Cases reported "Intracranial Aneurysm"

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1/22. An unusual fatal complication of low basilar trunk aneurysm surgery: isolated prepontine tension pneumocephalus.

    OBJECTIVE: A case of postoperative tension pneumocephalus after low basilar trunk aneurysm clipping is presented. To our knowledge, this is the first case of isolated prepontine tension pneumocephalus. BACKGROUND: A 63-year-old woman was admitted for repair of a basilar aneurysm that had caused a subarachnoid hemorrhage. She was cooperative and partially oriented. According to Hunt & Hess classification, she was considered Grade III. METHOD: The aneurysm was clipped, using a right lateral suboccipital craniectomy with the patient in the sitting position. In the early postoperative period, she had no new neurological deficit. However, 2 hours later the patient became lethargic and unresponsive to verbal commands. Emergency CT scan revealed an isolated prepontine tension pneumocephalus with prominent posterior displacement of the pons. She was immediately taken back to surgery. Upon incision of the dura mater, air could be heard escaping under pressure from the posterior fossa cavity. The clip was in its proper position and all arteries were patent. Spontaneous respiration and pupil reflexes returned soon after surgery, but she remained unconscious and died 3 days later. CONCLUSION: We believe that this death was directly attributable to the tension pneumocephalus and the distortion of the pons. Postoperative prepontine tension pneumocephalus, although this is an extremely rare condition, should be considered if a patient deteriorates after basilar aneurysm surgery in the sitting position.
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2/22. Posterior fossa decompression and clot evacuation for fourth ventricle hemorrhage after aneurysmal rupture: case report.

    OBJECTIVE AND IMPORTANCE: Massive intraventricular hemorrhage due to aneurysmal rupture is associated with a dismal prognosis. An intraventricular clot causing fourth ventricle dilation can cause compression to the brainstem similar to other posterior fossa masses such as cerebellar hemorrhage or infarction. The presence of fourth ventricle dilation carries a very high risk of death within 48 hours. Neither ventricular drainage nor fibrinolytic infusion has been successful in eliminating clots of the fourth ventricle. Posterior fossa decompression and direct evacuation of the clot could have good results in relieving brainstem compression caused by the clot. CLINICAL PRESENTATION: A 45-year-old woman was admitted to our intensive care unit after experiencing an aneurysmal subarachnoid hemorrhage. The neurological examination at admission revealed that she was in Grade V according to the World Federation of Neurological Surgeons grading system, but brainstem reflexes were present. Computed tomographic scanning revealed a massive intraventricular hemorrhage, with fourth ventricle dilation caused by an intraventricular clot. Bilateral external ventricular drains were placed to relieve elevated intracranial pressure. cerebral angiography revealed a 1-cm basilar tip aneurysm, which was embolized with Guglielmi detachable coils (boston Scientific, boston, MA) during the same procedure. INTERVENTION: Given the patient's poor neurological condition, it was decided that brainstem compression should be relieved. A posterior fossa decompressive craniectomy was performed immediately after coil therapy, with direct evacuation of the intraventricular clot. The patient experienced a clear improvement in the level of consciousness and has achieved a good neurological result at early follow-up. CONCLUSION: Dilation of the fourth ventricle by an intraventricular clot is a sign of brainstem compression that can be relieved by posterior fossa decompression and direct clot evacuation.
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ranking = 1.2868768549374
keywords = craniectomy, decompressive
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3/22. Far-lateral approach to intradural lesions of the foramen magnum without resection of the occipital condyle.

    OBJECT: The goal of this study was to determine whether drilling out the occipital condyle facilitates surgery via the far-lateral approach by comparing data from 10 clinical cases with that from studies of eight cadaver heads. methods: During the last 6 years at louisiana State University health Sciences Center-Shreveport, 10 patients underwent surgery via the far-lateral approach to the foramen magnum. Six of these patients harbored anterior foramen magnum meningiomas, one patient a dermoid cyst, two patients vertebral artery (VA) aneurysms, and an additional patient suffered from rheumatoid disease of the craniocervical junction. The surgical approach consisted of retromastoid craniectomy and C-1 laminectomy. The seven tumors and the pannus of rheumatoid disease were completely excised, and the two aneurysms were clipped without drilling the occipital condyle. In one patient a chronic subdural hematoma was found 3 months after surgery, but no patient displayed any complication associated with surgery. It is significant that in no patient was a cerebrospinal fluid leak present. All patients experienced improved neurological function postoperatively. To compare surgical visibility, eight cadaveric specimens (16 sides) were studied, including delineation of the VA and its segments around the craniocervical junction. Increase in visibility as a function of fractional removal of the occipital condyle was quantified by measuring the degrees of visibility gained by removing one third and one half of the occipital condyle. Removal of one third of the occipital condyle produced a mean increase of 15.9 degrees visibility, and removal of one half produced a mean increase of 19.9 degrees. CONCLUSIONS: On the basis of their findings the authors conclude that removal of the occipital condyle is not necessary for the safe and complete resection of anterior intradural foramen magnum tumors.
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4/22. Proposed use of prophylactic decompressive craniectomy in poor-grade aneurysmal subarachnoid hemorrhage patients presenting with associated large sylvian hematomas.

    OBJECTIVE: As a group, patients who present in poor neurological grade after aneurysmal subarachnoid hemorrhage (SAH) often have poor outcomes. There may be subgroups of these patients, however, in which one pathological process predominates and for which the initiation of specific therapeutic interventions that target the predominant pathological process may result in improved outcome. We report the use of prophylactic decompressive craniectomy in patients presenting in poor neurological condition after SAH from middle cerebral artery aneurysms with associated large sylvian fissure hematomas. Craniectomy allowed significant parenchymal swelling in the posthemorrhagic period without increased intracranial pressure (ICP) or herniation syndrome. methods: Eight patients (mean age, 56.5 yr; age range, 42-66 yr) presented comatose with SAH (five Hunt and Hess Grade IV, three Hunt and Hess Grade V). Radiographic evaluations demonstrated middle cerebral artery aneurysm and associated large sylvian fissure hematoma (mean clot volume, 121 ml; range, 30-175 ml). patients were brought emergently to the operating room and treated with a modification of the pterional craniotomy and aneurysm clipping that included a planned craniectomy and duraplasty. A large, reverse question mark scalp flap was created, followed by bone removal with the following margins: anterior, frontal to the midpupillary line; posterior at least 2 cm behind the external auditory meatus; superior up to 2 cm lateral to the superior sagittal sinus; and inferior to the floor of the middle cranial fossa. Generous duraplasty was performed using either pericranium or suitable, commercially available dural substitutes. RESULTS: All of the eight patients tolerated the craniectomy without operative complications. Postoperatively, all patients experienced immediate decreases in ICP to levels at or below 20 mm Hg (presentation mean ICP, 31.6 mm Hg; postoperative mean ICP, 13.1 mm Hg). ICP control was sustained in seven of eight patients, with the one exception being due to a massive hemispheric infarction secondary to refractory vasospasm. Follow-up (> or = 1 yr, except for one patient who died during the hospital stay) demonstrated that the craniectomy patients had a remarkably high number of good or excellent outcomes. The outcomes in the hemicraniectomy group were five good or excellent, one fair, and two poor or dead. CONCLUSION: The data gathered in this study demonstrate that decompressive craniectomy can be performed safely as part of initial management for a subcategory of patients with SAH who present with large sylvian fissure hematomas. In addition, the performance of decompressive craniectomy in the patients described in this article seemed to be associated with rapid and sustained control of ICP. Although the number of patients in this study is small, the data lend support to the hypothesis that decompressive craniectomy may be associated with good or excellent outcome in a carefully selected subset of patients with SAH.
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ranking = 14.295014839499
keywords = craniectomy, decompressive
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5/22. aneurysm of the distal posterior inferior cerebellar artery originating from the extracranial and extradural vertebral artery.

    A 42-year-old woman presented with a ruptured aneurysm of the distal posterior inferior cerebellar artery (pica), which had a rare extracranial and extradural origin. Medial suboccipital craniectomy and C-1 laminectomy were performed. The aneurysm had adhered to the right cerebellar tonsil, but was successfully clipped without difficulty. Intraoperatively, the pica origin was recognized in the extracranial and extradural space between the dorsal roots of the C-1 and C-2 nerves. The origin of the pica from the vertebral artery (VA) may occur at any portion of the VA from the site of penetration of the dura to the vertebrobasilar junction, but an extradural origin is uncommon. A ruptured aneurysm of the pica branching from the VA at a site proximal to the vertebrobasilar junction and below the foramen magnum may be overlooked by three-vessel angiography if the contrast medium cannot reflux to the contralateral pica origin.
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keywords = craniectomy
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6/22. Intracanalicular aneurysm of the anterior inferior cerebellar artery revealed by multi-detector CT angiography.

    A 62-year-old woman had sudden-onset headache and posterior neck pain, and a subarachnoid hemorrhage was revealed by unenhanced CT. Both multi-detector CT angiography and digital subtraction angiography were performed and revealed a small intracanalicular aneurysm of the left anterior inferior cerebellar artery. The patient underwent successful retrosigmoid craniectomy and trapping of the aneurysm. This case shows the ability of multi-detector CT angiography to indicate bony landmarks that can alter the surgical approach.
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7/22. Intracanalicular aneurysm at the meatal loop of the distal anterior inferior cerebellar artery: a case report and review of the literature.

    BACKGROUND: Distal aneurysms of the anterior inferior cerebellar artery (AICA) are rare. Most of the reported cases have been located near the internal auditory meatus. Among these cases, only six located in the internal auditory meatus have been reported in the literature. methods: A 64-year-old female presented with sudden onset of severe headache. Computed tomography (CT) revealed moderate subarachnoid hemorrhage and Gd-DTPA enhanced magnetic resonance imaging (MRI) showed a small high-intensity mass at the right cerebellopontine angle. Although initial digital subtraction angiography (DSA) showed no vascular abnormalities, repeated DSA disclosed a saccular aneurysm at the top of the meatal loop of the right AICA. The patient underwent a suboccipital craniectomy on the 18th day after the hemorrhage RESULTS: .In this case, the aneurysm was completely buried in the internal auditory meatus. After unroofing the meatus, the aneurysm was successfully clipped. After 3 months of hospitalization, the patient was discharged with right-sided deafness, partial facial palsy, and no other complications. CONCLUSIONS:We discuss some of the clinical features and pitfalls in the surgical management of intracanalicular AICA aneurysms and review previous reports of similar cases.
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keywords = craniectomy
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8/22. Treatment of vertebral artery aneurysms with posterior inferior cerebellar artery-posterior inferior cerebellar artery anastomosis combined with parent artery occlusion.

    BACKGROUND: In patients with aneurysms that involve the origin of the posterior inferior cerebellar artery (pica) and require occlusion of the vertebral artery (VA), revascularization of the pica is commonly performed. We present six patients with dissecting VA aneurysms who underwent pica-pica anastomosis combined with parent artery occlusion. methods: After a lower lateral suboccipital craniectomy and partial resection of the jugular tubercle, anastomoses were performed in a side-to-side fashion at the posterior medullary segment of the pica. The VA was subsequently occluded by clipping proximal and distal to the aneurysm, and the pica was occluded by clipping distal to the aneurysm. RESULTS: Postoperative cerebral angiography demonstrated patency of the anastomosis and regression of the aneurysm in five of six patients. The remaining patient experienced hemorrhage from contralateral VA dissection and subsequently died. One patient experienced myopathy of the lower extremities secondary to intraoperative fixed board compression and developed permanent lower extremity muscular weakness. The remaining four cases experienced no new neurologic deficits. CONCLUSION: pica-pica anastomosis is a useful procedure for reconstruction of the pica when parent vessel occlusion or trapping is necessary to exclude a VA aneurysm involving the origin of the pica.
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9/22. A large aneurysm of the persistent primitive hypoglossal artery.

    An aneurysm of a persistent primitive hypoglossal artery (PHA) particularly at its junction with the basilar artery, often poses therapeutic problems. This is attributable not only to the size and location of the aneurysm but also to the fact that the persistent PHA is functionally the single artery providing blood in posterior circulation. We report a 31-year-old man with a large aneurysm of the persistent PHA at its junction with the basilar artery and review the existing literature. We clipped the broad neck of the aneurysm through a lateral suboccipital craniectomy; however, the patient suffered a second episode of subarachnoid hemorrhage. Angiography disclosed a slipped clip incompletely obstructing the persistent PHA. He received no further treatment for the aneurysm because of his deteriorating condition. Direct surgical treatment, although it failed to obliterate the aneurysm neck in our patient, should be recommended for a persistent PHA aneurysm.
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10/22. Multiple anterior inferior cerebellar artery aneurysms associated with an arteriovenous malformation: case report.

    BACKGROUND: Multiple aneurysms of the proximal part of the anterior inferior cerebellar artery (AICA) associated with a distal arteriovenous malformation (AVM) are extremely rare lesions. methods: A 52-year-old man was admitted because of sudden headache. Neurological examination revealed ataxia. Computed tomography scan showed a right cerebellar and subarachnoid hemorrhage. Vertebral angiograms demonstrated 3 small aneurysms at the proximal part of the AICA and distal AVM. RESULTS: A right-sided lateral retromastoid suboccipital craniectomy was performed. We observed strangulation and obliteration at the AICA due to multiple clipping for aneurysms. Thus, aneurysms could not be clipped. At 11 years after bleeding, vertebral angiograms showed that 3 aneurysms had slightly enlarged but the AVM remained unchanged. To date, the patient is still doing well except for dizziness. CONCLUSION: This association is very rare at the AICA level, and definitive treatment of this association is sometimes complex.
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keywords = craniectomy
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