Calcified aneurysm of the vein of Galen—successful removal

We report the rare case of a thrombosed and entirely calcified aneurysm of the vein of Galen. This was demonstrated by computerized tomography and successfully removed using an infratentorial supracerebellar approach.     

Aneurysm of the Splenic Vein

Aneurysms of the portal venous system are increasingly reported in the past five years. Congenital weakness of the venous wall, trauma, pancreatitis and portal hypertension are possible etiologies. Surgical intervention is indicated in case of symptomatic aneurysms with or without progressive expansion of the aneurysm diameter. The treatment of asymptomatic splenic vein aneurysms remains debated. We report the case of an asymptomatic and uncomplicated splenic vein aneurysm for which a conservative approach was advocated with regular follow-up by means of Doppler ultrasonography. After six years of follow-up the aneurysm diameter has not changed and no complications were observed.     

Combined contralateral pterional and interhemispheric approach to a subchiasmal carotid-ophthalmic aneurysm

Summary A subchiasmal carotid-ophthalmic aneurysm was clipped through a combined contralateral pterional and interhemispheric approach. This combined approach seems very useful for some particular aneurysms of this portion because of no dead angle around the aneurysm and the minimum retraction required for the brain and optic nerve. Surgical approaches to subchiasmal carotidophthalmic aneurysms are discussed.     

Extra-hepatic portal vein aneurysm: A case report, overview of the literature and suggested management algorithm

INTRODUCTIONPortal venous aneurysms are a rare finding. The reported incidence is on the rise with increasing use of modern imaging techniques in clinical practice. However, there is still much to be elicited regarding their aetiology, natural history, and management.PRESENTATION OF CASEAn 80-year-old woman presented with abdominal pain and nausea. Investigations showed a hypoechoic area in the region of the head of pancreas on ultrasound, which was found to be a portal venous aneurysm on CT. In view of her multiple comorbidities, a conservative approach was taken.DISCUSSIONPortal venous aneurysms represent approximately 3% of all venous aneurysms with a reported prevalence of 0.43%. They may be congenital, due to failure of complete regression of the right vitelline vein, or acquired secondary to portal hypertension. The primary presentation of portal vein aneurysm is abdominal pain, followed by incidental detection on imaging, with a minority of patients presenting with gastrointestinal bleeding. Complications of PVA include thrombosis, biliary tract obstruction, inferior vena cava obstruction, and duodenal compression. On the whole PVAs are stable and have a low risk of complications with 88% of patients showing no progression of aneurysm size or complications on subsequent follow up scans.CONCLUSIONWe recommend that portal venous aneurysms be assessed using colour Doppler ultrasonography in the first instance with CT scans reserved for indeterminate cases or symptomatic patients. Due to the slow progression of such aneurysms, surgery is recommended only for symptomatic patients or those with complications secondary to portal venous aneurysms.     

神经内镜辅助锁孔手术治疗颅内动脉瘤

目的 探讨神经内镜辅助下的锁孔手术治疗颅内动脉瘤的手术效果。方法 对14例颅内动脉瘤行动脉瘤夹闭术。经眉弓或翼点锁孔开颅，手术显微镜下初步暴露动脉瘤，置入神经内镜，观察动脉瘤颈及其周围结构的局部解剖，动脉瘤夹夹闭，再次置入神经内镜了解夹闭情况。结果 14例患者均无手术并发症，未出现新的神经系统症状与体征，全部恢复良好出院。结论 应用神经内镜辅助下的锁孔手术治疗颅内动脉瘤，可充分暴露动脉瘤及周围结构的局部解剖结构，手术创伤小，手术时间缩短，手术效果明显提高。     

Drainage Pathway of the Superior Petrosal Vein Evaluated by CT Venography in Petroclival Meningioma Surgery

Objectives This study aimed to clarify the drainage location of the superior petrosal vein (SPV) in relation to Meckel''s cave and the internal acoustic meatus (IAM) and to discuss its significance in petroclival meningioma surgery.Design Prospective clinical study.Setting Hospital-based.Participants Five patients with petroclival meningioma and 50 patients (primarily unruptured supratentorial aneurysm patients, with a few hemifacial spasm patients) with no posterior fossa lesions.Main Outcome Measures On computed tomography venography (CTV), the drainage site was classified into three patterns based on its relationship to Meckel''s cave and the IAM: Meckel''s cave type, Intermediate type, and Meatal type.Results In all patients, the SPV was patent and emptied into the superior petrosal sinus (SPS). In patients without posterior fossa lesions, 35% had Meckel''s cave type, 54% had Intermediate type, and 11% had Meatal type. Of the five patients with petroclival meningioma, three had Intermediate type, and two had Meckel''s cave type.Conclusion The SPV is a significant vein that should be preserved to prevent venous complications. Preoperative knowledge of the SPV drainage site is helpful for planning the approach and preserving the SPV in petroclival meningioma surgery.     

A case report of venous aneurysm of the neck vein

We treated a 37 year old woman with venous aneurysm along left side of the neck. In the beginning, she was asymptomatic and with increase in size of the venous aneurysm she experienced severe pain. Pathohistological examinations revealed a destructive change of the venous wall and thrombosis. Therefore, in cases of venous aneurysm along the neck, such aneurysm should probably be treated surgically to prevent the occurrence of pulmonary embolism.     

The temporo-polar approach to basilar artery aneurysms with or without zygomatic arch translocation

Summary Since the publication of the temporo-polar approach to basilar artery aneurysms by Sano (1980 and 1987), various modifications of the approach were reported.The approach provides a better view and a wider operating field than the subtemporal or pterional ones.Usually the approach does not need temporary removal of the zygomatic arch. If however, a basilar tip aneurysm is located very high above the posterior clinoid, temporary removal of the zygomatic arch is necessary which is sutured back to its original position at the end of the operation.     

Intraventricular aneurysm of the medial posterior choroid artery clipped via the contralateral transcallosal approach

Summary In lesions located in the lateral ventricle of the dominant hemisphere the contralateral transcallosal approach provides maximum protection of the dominant side as well as excellent visualization of the cella media of the contralateral lateral ventricle. We demonstrated this safe approach in a rare case with intraventricular aneurysm of the left medial choroid artery. The literature on aneurysms in the lateral ventricle is discussed.     

Dissection of the Sylvian Fissure in the Trans-sylvian Approach Based on the Morphological Classification of the Superficial Middle Cerebral Vein

The superficial middle cerebral vein (SMCV) is one of the main factors that can impede a wide opening of the sylvian fissure. To reveal the most efficient SMCV dissection for a wide operative field while preserving the veins in the trans-sylvian approach, we retrospectively investigated the SMCVs through intraoperative video images. We characterized the SMCV as composed of the frontosylvian trunk (FST; receiving frontosylvian veins [FSVs] or parietosylvian veins [PSVs]), the temporosylvian trunk (TST; receiving temporosylvian veins [TSVs]), and the superficial middle cerebral common trunk (SMCCT; receiving both FSV/PSV and TSV), and classified the SMCVs of the 116 patients into 5 types based on the morphological classification of the SMCV. Type A SMCV (60.4%) with the SMCCT anastomosed to the frontal side had few bridging veins (BVs) between the SMCCT and the temporal side during dissection. Type B (7.8%) had the SMCCT with no anastomoses to the frontal side. In Type C (17.2%) consisting of the FST and TST and Type D (12.9%) with a merging of the vein of Trolard and Labbé posteriorly and the SMCVs dividing into the FST and the TST again proximally, there were few BVs between the FST and the TST during dissection. Finally, in Type E (1.7%) showing an undeveloped SMCV, there were no BVs between the frontal and the temporal lobes. Postoperative venous infarction occurred in 2.6%. Morphological classification of the SMCV can inform appropriate dissection line to create a wide operative field while preserving the veins in the trans-sylvian approach.     

A new surgical approach to the third ventricle with interruption of the striothalamic vein

Summary In the removal of tumours that develop within the third ventricle, most approaches are not entirely satisfactory. Therefore, a new approach has been devised: transfrontal exposure of the anterior portion of the frontal horn; coagulation and section of the striothalamic vein in order to open up the roof of the third ventricle; use of a blunt spatula introduced in the foramen of Monro and pushed backwards under the choroïd plexus. This approach has been used in ten cases. Postoperative mortality has been nil; the surgical approach has not apparently been responsible for any sequelae. It is simple and gives a good view of the third ventricle.     

An experience using spiral vein graft as arterial substitute

In two patients with aneurysmal changes due to arteriosclerosis in the axillary and the subclavian artery respectively, spiral vein grafts were used as a substitute for vascular reconstruction. After resection of the aneurysm, these vein grafts resulted in an excellent adaptation to the recipient vessel. Complicated techniques were not required and the construction time was minimal. Such an approach may be used even in adjacent sites to a joint.     

A transcrista galli, translamina terminalis approach for highly placed basilar bifurcation aneurysms

Summary Surgery for highly placed basilar bifurcation aneurysms is one of the most difficult operations in neurosurgery. Specific surgical techniques have been developed including the temporopolar, zygomatic, transzygomatic subtemporal, transclinoid trans-sellar transcavernous, and trans third ventricular approaches. The authors present some technical advances which have been developed for the transcristagalli translamina terminalis approach for the treatment of this aneurysm.     

Distal arch replacement for aortic aneurysm associated with pseudocoarctation through the L-incision approach

We report the case of a 16-year-old boy in whom we successfully repaired a distal aortic arch aneurysm associated with pseudocoarctation using double aortic cannulation and antegrade selective cerebral perfusion through the L-incision approach. This approach provided excellent exposure from the ascending aorta to the descending aorta, which enabled total body perfusion. We avoided cardiac arrest and hypothermic circulatory arrest during the surgery. The L-incision approach could be a better alternative for aortic arch surgery in adolescents.     

Extrahepatic Portal Vein Aneurysm—Report of Six Patients and Review of the Literature

Extrahepatic portal vein aneurysm is a rare condition. We report six patients with extrahepatic portal vein aneurysm, four of whom were surgically treated. In addition, a review of the literature was performed to examine natural history, management, and outcomes regarding portal vein aneurysm. Patients seen at our institution with extrahepatic portal vein aneurysm greater than 1.9 cm in diameter were reviewed (1998 to 2006). There were five females and one male; median age was 66.5 (30–77). Computed tomography (CT) scan was utilized for diagnosis in all cases. The median diameter of the aneurysm was 4.7 cm (2.7–6.0). Indications for surgery included gallstone pancreatitis, mass effect on the adjacent duodenum, a peripancreatic mass, and liver cirrhosis. Three patients underwent aneurysm resection, and one patient had an orthotropic liver transplant. Two patients were managed with observation. The median follow-up from first presentation and surgery was 50 months (9–181) and 5 months (2–73), respectively. At last follow-up, five patients were alive with radiologically proven portal vein patency. One patient died 2 months after liver transplantation. There was no case of aneurysmal rupture. One patient had intramural thrombus at presentation that resolved with conservative treatment. This report suggests that symptomatic aneurysms can be safely resected with excellent patency. This paper was presented at the AHPBA Meeting, April 19–22, 2007, Las Vegas, Nevada USA.     

Role of aneurysm projection in “A2” fork orientation for determining the side of surgical approach

Purpose  To determine factors that help decide the side of approach for anterior communicating artery (AComA) aneurysms, based on a prospective study. Methods  Between January 2004 and January 2006, 93 cases with AComA aneurysms were treated through pterional approach. They were classified as Type I, II (IIa, IIb), III and IV, based on the various projections and size of aneurysm. The principle for the choice of operative side was designed based on the type of aneurysm and the A2 fork orientation (the interrelations between the plane of bilateral A2, AComA, and mid-saggital plane). Results  There were 55 aneurysms of Type I, 10 of Type IIa, 14 of Type IIb, 12 of Type III, and 2 of Type IV. In Types I and IIa, the side posteriorly placed to A2 was chosen for the approach. In Type IIb, the side of the dominant A1 was selected. In Type III, the side anteriorly placed to A2 was chosen. Type IV aneurysms were difficult to handle even if approached from the dominant A1. There were 11 cases treated from the side of non-dominant A1. The overall outcome in the treatment of AComA aneurysms were considered excellent in 90.8% of cases according to the Glasgow Outcome Scale, with complete occlusion of aneurysms and complete patency of parent or perforating arteries. Conclusions  Applying three-dimensional computed tomography and magnetic resonance angiography, we classified AComA aneurysms as four types and undertook surgical clipping from the chosen side of approach, according to the type of aneurysm and the A2 fork orientation. The selective side of approach on the basis of individual decision-making has led to favourable outcomes.     

Contralateral Approach to Carotid Cave Aneurysms

BACKGROUND: To evaluate the surgical approach and clipping of aneurysms located at the carotid cave region. METHOD: Between 1980 and 1998 we have adopted the well known ipsilateral approach for exposure and securing of carotid cave aneurysms. In four patients, we had the opportunity to use a contralateral approach to carotid cave aneurysms, with easier dissection and application of a simple aneurysmal clip. The visual acuity of the patients did not deteriorate from the pre-operative level. FINDING AND INTERPRETATION: Aneurysms located at the carotid cave region may be approached easily and safely through a contralateral craniotomy with application of the aneurysm clip from an angle medial and inferior to the optic nerve.     

Novel entry point for intraoperative ventricular puncture during the transsylvian approach

Summary Objective. In dealing with cases of oedematous brain, relaxation during the transsylvian approach to supratentorial aneurysms has been accomplished by ventricular drainage by using the anatomic point defined by Dr. Paine. However, we have experienced patient complications when using this point. We propose a novel anatomic point to reduce catheter-related complications and facilitate adequate ventricular puncture during ruptured aneurysm operations. Methods. Ten patients underwent aneurysmal neck clipping for ruptured aneurysm by means of the transsylvian approach. The use of a novel anatomic point for intraoperative drainage was examined using a neuronavigation system. Results. Using the novel point of entry for ventricular cannulation proved to be reliable for puncture and reduced chance of malpositioning. Conclusion. Secure intraoperative ventricular cannulation is reliably achieved by pointing the catheter approximately 2 cm beyond a line extending from the anterior limb of the triangle described by Paine. This technique reduces injury to the deep brain and enhances preciseness and safety of ventricular cannulation.     

Aneurysm of fenestrated basilar artery

Two cases of aneurysms on fenestrated basilar arteries are presented. The combination of a fenestrated basilar artery and aneurysm is presumed to be more frequent than previously supposed. The surgical management of such aneurysms is described. In our experience the transoral-transclival approach is preferred.     

Intramedullary vascular lesions in the high cervical region: transoral and dorsal surgical approach. Two case reports

Intramedullary vascular malformations in the high cervical region are extremely rare. Two young adult patients with vascular lesions at the level C 2 and 3, and C 2–4 are reported. In one patient selective spinal angiography revealed a combined malformation with a ventral intramedullary arteriovenous angioma and a premedullary aneurysm. This malformation was approached and removed transorally after spondylectomy of C 2. In the second patient MRI and selective angiography showed an intramedullary hemangioblastoma extending from C 2–C 4. After embolization, this lesion was surgically removed via a dorsal approach. Both patients suffered from severe neurological deficits preoperatively. MRI and selective angiography showed the exact locations of the tumors within the spinal cord and indicated a transoral approach in one case and a dorsal approach in the other. After complete obliteration and removal of the lesions, the patients showed no neurological deficits and returned to their previous professions.