Faculty Bibliography

OBJECTIVE: The purposes of this article are to summarize recent developments and concerns in endovascular aneurysm therapy leading to the adjunctive use of endoluminal devices, to review the published literature on stent-supported coil embolization of cerebral aneurysms, and to describe our experience with this technique in a limited subgroup of problematic complex aneurysms over a medium-term follow-up period. METHODS: Between January 2003 and June 2004, 28 individuals among 157 patients with cerebral aneurysms we evaluated were identified as harboring aneurysms with exceptionally broad necks. Out of these 28 patients, 16 were treated with a combination of stents and detachable coils, preserving the parent artery. Recorded data included patient demographics, the clinical presentation, aneurysm location and characteristics, procedural details, and clinical and angiographic outcome. RESULTS: Over an 18-month period, 16 patients with large cerebral aneurysms additionally characterized by neck sizes between 7 and 14 mm were treated, using combined coil embolization of the aneurysm with stent reconstruction of the aneurysm neck. Thirteen out of the 16 aneurysms were occluded at angiographic reevaluation between 11 and 24 months (mean angiographic follow-up, 17.5 mo). There were no treatment-related deaths or clinically evident neurological complications. Thirteen patients experienced excellent clinical outcomes, with good outcomes in two patients and a poor visual outcome in one patient (mean clinical follow-up, 29 mo). A single technical complication occurred, involving transient nonocclusive stent-associated thrombus, which was treated uneventfully with abciximab. CONCLUSION: Stent-supported coil embolization of large, complex-neck cerebral aneurysms seems to provide superior medium-term anatomic reconstruction of the parent artery compared with historic series of aneurysms treated exclusively with endosaccular coils. In the near future, increasingly sophisticated endoluminal devices offering higher coverage of the neck defect will likely enable more definitive endovascular treatment of complex cerebral aneurysms and further expand our ability to manipulate the vascular biology of the parent artery

BACKGROUND: Roller coasters are probably one of the more popular rides at amusement parks around the world. Despite their relative safety, nontraumatic intracranial injuries have been reported following roller coaster rides. The presence of an intracranial arachnoid cyst may increase the risk of nontraumatic injury in this setting. CASE DESCRIPTION: We describe a 33-year-old female with a left middle fossa arachnoid cyst who presented with increasing headaches from bilateral subdural hygromas after a roller coaster ride. The patient underwent bilateral burr hole drainage of her subdural hygromas with resolution of her symptoms. CONCLUSION: This case demonstrates the potential risks of intracranial injury in patients with an underlying arachnoid cyst who engage in certain types of recreational activity

Gamma knife radiosurgery is an effective technique for treating arteriovenous malformations. However, treatment failures can occur as a result of incomplete visualization of the arteriovenous malformation nidus. We describe the use of bilateral femoral artery catheterization and simultaneous dual vessel cerebral angiography to facilitate treatment planning during gamma knife treatment

We report a case of a 19-year-old woman who underwent radiosurgical treatment of a residual arteriovenous malformation. Nine months after treatment, repeat angiography revealed a de novo paranidal aneurysm that was treated endovascularly. We postulate that changes in flow dynamics or vessel integrity after radiosurgery contributed to the formation of her de novo aneurysm

OBJECTIVE AND IMPORTANCE: Two cases of inflammatory aneurysms in patients with neurocysticercosis have been reported previously. Clinical and radiographic studies suggest a causal relationship. CLINICAL PRESENTATION: A man with neurocysticercosis presented with an acute subarachnoid hemorrhage from a left middle cerebral artery aneurysm. INTERVENTION: The patient underwent a craniotomy and clipping of his aneurysm. Diffuse inflammatory changes and multiple cysticercal cysts were found throughout the left sylvian fissure. CONCLUSION: The patient had an uneventful recovery. Angiography suggested an inflammatory rather than a congenital aneurysm. Although rare, neurocysticercosis may induce aneurysm formation in the appropriate setting

OBJECTIVE: Increasing evidence supports the presence of neuronal apoptosis after ischemic or excitotoxic brain injury. Astrocytes, which exhibit significant regional differences in function, may exert a protective effect on neurons exposed to ischemic injury. We examined the effects of astrocytes derived from different regions of the central nervous system on neuronal apoptosis after mild excitotoxic injury in tissue culture. METHODS: Purified astrocyte cultures derived from P4 rat cerebral cortex or mesencephalon showed transient cell swelling but no cell death when exposed to 50 micromol/L glutamate for 5 minutes. When mixed neuronal/glial cocultures were exposed to the same glutamate dose, neuron death was observed. Necrotic and apoptotic cell death during 24 hours was examined using morphological criteria, nuclear staining, triphosphate nick end labeling, and trypan blue exclusion. RESULTS: We found that cortical neurons that elaborate a more extensive dendritic arbor when grown on homotypic astrocytes are more likely to undergo apoptosis than neurons with a limited dendritic arbor grown on heterotypic astrocytes. By contrast, a similar number of neurons undergo necrotic cell death. CONCLUSION: This finding may be associated with 1) increased vulnerability of neurons with a more elaborate dendrite structure to mild excitotoxic injury, or 2) regional differences in the ability of astrocytes to attenuate apoptosis

Carotid cavernous aneurysms are distinct entities. The anatomy of the cavernous sinus region has been well defined, and most spontaneous aneurysms of the cavernous sinus region carry a benign prognosis. Progressively symptomatic, traumatic, or infectious aneurysms require treatment. This can be accomplished by carotid occlusion, extra cranial to intracranial bypass, or direct surgery