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   Table of Contents - Current issue
January-June 2021
Volume 9 | Issue 1
Page Nos. 1-58

Online since Friday, August 27, 2021

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Adapt and adopt: Remote delivery of healthcare in neurosurgical practice p. 1
Jaspreet Singh Dil
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Micro-catheter assisted coiling (MAC): A mid-path between simple and assisted coiling techniques in treating ruptured wide neck aneurysms and immediate post procedure outcomes p. 3
Vetrivel Muralidharan, Mario Travali, Tiziana Liliana Cavallaro, Letizia Tomarchio, Gabriele Corsale, Federica Cosentino, Marco Angelo Politi, Concetto Cristaudo
Background: Aneurysms with neck diameter >4 mm or dome to neck ratio <2 are wide-neck aneurysms. Balloons and stents are used to assist in coiling the wide-neck aneurysms, but these are associated with increased intra-procedure and peri-procedure risk in ruptured aneurysms. Microcatheter-assisted coiling (MAC) is an alternative salvage technique in these situations which is under reported. Materials and Methods: We describe our experience in a cohort of 16 patients with ruptured wide neck aneurysm treated with MAC technique. Our primary objective of intervention in acute setting was to secure the aneurysm to prevent rebleed. Results: Anterior communicating artery aneurysm was the most common (56.3%) followed by middle cerebral artery bifurcation aneurysm (18.8%), paraclinoid aneurysm (12.5%), posterior communicating artery aneurysm (6.3%) and basilar tip aneurysm (6.3%). Mean greatest dimension of dome and neck were 8.9 mm and 4.6 mm, respectively. Mean neck to dome ratio was 1.8. Fisher grade 3 and grade 4 subarachnoid haemorrhage (SAH) were observed in 56.3% and 43.7% patients, respectively. Immediate post-procedure digital subtraction angiography (DSA) showed Raymond Roy grade 1, grade 2 and grade 3 embolisation in 62.5%, 33.3% and 6.7% patients, respectively. No distal embolus, vessel occlusion, vessel perforation or aneurysm rupture was observed. Immediate post-procedure DSA showed good distal flow in all patients. Infarct was observed at 24 and 48 hours respectively, in two patients with Fisher Grade 3 SAH. Conclusion: Ruptured wide neck aneurysms can be embolised with complete preservation of branching vessel and distal flow. Total occlusion can be achieved in 2/3rd of patients.
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Is foetal variant of posterior cerebral artery a risk factor for ischemic stroke? p. 9
Karthik Thamarai Kannan, Madhavi Karri, Balakrishnan Ramasamy, Aleesha Ummer
Context: Posterior cerebral artery (PCA) derives its blood supply from the vertebrobasilar system. However, in 10% of the population, they get blood supply from the internal carotid artery via a posterior communicating artery. This variant is called as fetal type of PCA (fPCA). Whether fPCA is an anatomical variant or a predisposing factor for a cerebrovascular event remains an enigma. Aims: The aim is to assess if fPCA is associated with increased risk of ischaemic stroke or other vascular anomalies. Settings and Design: It is a retrospective cross-sectional observational study. Subjects and Methods: Patients who underwent MR or CT angiography, over 5 years for various neurological illnesses were screened for fPCA. Those patients were assessed for vascular anomalies and ischaemic stroke. Statistical Analysis Used: Chi-square in the Statistical Package for the Social Sciences v23. Results: On analysis of 250 patients, five had aneurysms; three had AV malformation, one with Fenestration and one with vascular loop. And 51% were found to have an ischaemic stroke, in which 34% had large vessel disease, 41% had lacunar infarct, 7% had a cardioembolic stroke and 18% had an embolic stroke of unknown source with predominantly middle cerebral artery territory infarct (55%). Among 127 patients with ischaemic stroke, 45% had infarcts ipsilateral to fPCA vs 28% on the opposite side of fPCA. Conclusions: We conclude that patients with fPCA had increased risk of MCA infarct probably due to poor collaterals from posterior circulation and fPCA is not associated with increased risk of aneurysms or AV malformations.
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Statistical corner: Logistic regression using R p. 14
Mikko Pyysalo
Introduction: Logistic regression is a regression with a categorical outcome variable and predictor variables that can be either continuous or categorical. Objectives: To demonstrate the basic workflow of logistic regression using R. Materials and Methods: A real world data-set has been used to present an example for the basic workflow of logistic regression using R. Results: Accurate results were obtained including deviance for analysing the fit of the model. Conclusions: Performing basic statistical modeling in R is simple and straightforward procedure. Analysing model fit is essential to be able to report the results.
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Role of angiography in primary capsulo-ganglionic haemorrhage: A review p. 16
Saurabh Beedkar, Ajay Hegde, Girish R Menon
Spontaneous intracerebral haemorrhage (SICH) is the second most common cause of stroke, accounts in contrast to ischaemic stroke and carries a high risk of morbidity and mortality. SICH refers to brain haemorrhage in the absence of trauma and is often associated with hypertension. It is a conventional belief that hypertension is the aetiology in most of the haemorrhage in the basal ganglia region, and angiography is rarely performed in such patients. This protocol carries a risk of missing potentially curable underlying vascular conditions such as arteriovenous malformations and aneurysms, especially in younger patients without a history of hypertension. Performing an angiogram for all patients however is an overkill and unnecessary waste of resources. The role of cerebral angiography to distinguish a primary SICH from secondary SICH in all patients with SICH is thus controversial. Hence, it is the choice of the type of angiogram between digital subtraction angiogram Digital Subtraction Angiography (DSA) and computerised tomography angiogram Computerised Tomography Angiography (CTA). This article attempts to review the current diagnostic angioimaging guidelines for intracerebral haemorrhage with an aim to evolve a management protocol.
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Surgical nuances of clip reconstruction of recurrent middle cerebral artery aneurysms: A technical note p. 22
Aravind Sabesan, Yoko Kato, Tsukasa Kawase, Yasuhiro Yamada, Riki Tanaka
Recurrence of an aneurysm is not frequently seen after microsurgical clipping. The exact incidence is varied among studies related to recurrent aneurysms from 0.02% to 0.52%. A 68-year-old male, diagnosed with unruptured left middle cerebral artery (MCA) aneurysm 8 years back, was treated by microsurgical clipping then. He was on periodic follow-up since. On yearly follow-up, in 2015, magnetic resonance imaging/magnetic resonance angiography showed small recurrent aneurysm. This was followed up with serial imaging, and the aneurysm slowly grew in size. 2 years after, he was found to have a recurrent aneurysm; in 2017, he was operated for the recurrent aneurysm with microsurgical clipping. Here, we report the technical difficulties and strategies to approach recurrent MCA aneurysm.
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Visual techniques in microsurgery for intra-cranial arteriovenous malformations p. 25
Sumeet Narang, Jaspreet Singh Dil, A Raja
Arterio-venous malformations (AVMs) are anomalous shunts between the arterial and venous systems, acting as a major risk factor for intra-cerebral haemorrhage, seen in 38%–71% of patients harbouring the pathology. Current techniques in the management of AVMs include observation, microsurgery, embolisation and radiosurgery, or combination therapy. AVMs are classically categorised based on the Spetzler-Martin grading and it is generally accepted that Grades I and II are best managed by microsurgical resection. To discuss the technique of astute visual inspection of AVM malformations on the operating table in microsurgical management of AVMs, and the surgical importance and significance of the valuable inferences derived from this routine. It is of utmost importance to visually distinguish between the arterial and venous ends of the nidus, and this can be effectively accomplished through eyeballing techniques by looking at the appearance of the vessels and noticing its colour, thickness, and underlying blood; and the variations in the turgor pressure of the nidus with changes in compression of the arterial and venous ends. It is equally important to visually identify the safe and effective plane to approach the target lesion by identifying the gliotic plane, the discoloured vertex of the underlying haematoma, or the widened subarachnoid spaces. Microsurgical resection is a definite mode of treatment of intra-cranial AVMs and flawless execution of surgery is vital. Eyeballing techniques must be aimed at correctly identifying the nature of the lesion and creating a mind-map before setting out to manipulate the AVM. A good initial visual inspection and survey is a crucial measure of safety and efficiency in AVM surgery.
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Incidental unruptured aneurysm of the distal M2 segment: Case report and review of literature p. 29
K Giridharan, Sudhakshina Nathan, Shashidhar Patil, Balamurugan Mangaleswaran
Aneurysms of the Middle cerebral artery (MCA) are more common at the bifurcation. Distal MCA aneurysm in M2, M3 and M4 segments are rare. Here, we discuss an incidental distal M2 segment aneurysm and its management along with a brief literature review. Fifty-one-year-old male, presented to us with a history of the giddiness of 1-week duration. During the evaluation for giddiness, his computed tomography (CT) brain plain showed a small well-defined hyperdense rounded lesion in the left Sylvian fissure. CT angiogram was done and it showed a saccular aneurysm measuring 7.7 mm × 7.3 mm and had a narrow neck of 1.5 mm arising from the distal M2 segment of MCA. The aneurysm was directed superiorly in the distal MCA. Digital subtraction angiogram showed a 6.4 mm × 6.9 mm distal M2 segment bilobed aneurysm with a neck of 3.8 mm and projecting superiorly. Surgical clipping of the aneurysm was done. Perioperative period was uneventful and the patient is doing well at 3 months follow-up. Review of the literature showed that the incidence of distal MCA aneurysm was low. Intra-operative CT angiogram, neuro-navigation, indocyanine green video angiography (ICGV) are some of the useful tools in improving outcomes in surgical clipping of these aneurysms. Distal MCA aneurysms are less frequently encountered. Surgical clipping is the treatment of choice in these cases. Challenge arises in localising these aneurysms and adjuncts such as intraoperative CT angiogram, neuro-navigation, ICGV can be useful to overcome that challenge.
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Bilateral carotid-cavernous sinus fistula: Case reports and review of the literature p. 32
Sachin Chemate, Joy Vargese, Pritam Chatterjee, G Sudhakshina Nathan, M Balamurugan
Carotid-cavernous fistula (CCF) is an abnormal vascular connection between the carotid artery and the cavernous sinus. There are various classifications based on haemodynamic, aetiology or anatomically. Haemodynamic classification is based on whether the fistula is high or low flow. Etiologically, it can be secondary to trauma or can develop spontaneously due to pre-existing aneurysm or medical conditions predisposing to arterial wall defects. Bilateral CCFs are very rare. We present two cases of bilateral CCF – one secondary to trauma and other occurred spontaneously. Both the patients presented with the signs of raised intraocular pressure – decreased vision, chemosis, proptosis and ophthalmoplegia. Magnetic resonance imaging and digital subtraction angiography confirmed a bilateral CCF. Both the patients underwent two settings of endovascular embolisation procedures, and complete embolisation of bilateral CCF was achieved. Available literature is unclear about the aetiology of bilateral CCF, technique of endovascular embolisation and the prognosis of bilateral CCF. In our both the cases, we were able to achieve complete embolisation in two settings.
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Endovascular treatment of a saccular aneurysm associated with fenestrated basilar artery and proximal stenosis of vertebral artery origin - A treatment challenge p. 38
Himanshu R Patel, Barve S Pandurang, Trimurti D Nadkarni
A 52-year-old woman had subarachnoid haemorrhage due to an aneurysm at a fenestration of the vertebrobasilar artery junction. The fenestration and aneurysm filled by the dominant left vertebral artery (VA). The left VA had a tight stenosis at its origin from the left subclavian artery. The patient underwent a stent-assisted coiling of the aneurysm after balloon dilatation of the proximal stenosis. The management of this unusual and rare entity is discussed. The relevant literature on the subject is presented.
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Pseudo-hyperdense MCA sign: The value of comparing CT densities of vessels on both sides p. 41
Prasad Krishnan
Hyperdense middle cerebral artery (MCA) sign is a well-recognised sign of stroke radiology. However, less often reported is the pseudo 'hyperdense MCA sign' that looks ominous and may confound the clinician into thinking that he is dealing with a case of ischaemic stroke. We report a 56-year-old male who nearly underwent thrombolysis due to this sign seen on initial computed tomography imaging and highlight the way to avoid this pitfall.
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Cranio-vertebral junction arteriovenous fistula presenting with subarachnoid haemorrhage: A case report p. 43
Abhishek Katyal, BC Anil Kumar, Shaam Bodeliwala, Anita Jagetia, Arvind Kumar Srivastava
Perimedullary arteriovenous fistulas are uncommon vascular malformations particularly if they involve the craniovertebral junction. The complexity of the angioarchitecture of these lesions poses a further diagnostic challenge. Moreover, the therapeutic management is controversial and can include observation alone, endovascular occlusion, or surgical exclusion, depending on both patient and the angiographic characteristics of the lesion.
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A giant spontaneous dural arteriovenous fistula of the spheno-parietal sinus clinically masquerading as carotico-cavernous fistula: A case report p. 46
Dibya Jyoti Mahakul, Rahul N Inganal, Daljit Singh
Dural arteriovenous fistulas (DAVF) are abnormal connections between the feeding arteries and veins within the dural leaflets and constitute 10%–15% of all intracranial arteriovenous malformations. DAVF draining into sphenoparietal sinus is a rare pathologic entity that is fed by the middle meningeal artery and is associated with a history of prior trauma. We report a unique case of DAVF of sphenoparietal sinus that had developed spontaneously. Being giant in morphology, it had eroded into the orbit and presented with proptosis, chemosis and restriction of eye movement. Although the clinical findings pointed towards caroticocavernous fistula, the real pathomorphology was unveiled by the six-vessel catheter angiography with selective catheterisation of smaller feeding vessels. All the feeding vessels were meticulously mapped out, and the fistulous connection was vividly identified and subsequently obliterated using detachable coils and n-butyl cyanoacrylate.
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Double adjacent basilar artery fenestration with cerebellar infarct: Case report and new classification of double basilar fenestrations p. 49
Trilochan Srivastava, Ashwini Shivayya Hiremath
Basilar artery (BA) fenestration is an uncommon congenital variant associated with aneurysms and posterior circulation infarcts. We present a 42-year-old male, smoker and hypertensive who came with acute onset vertigo and gait ataxia. Cerebellar signs were positive on the left side. Diffusion-weighted brain magnetic resonance imaging showed acute infarct in the left anterior inferior cerebellar artery (AICA) territory. Computed tomography angiography showed BA double adjacent fenestration of proximal segment of BA, without thrombus, dissection/aneurysm. To the best of our knowledge, only three cases of double adjacent BA fenestration have been described so far. The association between vertebro-BA fenestrations and posterior circulation stroke is controversial. It has been suggested that turbulent flow at the site of fenestration predisposes to thrombus formation, which may be cause of stroke. This rare anatomic variant of the posterior circulation is important to recognize and may have associated neurologic consequences (double BA fenestrations are rare yet known congenital variants associated with aneurysms and associated neurological implications) (double adjacent BA fenestration presenting with AICA infarct are still rarer with only three cases reported across the world).
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Cerebral venous sinus thrombosis following trans-sphenoidal excision of pituitary adenoma: A case report p. 52
Piyush R Thombare, Viraj T Nadkarni, Srikant Balasubramaniam
A 52-year-old female diagnosed to harbour a non-functioning pituitary adenoma underwent trans-sphenoidal excision of the tumour. On the 8th post-operative day, the patient developed severe headaches and had an episode of generalised convulsion. Post-ictally, the patient was drowsy, irritable, apahasic and developed right-sided hemiparesis. Computed tomography of the brain revealed a left parietal venous infarct. Magnetic resonance venography confirmed thrombosis of the straight sinus, left transverse sinus, left sigmoid sinus, left internal jugular vein and cortical veins in the left high parietal region. The patient's thrombophilia profile was positive only for heterozygous Factor V Leiden mutation. The patient was treated conservatively with anticonvulsants and low-molecular-weight heparin. The patient recovered completely within a week and was discharged. Cerebral venous sinus thrombosis (CVST) has been rarely reported in the post-operative period following trans-sphenoidal surgery for pituitary adenoma. Early diagnosis and treatment of CVST is necessary for a favourable outcome.
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Proximal A1 segment aneurysm presenting with visual symptoms: A case report p. 56
Shyam Sundar Krishnan, Pulak Nigam, Girish R Menon, Madabushi Chakravarthy Vasudevan
Proximal A1 segment aneurysms are technically challenging aneurysms that require careful and meticulous adherence to surgical principles for optimising the outcomes. They usually present with rupture and headache and visual symptoms are uncommon due to the optic nerve not being in proximity to the aneurysm. Important, delicate perforators arise from the segment and their preservation is the key to a good surgical outcome.
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