Cerebral Venous Sinus Thrombosis Presenting with Altered Mental Status

Cerebral venous sinus thrombosis (CVST) is a rare cause of stroke, but if left untreated, it can result in significant morbidity or mortality. Complications of CVST include cerebral infarction, cerebral hemorrhage, focal neurologic deficit, hydrocephalus, seizure, coma, and death. Therefore, prompt diagnosis and initiation of treatment is critical. Noninvasive imaging modalities can often readily identify CVST. Systemic anticoagulation is the mainstay of CVST treatment, even in cases associated with cerebral hemorrhage. For patients who are refractory to medical management, endovascular therapy may be used as an adjunctive treatment. After the acute phase, evaluation for underlying hypercoaguable disorders is necessary to risk stratify patients and determine their duration of anticoagulation. This chapter presents a case of a patient with symptomatic CVST. Relevant diagnostic and treatment strategies are discussed.

Giant Aneurysm of the Middle Cerebral Artery Presenting with Headache

This chapter reviews the diagnosis, preparation, and treatment options for giant middle cerebral artery aneurysms. Despite advancements in the techniques of microneurosurgery and the rapid technological developments in the field of neuroendovascular surgery, giant aneurysms of the middle cerebral artery remain a persistent management challenge. Due to the involvement and relation of multiple branching arteries, endovascular treatment options are often limited. The surgeon and surgical team must be well versed in the techniques of complex clip reconstruction as well as a number of possible variations of bypass options. In addition, they must be prepared with contingency plans for the varying intraoperative and postoperative complications that can occur. These larger aneurysms require both more complex decision-making and higher technical skills to treat successfully.

Incidental Anterior Communicating Artery Aneurysm

Anterior communicating artery aneurysms are among the most commonly encountered aneurysms in neurosurgical practice. While many are treatable using modern endovascular techniques, because of their often complex anatomy, both ruptured and unruptured anterior communicating artery aneurysms often require microsurgical treatment. Pre-operative analysis of the collateral circulation, the aneurysm orientation, the aneurysm height, morphology, and the dome-to-neck ratio can all affect decision-making. For unruptured aneurysms, a careful analysis of the natural history of rupture risk versus the risks of surgery or endovascular treatment will determine if treatment is recommended and what modality. At surgery, perforating artery preservation is of utmost importance. This chapter discusses these issues as considered in the management of an incidental, unruptured anterior communicating artery aneurysm.

Blister Aneurysm of the Internal Carotid Artery

Blister aneurysms are a rare cause of subarachnoid hemorrhage. They are easily overlooked on conventional imaging and catheter angiography due to their small size and unusual anatomic location. Whereas the medical management of subarachnoid hemorrhage is similar to that of saccular aneurysms, the surgical management of blister aneurysms is more challenging due to their unique pathology and higher risk of intraoperative rupture. Special consideration should be made for open management such as preparation of the option of bypass or the emerging use of endovascular techniques such as flow diversion. This chapter reviews the diagnosis and medical and surgical management of blister aneurysms.

Spinal Dural Arteriovenous Fistula Presenting with Myelopathy

Spinal dural arteriovenous fistulas are a rare cause of congestive myelopathy. Symptoms are insidious in onset and may be confused with degenerative spinal disease. MRI characteristically shows edema of the spinal cord with serpiginous flow voids that follow the surface of the spinal cord. Careful evaluation with spinal angiography is required to ensure accurate diagnosis. Spinal dural arteriovenous fistulas differ from spinal arteriovenous malformations in that most fistulas have only a single fistulous point without a nidus. Spinal dural arteriovenous fistulas may be treated successfully with either surgical resection or endovascular embolization depending on their anatomy. Earlier treatment is associated with better outcomes.

Transverse Sinus Arteriovenous Fistula Presenting with Tinnitus

Arteriovenous fistulae present in any of a number of characteristic locations in the brain, such as the ethmoidal region, the petrosal sinus, and the transverse sinus and torcula. The fistula is an abnormal connection between an artery and vein. While there are multiple accepted classification systems, the risk they represent to the patient depends primarily on the degree of reflux of the venous drainage back to the cortex of the brain. While the inflow and outflow may be very complex, isolation of the fistulous point where this abnormal connection occurs is the key to successful treatment. This may be achieved through either endovascular or open surgical techniques deoending on the anatomy.

Unruptured Eloquent Arteriovenous Malformation Presenting with Arm Weakness

Cerebral arteriovenous malformations are often located in regions of the brain that are not surgically accessible, or they are found in patients who are not candidates for microsurgery. If the expected neurological morbidity of surgical extirpation is unacceptably high, or if the patient’s medical condition presents an unacceptable risk for surgery, either conservative management or radiosurgery should be offered. Stereotactic radiosurgery provides a noninvasive treatment of such lesions and should be considered in the discussion of management of all arteriovenous malformations. Customization of treatment strategy to each arteriovenous malformation is necessary, as obliteration rates and complications share an inverse relationship depending on treatment volume and radiation dose. This chapter presents the key considerations in the work-up and radiosurgical management of patients with arteriovenous malformations.

Symptomatic Cervical Carotid Artery Stenosis

This chapter discusses the medical and surgical management of carotid artery disease, including both surgical and endovascular revascularization. Surgical treatment for symptomatic cervical carotid artery stenosis is one of the most effective means of preventing ischemic stroke. It has been validated through multiple high-quality prospective surgical trials. There is substantial reduction of stroke risk versus best medical management with treatment of carotid stenosis via carotid endarterectomy. Although endovascular management with carotid artery angioplasty and stenting has emerged as another high-quality treatment, carotid endarterectomy remains the treatment of choice for patients who are of acceptable medical risk for surgery. The details of the carotid endarterectomy procedure and its perioperative management are discussed.

Giant Cavernous-Segment Internal Carotid Artery Aneurysm Presenting with Cranial Neuropathy

This chapter discusses issues surrounding the management of giant cavernous carotid artery aneurysms. These aneurysms most commonly present with symptoms of cranial neuropathy. They present a unique treatment challenge given their location and often large size. Endovascular flow diversion has emerged as the mainstay of treatment, although parent vessel sacrifice, high-flow bypass, and surgical trapping are important alternatives. Evaluation of the nature of collateral circulation and the tolerance of the intracranial circulation to carotid artery sacrifice should also be part of the work-up. The technical details of endovascular flow diversion strategy are described, as well as the management of known post-procedural complications.

Unruptured Ophthalmic Artery Aneurysm Presenting with Vision Loss

Intracranial aneurysms pose a significant clinical challenge for cerebrovascular and endovascular neurosurgeons both in treatment decision-making and in the technical aspects. The most important question is whether the aneurysm has ruptured, thereby necessitating urgent treatment. In the unruptured ophthalmic artery aneurysm case with vision loss, the decision to treat rests on understanding the risk of hemorrhage, the success in addressing neurological deficits, and the morbidity of any potential treatment. Computed tomography angiography, conventional angiography, and magnetic resonance imaging are critical and complementary in the diagnosis and management of ophthalmic artery aneurysms, which have also been termed paraclinoid or junctional aneurysms. Due to technological advances, multiple treatment methods are possible, including surgical clipping, endovascular coiling, and flow diversion. Flow diversion is emerging as an effective, less invasive technique with good vision outcomes. This chapter discusses the data behind decision-making, reviews the surgical technique of flow diversion, and emphasizes important aspects of perioperative management.