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   Table of Contents - Current issue
July-December 2021
Volume 9 | Issue 2
Page Nos. 59-121

Online since Tuesday, April 5, 2022

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Practicality of aneurysm clipping over coiling in semi-urban and rural India p. 59
Jaspreet Singh Dil
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Microsurgery of complex intracranial aneurysms p. 61
Basant K Misra, Harshad R Purandare
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Clinical Significance of Serial Measurements of Interleukin-6 and High-Sensitivity C-Reactive Protein as Early Predictor of Poor Neurological Outcome in Aneurysmal Subarachnoid Haemorrhage p. 68
Amit Kumar Sharma, Ruhi Mamualiya, Rahul Inganal, Daljit Singh, Bhawna Mahajan
Introduction: The inflammatory events are implicated in the pathophysiology of subarachnoid haemorrhage (SAH) and secondary brain injury. The goal of this study was to determine the role of interleukin-6 (IL-6) and high-sensitivity C-reactive protein (hsCRP) as an early predictor of the poor neurological outcome at 6 months in individuals with SAH. Methods: In this prospective, observational study of consecutive patients with aneurysmal SAH included over 1 year. Peak IL-6 and hsCRP were used as an indicator of the inflammatory response. Initial IL-6 and hs-CRP levels were collected within 12 h from admission and then for the next consecutive 7 days. The primary outcome was neurological status at 6-month follow-up assessed with the Modified Rankin Scale (0–6) with a score with or higher than 3 labelled as poor outcome. Logistic regression analyses were used to evaluate the associations between the peak serum IL-6 and hs-CRP levels and the neurological outcome. Results: The median peak levels of both markers were significantly higher in the poor outcome group on all 7 days. A significant correlation was seen between peak IL-6 and poor Hunt and Hess grade (P = 0.006), infarction (0.033) and systemic infection (0.03), whereas peak hsCRP had a correlation with rebleed (P = 0.017) and clipping (P = 0.032). Significant risk factors for the poor outcome were poor Hunt and Hess grade (P < 0.000) and high Fisher grades (P = 0.021) and peak IL-6 levels (P = 0.014) on regression analysis. Conclusion: The serial measurements of inflammatory markers IL-6 and hsCRP may be used to predict the neurological outcome in aSAH patients. The peak IL-6 levels correlated significantly with poor neurological outcome. Although hsCRP was elevated in patients with the poor outcome, it was statistically non-significant, suggesting a non-specific inflammatory stress response.
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Adenosine in facilitating aneurysm clipping: An institutional experience p. 76
Ganesh Kumar Manoharan, R J V. V. Prasad, Senthil Kumar, KR Arvind
Introduction: Intracranial aneurysms are the one of most complicated conditions confronted by a neurosurgeon. Even though endovascular procedure is preferred, open surgery and clipping of the aneurysm still remains gold standard procedure for many aneurysms. Proximal control of the parent vessel remains one of the most critical steps in clipping the aneurysms and this can be achieved by various ways such as temporary clipping and transient cardiac standstill using adenosine. Temporary clipping is associated with complications such as infarct and injury to the vessel, whereas temporary hypotension using adenosine provides a way for successful clipping of the aneurysm. Here, we present our experience with adenosine in patients undergoing clipping of aneurysms in our institution between 2017 and 2020. Methodology: It is a retrospective cohort study conducted on patients undergoing craniotomy and clipping of aneurysms and in those where adenosine is not contraindicated. Patients are divided into Group A where adenosine is not used and Group B where adenosine is used. Results: In Group B, where adenosine is used, clipping was easier, with less incidence of intraoperative ruptures, less usage of Temporary clip (TC) and less incidence of infarct, reduce clipping time with no side effects. Conclusion: Adenosine-induced transient cardiac arrest and hypotension are a safe and effective method in facilitating aneurysm clipping.
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A concise operative atlas of microvascular decompression – Different intraoperative scenarios and technical nuances p. 80
Roopesh V R. Kumar, Arunkumar Karthikayan
Background: Trigeminal neuralgia is one of the most common facial pain syndromes. Although there are many postulated hypotheses explaining the pain, microvascular compression of the root entry zone (REZ) of the trigeminal nerve is commonly accepted to be the pathology for neuralgia. Various medical and surgical treatments are available to relieve the pain and microvascular decompression of the trigeminal nerve at the REZ is considered as the most successful modality and the gold standard. Methods: In this video atlas on operative nuances, we have described nine common scenarios that could be encountered during this surgery. Conclusion: Thorough knowledge of the different intraoperative scenarios is crucial for a complete microvascular decompression that translates into a good post-operative outcome.
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Do intra operative brain conditions during clipping for ruptured intra cranial aneurysms affect the outcome? Being devil's advocate p. 84
Navneet Singla, K Ramanadha Reddy, Ashish Aggarwal, Rajesh Chhabra, Hemant Bhagat
Introduction: For a disease like aneurysmal subarachnoid haemorrhage (aSAH) which continues to have high morbidity and mortality, prognostication is imperative. This gives realistic goals to both the health-care worker and the patient. Unfavourable brain conditions during surgery like dural bulge, brain swelling, petechial haemorrhages, need for ventricular tap are conventionally thought to be harbingers of poor outcomes. But is it really so? Methods: Fifty-four consecutively operated patients of aSAH were studied. Clinical grade at admission (H and H, World Federation of Neurosurgical Societies (WFNS)), Dural bulge, brain swelling, petechial haemorrhages, need for ventricular tap, and brain pulsatility were studied for outcome parameters like Glasgow outcome scale (GOS) at 1 and 3 months and development of focal deficits. Results: H and H and WFNS grades had a significant correlation with GOS. We found that the need for augmentation duraplasty had a significant association with the outcome and appearance of focal deficits. However, unfavourable brain conditions like--dural bulge, brain swelling, petechial haemorrhages, need for ventricular tap, absence of brain pulsatility during surgery did not have a significant impact on the outcome. Conclusions: Clinical grading by far remains the best predictor of outcome. Intra-operative brain conditions did not have a bearing on the outcome. The mechanism by which poor grade patients exhibit poor outcomes remains elusive. At least in the present study, it was not by way of manifesting as unfavourable brain conditions. A word of caution--further large studies are required before definite conclusions can be drawn.
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Statistical corner: Building own functions in R p. 90
Mikko Pyysalo
Introduction: R is a programming language that can be used to efficiently solve statistical problems. Objectives: To demonstrate the method of building functions using R in statistical analysis and storing it for future use. Materials and Methods: A real world example of comparison of statistical values in aneurysm research with respect to its locations has been used to demonstrate how one might build a function using R. Results: Accurate results could be obtained and the function can be stored for later use. Conclusions: As the statistical tools required in research are recurrent, building functions in R and storing them for future use is highly recommended.
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Optico-chiasmatic hypothalamic cavernomas - A report of three cases and review of literature p. 92
Roopesh V R Kumar, Arunkumar Karthikayan, Adhithyan Rajendran
Optochiasmatic hypothalamic cavernous malformations (CMs) are exceedingly rare lesions and can manifest with visual deficits of varying magnitudes. They also can result in sudden-onset visual loss due to apoplexy. Magnetic resonance imaging can delineate the lesions and differentiate it from other common lesions like glioma or craniopharyngioma. Preoperative visual assessment including perimetry and optical coherence tomogram has to be performed whenever possible to assess the degree of deficits and also for prognostication. Microsurgical excision improves the visual deficits in majority of instances as documented by earlier reports and has to be undertaken as an emergency in apoplexy. Various corridors can be used to reach the lesion including anterolateral, midline transbasal anterior interhemispheric approach, and transnasal endoscopic approaches. The aim should be to achieve a gross total excision with minimal manipulation of surrounding white matter tracts to improve the visual outcome. There is a limited role for stereotactic radiosurgery. In the present study, we report three cases of CMs involving optic chiasm and hypothalamus including a case of apoplexy managed by gross total microsurgical resection with good outcome and also review the relevant literature on the natural history and management strategies
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Outcome of microsurgical clipping of anterior communicating aneurysms: A single-centre experience p. 98
M Ganesh Kumar, Rjvv Prasad, Senthil Kumar, A Pravallika
Anterior communicating (ACOM) aneurysms are the most common intracranial aneurysms. About 30%–40% of ruptured intracranial aneurysms are ACOM aneurysms. Its complex structural and anatomical variability and its critical location pose a great challenge to the surgeon during microsurgical clipping. We share our experience in clipping these aneurysms and its outcome. The aim was to study the outcome following microsurgical clipping of ACOM artery aneurysm presenting with rupture and subarachnoid haemorrhage and to determine the factors which dictate the clinical outcome after 6 months. The study includes all cases of ruptured ACOM aneurysms who underwent microsurgical clipping between the period of 2016 and 2020. The medical records were analysed retrospectively and results were recorded. The study shows that the outcome of the patients depends on presenting World Federation of Neurological Surgeons grade, anterosuperiorly projecting aneurysms are at high risk for intraoperative rupture and complications such as lacunar infarcts are common with the usage of temporary clips.
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Spontaneous thrombosis of internal carotid artery with occlusion of giant cavernous carotid aneurysm and malignant hemispheric infarct – Cure or curse? p. 103
Girish Menon, Aseem Pradhan, Ajay Hegde
Spontaneous thrombosis of giant intracranial aneurysm with parent artery occlusion is uncommon. We present an unusual case of a 28-year-old female who presented with a hemispheric infarct probably secondary to dissection of the cervical internal carotid artery (ICA). The cervical ICA occlusion simultaneously induced total thrombosis of pre-existing incidental giant cavernous ICA aneurysm. We discuss the various theories and probable mechanisms involved.
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Post-Operative ischaemic stroke as a sequelae of unnoticed small internal carotid artery intimal flap p. 106
Amit Kumar Sharma, Anita Jagetia, Arvind Kumar Srivastava, Daljit Singh
The risk of stroke associated with aneurysm coiling can occur as a result of thromboembolic complications. The iatrogenic internal carotid artery (ICA) dissection can also lead to ischemic stroke. A 42-year-old patient was diagnosed with a left ICA paraclinoid aneurysm. The endovascular coil embolisation was done. The aneurysm was completely obliterated with preservation of parent artery and distal flow. In the post-operative period, the patient developed a left middle cerebral artery territory infarct. The patient underwent decompressive hemicraniectomy and check data structures and algorithms (DSA) showed ICA dissection with no distal flow. The retrospective examination of earlier DSA revealed a suspected small intimal flap which later progressed to complete dissection and resulted in the infarct. We are reporting this case intending to emphasize careful examination of angiogram and findings suggestive of even a small intimal flap of ICA must not be overlooked. It might progress to frank dissection, stenosis of ICA and even fatal ischaemic stroke.
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Torcular herophili dural arteriovenous fistula of the brain – Balloon-assisted flow-controlled embolisation with venous sinus preservation p. 109
Srinivasan Paramasivam, Kannah Elangovan
Dural arteriovenous fistulas (DAVF) are rare acquired vascular malformations of the brain with varied clinical presentations based on the location and pattern of venous drainage. Aggressive management of DAVF is predominantly endovascular with open surgical obliteration reserved for a few selected cases. DAVF around the trocular herophili are challenging as we need to preserve the superficial and deep venous channels for the normal drain drainage. We describe a case of complex DAVF centered around torcula herophili and left transverse sinus with complete obliteration of left sigmoid sinus and stenosis of the left transverse sigmoid sinus. The DAVF had retrograde venous drainage through the superficial and deep venous sinuses, cortical veins, competing with normal venous drainage of the brain with significant venous hypertension and cognitive impairment. Our goal was complete obliteration of all the feeders with preservation of the venous sinuses and reduction of venous hypertension to achieve cognitive improvement. Endovascular embolisation by transarterial route was done with flow control on the venous side using dimethyl sulfoxide compatible balloon. We have described the technical challenges and strategy to achieve complete obliteration of all the feeders around the sinus, with preservation of torcula using balloon inflation. Venous system flow was restored to the normal pattern and anti-coagulated for 24 h. Endovascular embolisation is the mainstay treatment for DAVF. To achieve cure, strategising the approach and extent of obliteration based on anatomy and venous drainage pattern of the brain is essential. Torcular DAVF pose a specific challenge, at it is the confluence of the superficial and deep venous system. Transvenous Balloon-assisted embolisation is a safe and effective method to achieve complete obliteration of DAVF with preservation of the venous sinuses.
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Combined Sub-temporal and Pterional Exposure for Clipping of Posterior Cerebral Artery Aneurysm p. 115
Girish Menon, Arla Sai Varsha, Vinod Kumar, Ajay Hegde
Posterior cerebral aneurysms are rare posterior circulation aneurysms. Clinical presentation can be varied from life-threatening subarachnoid hemorrhage to mass effect on adjacent structures. Due to their complex anatomical location, microsurgical clipping is not without challenges. Several approaches have been described based on the location of the aneurysm in relation to the segment of the posterior cerebral artery (PCA). We describe a combined approach for surgical clipping of a postcommunicating anterior segment PCA aneurysm.
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Thrombolysis beyond the time window in takayasu's arteritis: A challenging experience p. 118
Madhavi Karri, Balakrishnan Ramasamy, Elango Swamiappan, Santhosh Perumal, Karthik Thamarai Kannan
Takayasu's arteritis (TA) is chronic inflammatory vasculopathy preferentially affecting the aorta and its major branches. It is one of the potential causes of stroke in young adults. Here, we report a young female who presented to us with an acute-onset right hemiparesis with motor aphasia after 10 h of symptoms onset. Her National Institute of Health Stroke Scale (NIHSS) score at admission was 12. The stroke imaging showed acute infarct in the left middle cerebral artery territory with arterial spin labelling perfusion sequence showing diffusion perfusion mismatch with good penumbra. She underwent intravenous thrombolysis with tenecteplase, based on imaging findings and despite being out of window period. She had an excellent clinical recovery and was discharged with oral anticoagulant and azathioprine. After 3 months of stroke and recovery, follow-up was unremarkable with minimal residual deficits with an NIHSS score of 4 and Modified Rankin Scale of 1. Hence, appropriate early interventions in acute stroke in TA individuals are highly beneficial and timely considered for a good outcome and better quality of life.
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