 – 9.1) for clipped and coiling ruptured DACA aneurysms respectively. Pooled rate of intraoperative rupture for clipped and coiled ruptured DACA aneurysms was 10.0% (95%CI: 2.5 – 20.6) and 5.7% (95%CI: 1.1 – 12.5) respectively. Pooled rate of acute hydrocephalus for clipped and coiled ruptured DACA aneurysms was 7.8% (95%CI: 0.5 – 19.7) and 1.4% (95% CI: 0.0 – 11.3) respectively. Pooled rate of perioperative mortality was 0.002% (95% CI: 0.0 – 0.7) ruptured DACA aneurysms treated by clipping. For clipped unruptured DACA aneurysms, pooled rates of procedure-related morbidity, intraoperative rupture, acute hydrocephalus were 2.5% (95%CI: 0.0 – 7.5), 0.002% (95%CI: 0.0 – 3.1) and 0.5% (95%CI: 0.0 – 5.1) respectively. Conclusions Clipping results in poorer short-term outcomes when compared to coiling. However, the final decision-making should be shared with the patient and be performed on a selective, case-by-case basis in order to maximize patient benefits.

Microsurgical Management of Blister-Type Basilar Artery Apex Region Aneurysms: Companion Cases Demonstrate Technical Nuances of the Subtemporal Approach: 2-Dimensional Operative Video

The proportion of intracranial aneurysms treated by microsurgical clip ligation has drastically decreased in the endovascular era. However, some aneurysms cannot be treated by current endovascular techniques. Therefore, trainees and young vascular neurosurgeons must develop and maintain microsurgical skills to safely treat aneurysms that require surgery. Ruptured, basilar artery apex, blister-type aneurysms are particularly treacherous and require a high degree of skill to safely manage them surgically. In this video, 2 companion cases are exhibited to demonstrate the nuances of the subtemporal, skull base, approach to the basilar apex region. In each case, the patient consented to surgery and anonymized recording. The subtemporal approach is favored over the trans-sylvian for posteriorly directed basilar apex region aneurysms as the former affords a complete view of the relevant anatomy. Points for consideration include variations on the standard subtemporal approach, use of retractors vs lumbar drainage to mobilize the temporal lobe, and splitting the tentorium vs a suture-retraction technique for visualization of the basilar artery apex region. Techniques for successful navigation of intraoperative rupture are demonstrated. As the number of intracranial aneurysms treated by microsurgery continues to ebb, high-quality educational videos that supplement surgeon experience will become increasingly critical to ensure that a cohort of capable microvascular neurosurgeons is prepared to tackle challenging, but manageable aneurysms, such as the blister-type basilar apex variety. Video (c) Emory University School of Medicine, 2021. Used with permission.

Woven EndoBridge device for the treatment of ruptured intracranial aneurysms: A systematic review of clinical and angiographic results

Background and objective The clinical outcome and angiographic outcome data of Woven EndoBridge (WEB) device for the treatment of ruptured intracranial aneurysms (IAs) are limited. We conducted a meta-analysis of the latest literature on the WEB device in the treatment of ruptured IAs. Methods A comprehensive literature search of 4 databases (PubMed, Web of Science, Cochrane library, and Embase) was conducted for studies published from January 1, 2010 to December 31, 2020. Two reviewers independently extracted variables (aneurysm and patient characteristics) using a prespecified data-collection sheet. Outcomes studied included initial and latest follow-up angiographic outcomes, technical success rate, perioperative mortality, retreated rate, perioperative re-bleeding, complication, intraoperative rupture, favorable neurologic outcome at discharge. We used random-effects model to pool the data. Results We finally presented the results of 7 articles including 276 patients with 283 aneurysms. Initial complete and adequate occlusion rate were 38% (95% CI, 25%–50%) and 98% (95% CI, 95%–100%), respectively. Latest follow-up complete and adequate occlusion rate were 61% (95% CI, 46%–75%) and 91% (95% CI, 84%–98%), respectively.Technical success rate was 99% (95% CI, 98%–100%). Perioperative mortality rates and perioperative re-bleeding rate were 9% (95% CI, 3%–15%) and 1% (95% CI, 0%–2%), respectively. Retreated rate was 6% (95% CI, 3%–10%). Overall and WEB treatment-related thromboembolic complication was 10% (95% CI, 6%–13%) and 7% (95% CI, 2%–12%), respectively. Intraoperative rupture rate was 3% (95% CI, 0%–6%). Conclusion Endovascular treatment of ruptured IAs with the WEB device has a good safety profile and an acceptable aneurysm occlusion rate.

How Safe and Effective Is Shifting from Pterional to Supraorbital Keyhole Approach for Clipping Ruptured Anterior Circulation Aneurysms? A Surgeon’s Transition Phase Comparative Study

Background Comparative studies between standard pterional and supraorbital keyhole approaches for aneurysms had potential biases with the heterogeneity of patient selection, differences among surgeons, or varying expertise across the surgeon’s learning curve. This is a study of a surgeon’s transition from pterional to keyhole approach for early clipping of selected consecutive ruptured anterior circulation aneurysms. Methods Patients more than 18 years, presenting within 72 hours of ictus, in good clinical grades 1 to 3, no midline shift, with saccular aneurysms less than 25 mm at either communicating segment of internal carotid artery, anterior communicating artery, or middle cerebral artery segment till bifurcation were studied between the last 25 cases of pterional and first 25 cases of the keyhole, for the intraoperative and postoperative surgical outcome parameters. Results There was no significant difference among baseline parameters, including the location of aneurysms across both groups. While only four cases of pterional had an intraoperative ventricular puncture, the lumbar drain was electively inserted in all keyhole patients. The intraoperative parameters, such as a dural tear, adequate parent vessel exposure, temporary clipping, and intraoperative rupture, did not show any significant difference. None had immediate postoperative deficits. While delayed cerebral ischemia and wound complaints were similar in both groups, temporal hollowing and chewing difficulty were significantly more in pterional patients(p = 0.01). Conclusion A surgeon experienced in pterional approach can comfortably and safely shift to the keyhole for early clipping of selected ruptured aneurysms less than 25 mm, with a comparable surgical outcome but better cosmesis and mastication.

Microsurgical Clip Trapping of Dorsal Internal Carotid Artery Blister Ruptured Aneurysm: 2-Dimensional Operative Video

Dorsal internal carotid artery (ICA) blister aneurysms are an uncommon aneurysm variant constituting 0.3% to 1% of intracranial aneurysms and can be due to ulceration, atherosclerosis, or dissection.1-3 Despite its rarity, it carries a high risk of rupture with an estimation of 0.9% to 6.5% among intracranial aneurysms.1,2 Blister aneurysms are small in size, have no distinguishable neck, and have a friable wall that can easily rupture if manipulated, hence the difficulty in its treatment utilizing both microsurgical and endovascular techniques.1,2,4-6 Endovascular coiling of these lesions may not be adequate due to the broad-based size; stenting requires the use of antiplatelet medications, which could lead to rebleeding; flow diversion takes longer to exert its treatment effect.1,4 Conversely, microsurgical management carries a higher intraoperative rupture rate.2 Microsurgical options include clipping, clip reconstruction, trapping with bypass, and wrapping.4,7 We present a case of a 38-yr-old man who presented with a ruptured right dorsal ICA blister aneurysm treated with microsurgical trapping with intraoperative flow measurements. We demonstrate how the use of quantitative intraoperative flow measurements allows confident sacrifice of the supraclinoid ICA. We also demonstrate in contrast another case example of utilizing a clip-graft repair. The patient remained unchanged with an intact neurological exam, and postoperative imaging showed no aneurysm remnant and patent anterior choroidal artery. We review the literature and management of dorsal ICA aneurysms.8-15 We also review the technical nuances and different endovascular and microsurgical treatments that can be used for this condition. The patient gave informed consent for the procedure and verbal consent to the publication.

WEB device for treatment of posterior communicating artery aneurysms

BackgroundWoven EndoBridge (WEB) device treatment of wide-neck bifurcation aneurysms has proved to be safe and effective, but the use of these devices in sidewall aneurysms has been reported only in a small number of case series.ObjectiveTo report our results in a cohort of consecutive patients in whom a WEB device was used as first-line treatment for posterior communicating artery (PComA) aneurysms.MethodsWe conducted a retrospective analysis of a prospectively maintained database of PComA aneurysms treated with a WEB device in our institution from June 1, 2012 to November 15, 2020. Clinical and radiological findings were evaluated at immediate and last follow-up.ResultsA total of 219 aneurysms were treated with a WEB device, including 15 PComA aneurysms in 15 patients, 10 of which were ruptured. Aneurysms were wide necked, with a mean aspect ratio of 1.6 (range 0.7–3.0) and a mean neck size of 4.2 mm (range 2.6–7.4 mm). No intraoperative rupture occurred and only one thromboembolic event was noted. Among the group with at least a 3-month digital subtraction angiography (DSA) follow-up, complete and adequate occlusion were obtained in 54% and 72%, respectively (average follow-up 13 months). Re-treatment was needed for two initially ruptured aneurysms. No procedure-related morbidity or mortality was reported.ConclusionThis series suggests the high safety profile of WEB devices even when used in off-label indications. Treatment with these devices seems to be a valuable strategy for ruptured wide-neck PComA aneurysms, avoiding the need for antiplatelet medication. However, occlusion rates should be investigated in further larger studies.