P.195 Giant aneurysm, tiny patient: flow diversion stenting of a giant
                        MCA aneurysm in a young child

Background: A 3-year-old girl presented with a 6-day history of severe headaches. On examination, upper motor neuron signs were noted in the left upper and lower extremities with increased tone, reflexes, and a positive Babinski sign. MRI of the brain revealed a giant right middle cerebral artery (MCA) aneurysm with significant mass effect, associated with cerebral edema and ventricular effacement. CT and CT angiogram showed evidence of aneurysmal wall calcification and lamellar thrombosis within the aneurysmal sac. In addition, there was a smaller right MCA aneurysm in close proximity to the giant aneurysm. Methods: After a balloon occlusion test to assess collateral blood flow to the MCA territory, it was decided to treat both aneurysms with a flow diverting stent. Dual antiplatelet loading was done with aspirin and clopidogrel. The smallest available diameter of Pipeline Shield stent was deployed. Results: The patient remained neurologically unchanged. Early follow-up imaging demonstrated stent patency, reduced size and mass effect of the large aneurysm, reduced cerebral edema, and no flow into the smaller aneurysm. Conclusions: Flow diversion stenting may be employed successfully in pediatric patients, though has unique technical considerations including small size vessels and limited evidence for antiplatelet agent choice and dosing.

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Left pterional craniotomy for thrombectomy and clipping of ruptured left MCA giant aneurysm

Neurosurgical FOCUS ◽

10.3171/2015.7.focusvid.14550 ◽

2015 ◽

Vol 39 (videosuppl1) ◽

pp. V1

Author(s):

William T. Couldwell ◽

Aaron Cutler ◽

Jayson A. Neil

Keyword(s):

Superficial Temporal Artery ◽

Motor Evoked Potential ◽

Giant Aneurysm ◽

Temporal Artery ◽

Mass Effect ◽

Left Middle Cerebral Artery ◽

Vessel Patency ◽

Vein Bypass ◽

Mca Aneurysm ◽

Evoked Potential Monitoring

Giant aneurysms present a challenge to cerebrovascular surgeons on many fronts. These lesions have significant mass effect on surrounding tissues and are often partially thrombosed with thickened or calcified walls; these difficulties are amplified in cases of subarachnoid hemorrhage. The treatment of these lesions often requires debulking or resection of the aneurysm with or without trapping and bypassing the aneurysm segment. The case presented is of a man with a ruptured giant left middle cerebral artery (MCA) aneurysm presenting with seizure. The treatment of this giant aneurysm involves dissection, opening and internal evacuation including the use of ultrasonic aspiration, resection, and clipping. The patient was given aspirin preoperatively in preparation for possible superficial temporal artery-MCA or saphenous vein bypass if clipping was not possible. Vessel patency was evaluated using intraoperative Doppler and indocyanine green angiography. Intraoperative somatosensory and motor evoked potential monitoring is performed in all cases. Postoperatively, the patient was neurologically intact. At 1 year his modified Rankin Scale is 1, with his only symptom being intermittent headache.The video can be found here: http://youtu.be/8dimNdiIObE.

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Effect of flow diversion with silk on aneurysm size: A single center experience

Interventional Neuroradiology ◽

10.1177/1591019915576433 ◽

2015 ◽

Vol 21 (1) ◽

pp. 12-18 ◽

Cited By ~ 7

Author(s):

Lee-Anne Slater ◽

Cathy Soufan ◽

Michael Holt ◽

Winston Chong

Keyword(s):

Time Of Flight ◽

Mass Effect ◽

Flow Diversion ◽

Retrospective Evaluation ◽

Single Center Experience ◽

Aneurysm Size ◽

Small Series ◽

Subsequent Decrease ◽

Complete Collapse

Alterations in aneurysm size and mass effect can result in alleviation or aggravation of symptoms. We assessed the effects of flow diversion with SILK stents on aneurysm sac size and associated factors. A retrospective evaluation of 14 aneurysms treated with SILK stents alone with MRI follow-up was performed. Aneurysm sac size was measured using the sequence best demonstrating the sac. Aneurysm characteristics and flow-related enhancement on time of flight images were documented. Clinical histories were reviewed for evolution of symptoms. Complete collapse of the aneurysm sac was demonstrated at three and 18 months in 2/14 aneurysms. Increase in size was observed in 2/14 aneurysms with associated persistent flow on time of flight MRA. Blister formation with aggravation of symptoms was observed in one aneurysm, and subsequent decrease in size occurred after treatment with a second SILK. The other aneurysm which increased in size initially continued to enlarge asymptomatically despite retreatment with a second SILK, however at 24 months thrombosis of the sac and decrease in size was observed. The remaining 10/14 aneurysms decreased in size. Nine had corresponding MRA occlusion and the tenth demonstrated decreased but persistent flow on the time of flight MRA. No aneurysm with MRA occlusion increased in size. Decrease in sac size was associated with MRA occlusion in our study. Persistence of flow and blistering were associated with increased sac size. As previously demonstrated flow diversion may be effective in the treatment of large aneurysms presenting with mass effect, however rates of sac obliteration in this small series were not as high as previously reported.

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Intracranial bleeding (ICB) as a catastrophic complication of Streptococcus gordonii infective endocarditis (IE) in an immunocompetent patient

BMJ Case Reports ◽

10.1136/bcr-2018-225265 ◽

2018 ◽

pp. bcr-2018-225265

Author(s):

Mohd Shakirin Pairan ◽

Nurashikin Mohammad ◽

Sanihah Abdul Halim ◽

Wan Syamimee Wan Ghazali

Keyword(s):

Infective Endocarditis ◽

Late Onset ◽

Mass Effect ◽

Immunocompetent Patient ◽

Interesting Case ◽

Vascular Complication ◽

Intracranial Bleeding ◽

Streptococcus Gordonii ◽

Ct Angiogram ◽

Ct Brain

We present an interesting case of late-onset intracranial bleeding (ICB) as a complication of Streptococcus gordonii causing infective endocarditis. A previously healthy young woman was diagnosed with infective endocarditis. While she was already on treatment for 2 weeks, she had developed seizures with a localising neurological sign. An urgent non-contrasted CT brain showed massive left frontoparietal intraparenchymal bleeding. Although CT angiogram showed no evidence of active bleeding or contrast blush, massive ICB secondary to vascular complication of infective endocarditis was very likely. An urgent decompressive craniectomy with clot evacuation was done immediately to release the mass effect. She completed total 6 weeks of antibiotics and had postoperative uneventful hospital stay despite having a permanent global aphasia as a sequel of the ICB.

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Abstract T P45: Automated CSF Segmentation to Quantify Cerebral Edema Following Large Hemispheric Ischemic Stroke

Stroke ◽

10.1161/str.46.suppl_1.tp45 ◽

2015 ◽

Vol 46 (suppl_1) ◽

Author(s):

Yasheng Chen ◽

Qingyang Yuan ◽

Raj Dhar ◽

Kristin Guilliams ◽

Laura Heitsch ◽

...

Keyword(s):

Ischemic Stroke ◽

Cerebral Edema ◽

Large Population ◽

False Negative ◽

Hounsfield Unit ◽

Ground Truth ◽

Mass Effect ◽

Stroke Patients ◽

Segmentation Strategy ◽

Combined Strategy

Introduction: Cerebral edema with resultant mass effect is a potentially fatal consequence of ischemic stroke, but early and sensitive biomarkers of brain tissue compression are lacking. To quantify brain mass effect, we developed a novel, automated segmentation method to delineate CSF spaces in CT images from ischemic stroke patients. Methods: CTs from sixteen acute ischemic stroke patients (median NIHSS 16.5, median age 61.5 yrs, 14-92 hrs after stroke onset) were included after informed consent was obtained. After infarction, conventional CSF segmentation using Hounsfield unit (HU) thresholding is suboptimal due to infarct hypodensity. Utilizing manually delineated infarct and CSF spaces as training samples, we augmented conventional HU threshold segmentation with level sets, sparse regression and random forest segmentation methods. Using leave-one-out cross-validation, the combined approach was compared to HU thresholding using Dice ratios (a measure of the overlap between the segmented and the ground-truth CSF spaces). Results: Shown is an example of a CT brain slice segmented by HU thresholding and the combined strategy: false negative (red), false positive (green), and true positive (yellow). The Dice ratios for HU thresholding and the combined approaches were 58.2±16.3% and 68.9±14.6%, respectively, demonstrating the significantly improved performance for the combined strategy (p=0.0014). Conclusions: We have developed an advanced image segmentation strategy to delineate CSF spaces which outperforms conventional HU thresholding. An automated CSF segmentation strategy will permit quantification of cerebral edema in a large population of stroke patients, as required for genetic studies, for example.

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Growth of a giant aneurysm following complete thrombosis by detachable balloon occlusion

Surgical Neurology ◽

10.1016/0090-3019(92)90042-l ◽

1992 ◽

Vol 38 (4) ◽

pp. 283-286 ◽

Cited By ~ 15

Author(s):

Takehiko Hirasawa ◽

Takashi Tsubokawa ◽

Yoichi Katayama ◽

Yuji Koike ◽

Yuichi Ueno ◽

...

Keyword(s):

Giant Aneurysm ◽

Balloon Occlusion ◽

Detachable Balloon ◽

Complete Thrombosis

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Balloon occlusion of a spontaneous fistula of the posterior inferior cerebellar artery

Journal of Neurosurgery ◽

10.3171/jns.1983.58.2.0287 ◽

1983 ◽

Vol 58 (2) ◽

pp. 287-290 ◽

Cited By ~ 22

Author(s):

Fernando Viñuela ◽

Allan J. Fox ◽

Shinichi Kan ◽

Charles G. Drake

Keyword(s):

Arteriovenous Fistula ◽

Posterior Inferior Cerebellar Artery ◽

Mass Effect ◽

Balloon Occlusion ◽

Cerebellar Syndrome ◽

Detachable Balloon ◽

Content Type ◽

Cerebellar Artery ◽

Fistula Site ◽

Fine Print

✓ A case is reported of a large spontaneous right posterior inferior cerebellar artery fistula in which the patient presented with a right cerebellopontine (CP) angle and right cerebellar syndrome. The patient was successfully treated by balloon occlusion at the fistula site. The location of the arteriovenous fistula, the mass effect of its enlarged draining veins on the cerebellum and CP angle structures, and the simple therapeutic endovascular occlusion with a detachable balloon make this case unique.

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Ruptured giant aneurysm of a cortical middle cerebral artery: A case report

Surgical Neurology International ◽

10.25259/sni_952_2020 ◽

2021 ◽

Vol 12 ◽

pp. 95

Author(s):

Samer S. Hoz ◽

Zaid Aljuboori ◽

Sajaa A. Albanaa ◽

Zahraa F. Al-Sharshahi ◽

Mohammed A. Alrawi ◽

...

Keyword(s):

Middle Cerebral Artery ◽

Cerebral Artery ◽

Giant Aneurysm ◽

Neurological Deficits ◽

Intracerebral Hematoma ◽

Microsurgical Clipping ◽

Level Of Consciousness ◽

History Of ◽

Posterior Parietal ◽

Mca Aneurysm

Background: Aneurysms of the cortical branches of the middle cerebral artery (MCA) are rare. They usually are secondary to traumatic or infectious etiologies and are rarely idiopathic. The specific characteristics of idiopathic aneurysms in such location are not well defined in the literature. The authors report a rare case of a ruptured giant idiopathic cortical MCA aneurysm with review of the available literature on this clinical entity. Case Description: A 24-year-old female presented with headache, disturbed level of consciousness, and right-sided weakness. Imaging studies showed a left frontoparietal intracerebral hematoma and a giant saccular aneurysm in the posterior parietal cortical branch of the MCA. The patient had no history of head trauma or active infection; therefore, the aneurysm was considered idiopathic. A microsurgical clipping of the aneurysm with evacuation of the hematoma was performed. There were no surgical complications, and the patient achieved a good outcome modified Rankin Scale of 1 with no neurological deficits. Conclusion: Idiopathic aneurysms of the cortical branches of the MCA are rare, and usually present with intraparenchymal hemorrhage due to rupture. There is no clear consensus regarding the optimal management strategy. This case shows that timely management can lead to good outcomes.

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Progressive enlargement of a previously coiled posterior inferior cerebellar artery aneurysm

10.7287/peerj.preprints.882v1 ◽

2015 ◽

Author(s):

Michael Karsy ◽

Aaron Cutler ◽

Christian Bowers ◽

Richard Schmidt

Keyword(s):

Relevant Literature ◽

Multidisciplinary Treatment ◽

Posterior Inferior Cerebellar Artery ◽

Cerebral Aneurysms ◽

Artery Aneurysm ◽

Mass Effect ◽

Left Vertebral Artery ◽

Endovascular Coiling ◽

Ct Angiogram ◽

Cerebellar Artery

Multidisciplinary treatment of cerebral aneurysms includes endovascular coiling and open neurosurgical clipping techniques, however our understanding of long-term outcomes after coiling of large cerebral aneurysms remains limited. We present a case involving the development of a previously coiled posterior inferior cerebellar artery (PICA) aneurysm in a 64-year-old man with lesion enlargement and symptomatic mass effect. CT angiogram demonstrated a 3.9×2.6×2.4-cm partially thrombosed aneurysm adjacent to the left vertebral artery. The patient underwent resection to relieve the compressive effect. We discuss the efficacy of endovascular coiling and surgical clipping in this case as well as review the relevant literature.

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Interhemispheric transcallosal transforaminal approach for decompression of a giant superior cerebellar artery thrombosed aneurysm: Three-dimensional operative video

Surgical Neurology International ◽

10.25259/sni_78_2020 ◽

2020 ◽

Vol 11 ◽

pp. 84

Author(s):

Juan Leonardo Serrato-Avila ◽

Marcos Devanir Silva Da Costa ◽

Michel Eli Frudit ◽

Juan Pablo Carrasco-Hernandez ◽

Sebastián Aníbal Alejandro ◽

...

Keyword(s):

Cranial Nerves ◽

Giant Aneurysm ◽

Mass Effect ◽

Endovascular Embolization ◽

Surgical Anatomy ◽

Vasa Vasorum ◽

Superior Cerebellar Artery ◽

Transforaminal Approach ◽

Flow Diverter Stent ◽

Cerebellar Artery

Background: Giant brain aneurysms account for approximately 5% of all intracranial aneurysms, often presenting with intraluminal thrombosis that causes a mass effect in surrounding neural structures. Although its exact growing mechanism remains unknown, they have to be treated. Despite the most recent advances in neurosurgical fields, the best treatment modality remains unknown and surgery of giant superior cerebellar artery (SCA) aneurysms still is a challenge even for the most experienced neurosurgeons, due to their deep location, surrounding perforating vessels, and intraluminal thrombosis. Case Description: In this video, we present the case of a 65-year-old woman with progressive hemiparesis and paresis of low cranial nerves. The symptoms were caused by a giant aneurysm located in the origin of the SCA. Despite endovascular embolization of the aneurysm and placement of a flow diverter stent, the aneurysm increased in size causing symptoms progression. In that scenario, we decided to perform a microsurgical decompression of the aneurysm thrombus and coagulation of the vasa vasorum, to reduce the mass effect and prevent the aneurysm from keep growing. Conclusion: Through an extensive description of the surgical anatomy, we illustrate an interhemispheric transcallosal transforaminal approach, with the removal of anterior thalamic tubercle to widely expose the aneurysm dome. The surgery was successfully performed, and the patient symptoms improved. The patient signed the Institutional Consent Form, which allows the use of her images and videos for any type of medical publications in conferences and/or scientific articles.

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A Web Based Dynamic MANA Nomogram for Predicting the Malignant Cerebral Edema in patients with large hemispheric infarction

10.21203/rs.3.rs-31715/v4 ◽

2020 ◽

Author(s):

Wenzhe Sun ◽

Guo Li ◽

Yang Song ◽

Zhou Zhu ◽

Zhaoxia Yang ◽

...

Keyword(s):

Cerebral Edema ◽

Clinical Decision Making ◽

Mass Effect ◽

Clinical Decision ◽

Chinese Patients ◽

Midline Shift ◽

Patient Death ◽

Exact Probability ◽

Decompressive Hemicraniectomy ◽

Hemispheric Infarction

Abstract Background: For large hemispheric infarction (LHI), malignant cerebral edema (MCE) is a life-threatening complication with a mortality rate approaching 80%. Establishing a convenient prediction model of MCE after LHI is vital for the rapid identification of high-risk patients as well as for a better understanding of the potential mechanism underlying MCE.Methods: 142 consecutive patients with LHI within 24h of onset between January 1, 2016 and August 31, 2019 were retrospectively reviewed. MCE was defined as patient death or received decompressive hemicraniectomy (DHC) with obvious mass effect (≥ 5mm midline shift or Basal cistern effacement). Binary logistic regression was performed to identify independent predictors of MCE. Independent prognostic factors were incorporated to build a dynamic nomogram for MCE prediction.Results: After adjusting for confounders, four independent factors were identified, including previously known atrial fibrillation (KAF), midline shift (MLS), National Institutes of Health Stroke Scale (NIHSS) and anterior cerebral artery (ACA) territory involvement. To facilitate the nomogram use for clinicians, we used the “Dynnom” package to build a dynamic MANA (acronym for MLS, ACA territory involvement, NIHSS and KAF) nomogram on web (http://www.MANA-nom.com) to calculate the exact probability of developing MCE. The MANA nomogram’s C-statistic was up to 0.887 ± 0.041 and the AUC-ROC value in this cohort was 0.887 (95%CI, 0.828~0.934).Conclusions: Independent MCE predictors included KAF, MLS, NIHSS, and ACA territory involvement. The dynamic MANA nomogram is a convenient, practical and effective clinical decision-making tool for predicting MCE after LHI in Chinese patients.

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