Dawn Sowards Brezina, MD

• Assistant Professor of Medicine

https://medicine.duke.edu/faculty/dawn-sowards-brezina-md

During times of temporary arterial occlusion medicine interactions buy reminyl 4mg, the surgeon must move quickly and thoughtfully to minimize the ischemic risk medicine ketoconazole cream buy reminyl without prescription. In the current era treatment alternatives trusted 4 mg reminyl, surgical teams must be able to slip in and out of these narrow confines treatment hepatitis c buy generic reminyl on line, leaving only a clip or two as evidence that the spaces have been violated treatment plant discount reminyl express. Causes of morbidity and mortality from surgery of aneurysms of the distal basilar artery medications dialyzed out reminyl 4 mg low price. Bleeding aneurysms of the basilar artery: direct surgical management in four cases. Surgical clipping of complex basilar apex aneurysms: a strategy for successful outcome using the pretemporal transzygomatic transcavernous approach. Basilar apex aneurysms: surgical results and perspectives from an initial experience. Ligation of the vertebral (unilateral or bilateral) or basilar artery in the treatment of large intracranial aneurysms. Advances in the neurosurgical treatment of aneurysms, arteriovenous malformations, and hematomas of the vertebral circulation. The use of extracorporeal circulation and profound hypothermia in the treatment of ruptured intracranial aneurysm. Giant fusiform intracranial aneurysms: review of 120 patients treated surgically from 1965 to 1992. A Comprehensive Reference Guide to the Diagnosis and Management of Neurosurgical Problems. Microsurgical treatment of basilar apex aneurysms: perioperative and long-term clinical outcome. Partial anterior petrosectomies for upper basilar artery trunk aneurysms: a cadaveric and clinical study. A combined trans-sylvian and subtemporal approach for basilar bifurcation aneurysms. Combined transsylviansubtemporal exposure of cerebral aneurysms involving the basilar apex. The carotid-oculomotor window in exposure of upper basilar artery aneurysms: a cadaveric morphometric study. Anatomical study of the orbitozygomatic transsellar-transcavernous-transclinoidal approach to the basilar artery bifurcation. Mobilization of the transcavernous oculomotornerve during basilar aneurysm surgery: biomechanical bases for better outcome. Role of uncal resection in optimizing transsylvian access to the basilar apex: cadaveric investigation and preliminary clinical experience in eight patients. Early treatment of ruptured aneurysms with Guglielmi detachable coils: effect on subsequent bleeding. Guglielmi detachable coil embolization of acute intracranial aneurysm: perioperative anatomical and clinical outcome in 403 patients. Endovascular treatment of acutely ruptured and unruptured aneurysms of the basilar bifurcation. Intracranial aneurysms treated with the Guglielmi detachable coil: midterm clinical results in a consecutive series of 100 patients. Albuquerque As with most types of technology-heavy fields, the specialty of endovascular neurosurgery has seen a tremendous amount of growth and refinement with the inexorable march of progress. The previous introduction of balloon- and stent-assisted coiling and the current availability of flow-diverting stents have helped usher in this new era of growth. Furthermore, the natural history and risk of rupture must be weighed against the safety of the proposed treatment as well as the medical condition and life expectancy of the patient. In general, incidental cerebral aneurysms are treated more aggressively in younger than in older patients. Likewise, larger aneurysms and aneurysms located in the posterior circulation tend to be treated more often than smaller, anterior circulation lesions. An exhaustive discussion of this complicated decision-making process is beyond the scope of this chapter. Aneurysms located on or around the circle of Willis were the first lesions treated successfully with endovascular techniques. Detachable balloons were previously flow-directed down the vessels until the target lesion was reached. Guglielmi and associates7,8 initially described a small neck diameter as a potential factor in determining completeness of aneurysm occlusion using the Guglielmi detachable coil. They described their series of 43 posterior circulation aneurysms in 42 patients treated with their detachable coil. Of these 42 aneurysms, 16 had neck diameters less than 4 mm, and 26 had neck diameters of 4 mm or more. The investigators achieved complete occlusions in 13 of the 16 narrow-necked aneurysms but in only 4 of the 26 wide-necked aneurysms. They hypothesized that a the smaller neck diameter allowed for a more dense packing of coils and better remodeling of the neck of the aneurysm. The same group followed up this initial multicenter retrospective review with a retrospective single-center study specifically addressing neck diameter as a determinant of aneurysm occlusion. Using published measurements of the diameters of the reference vessels, the investigators were able to correct for image magnification to calculate the "real" neck diameters of the aneurysms in their series. Complete aneurysm occlusion was noted in 17 of 20 (85%) narrow-necked aneurysms, compared with only 8 of 51 (15. A three-dimensional rotational angiogram demonstrates a neck diameter less than 4 mm (short arrow), a dome diameter greater than 8 mm (long arrow), and a dome-to-neck ratio greater than 2: 1. Overall clinical and radiographic outcomes were better in the second cohort (Group 2), in which aneurysms were selected for coiling on the basis of their dome-to-neck ratio and neck diameter, than in the initial 25 patients (Group 1). Two patients (8%) in Group 1 experienced permanent neurological complications directly related to aneurysm coiling. In Group 2, there were no deaths and only 1 case (1%) of a permanent neurological deficit related to aneurysm coiling. Aneurysm occlusion rates were reportedly 72% with ruptured and 80% with unruptured aneurysms that were selected on the basis of favorable angiomorphologic characteristics but only 53% for aneurysms with dome-to-neck ratios less than 2: 1. Since the study, these findings have served as a basis for the selection of cerebral aneurysms for primary coil embolization. Generally, most interventional procedures can be performed with patients under conscious sedation or general anesthesia according to the preferences of the endovascular neurosurgeon. With use of conscious sedation, real-time neurological assessments can be made, as necessary, to ensure the safety of the patient during the procedure. Performing interventions in this manner requires the patient to remain still and cooperative throughout the procedure, which can be difficult in certain conditions. Although general anesthesia involves more resources, time, and effort, it affords the surgeon a nearly still canvas upon which to operate. To compensate for the loss of the neurological examination, electrophysiologic monitoring can be employed. With any neurointerventional procedure, it is crucial to employ aggressive anticoagulation to minimize the risk of thromboembolic complications. An appropriate weight-based dosing of heparin should be administered at the earliest opportunity, and anticoagulation should be maintained throughout the procedure, either with a periodic repeat bolus or continuous administration. Generally, it is our practice to administer heparin after access is obtained in elective treatments. In the setting of subarachnoid hemorrhage, we reserve anticoagulation until after the initial coils are placed to reduce the risk of catastrophic rerupture or aneurysm perforation. A number of suitable guide catheters are available to support primary embolization of aneurysms. It is important that the guide catheter have sufficient purchase to allow for navigation of the microcatheter to the target lesion. The newer generation of guide catheters with more compliant distal tips allows for positioning up to and even past the skull base to ensure adequate support. The morphology of the aneurysm along with its relationship with the parent artery and any side branches or perforating arteries must be studied carefully. Additionally, the presence or absence of collateral circulation to the parent vessel can affect the planned treatment strategy. Microcatheter selection depends on the size of the coil selected for the aneurysm. By definition, narrow-necked aneurysms have neck diameters less than 5 mm, which tends to limit the size of the aneurysm. Therefore, 18-system or larger coils are less often employed in the treatment of narrow-necked aneurysms. The microcatheter should be the smallest size possible to allow for the advancement of coils. A larger space between the walls of the microcatheter and the coils, however, may inhibit smooth passage because there is room for the coil to buckle. A microcatheter may also be shaped with steam to customize the tip for the particular situation. The microcatheter is advanced over a suitable microwire and carefully positioned within the aneurysm dome. The tip should not be perpendicular to the wall of the aneurysm, to minimize the chance of iatrogenic perforation during the placement of the initial framing coil. We prefer to position the tip of the microcatheter one-half to two-thirds of the way into the aneurysm to allow the microcatheter to freely move or "paint brush" the aneurysm while the coils are being deployed. This freedom of movement is crucial to minimize the force with which coil loops may push against the aneurysm wall and to allow for a more even distribution of coils within the aneurysm. As coiling is undertaken, periodic guide catheter angiograms can be obtained to follow the progressive occlusion of the aneurysm. It may be necessary to reposition the microcatheter during the course of the treatment to achieve better filling of certain areas of the aneurysm or if the microcatheter is kicked out of the aneurysm before successful occlusion is complete. Once the decision is made to terminate the procedure, the microcatheter is carefully removed to ensure no disruption or dislodgement of the existing coil mass. Coils can be selected according to configuration, size, length, diameter, materials used, and stage of treatment. D, Final working-angle projection demonstrates a Raymond 2 occlusion with residual filling of the aneurysm neck. B, Roadmap view of balloon microcatheter spanning the neck of the aneurysm (arrowheads). C, Roadmap view with balloon inflated (arrowhead) spanning the neck of the aneurysm while framing coil loop (arrow) is being deployed. D, Final working-angle projection demonstrates complete occlusion of the aneurysm. They should also create a scaffold across the neck of the aneurysm to minimize the chance that errant loops will invaginate into the parent vessel and to disrupt the inflow zone of the aneurysm. Filling and finishing coils are used to pack the aneurysm and to occlude it from the circulation. A more densely packed aneurysm is more likely to resist deformation due to blood flow over time so dense packing minimizes recurrences. An extensive discussion of the available coil systems is beyond the scope of this chapter. The balloon remodeling technique, initially introduced by Moret and colleagues9,12 in 1994, can be of service in the treatment of narrow-necked aneurysms and can improve outcomes and increase the safety of the primary treatment when used judiciously. It can also improve control of the microcatheter tip during embolization and potentially increase the coil packing density. For these reasons, some neurosurgeons have advocated the routine use of balloon-assisted coiling of cerebral aneurysms irrespective of dome-to-neck ratio. If there is evidence of intraprocedural aneurysm rupture or perforation by the coils and/or microcatheter, the balloon can be inflated under roadmap visualization to occlude the neck of the aneurysm and minimize the amount of subarachnoid hemorrhage and/or contrast extravasation. With the neck temporarily secured, coil embolization of the aneurysm can proceed in an expeditious manner. We have even allowed the patient to remain anticoagulated during these instances, since the relative occlusion of the aneurysm by the inflated balloon tends to decrease the chance of thromboembolic complications, with reversal of anticoagulation during distal cerebrovascular access. Of course, balloon microcatheters can become a source of potential complications as well as a source of improved results. Earlier generations of balloon microcatheters were not specifically designed for intracranial navigation and were generally much more rigid than the compliant models available currently. The uninflated balloon microcatheter (arrows) is positioned across the neck of the aneurysm. B, Final subtracted angiogram demonstrates complete occlusion of the aneurysm with preservation of the posterior communicating artery. The microcatheter has been removed, but the balloon microcatheter remains in position (arrows). They noted a statistically significant higher rate of procedure-related complications leading to disability and/or death with the use of a balloon microcatheter (14. Furthermore, they did not identify any improvement in coil packing densities or follow-up angiography at 6 months when balloon remodeling was used and noted a higher tendency for re-treatment after its use. They concluded that balloon remodeling techniques for the treatment of cerebral aneurysms should be reserved for those aneurysms not amenable to primary coil embolization or surgical clip ligation. This retrospective series has been criticized, however, for its infrequent use of the balloon remodeling technique and for the use of earlier-generation balloon microcatheters. However, the balloon remodeling technique was used more often in aneurysms larger than 10 mm and/or with neck diameters larger than 4 mm. Despite the difference in aneurysm size and dome-to-neck ratio in the balloon remodeling cohort, there was not a statistically significant difference between the two groups in either incidence of treatment-related complications or cumulative and global morbidity and mortality rates.

As for the age distribution medicine 6 times a day order reminyl 4mg with amex, the higher incidence was observed in adults 45 to 49 years of age treatment zinc overdose purchase reminyl 8 mg with visa, and the second in children 5 to 9 years of age symptoms testicular cancer discount reminyl on line. Individuals who have had moyamoya patients in their family are aware of familial moyamoya disease medicine 1800s 4 mg reminyl. The tendency for a decrease in the number of children affected in the population might be another reason for these changes treatment 6th nerve palsy purchase reminyl no prescription. Previously medicine cat herbs discount reminyl 4mg mastercard, about 10% of patients had a familial form of the disease, but the recent report indicates an increased incidence of up to 15%. In the United States and Europe, however, familial occurrence has been reported to be less common (<6%). In perforating arteries, microaneurysm formation and fragmented elastic lamina have been detected and are considered to be one of the reasons for intracerebral hemorrhage, as discussed later. In addition, elevated serum levels of soluble vascular cell adhesion molecule type 1, intracellular adhesion molecule type 1, and E-selectin and elevated cerebrospinal fluid levels of nitric oxide metabolites or some specific polypeptides have been reported as well. Typical angiogram of a patient with moyamoya disease and abnormal vasculature along with their schematic representation. B, Lateral view showing typical stenosis at the carotid fork and basal moyamoya vasculature along with ethmoidal moyamoya (arrows). D, Schematic drawing of various moyamoya manifestations: 1, arteria temporalis superficialis; 2, arteria meningea media; 3, arteria temporalis profunda; 4, arteria sphenopalatina; 5, arteria infraorbitalis; 6, arteria facialis. Patients with this polymorphism have significantly earlier disease onset and a more severe form of moyamoya disease, such as the presentation of cerebral infarction and posterior cerebral artery stenosis. In line with our observation and that of other authors, however, cerebral ischemia and not bleeding seems to be the usual manifestation in Europe and the United States. Such hemorrhages often recur, with an annual rebleeding rate of 7%, and one third of patients eventually suffer further hemorrhage after a variable interval (days to years)45-47; the morbidity and mortality associated with these hemorrhages have been reported to be considerable, with only 45% of patients having good neurological recovery and 7% dying. Rebleeding, which often occurs at a location different from the original bleeding site, carries an even graver prognosis: only 20% of patients have a good recovery, and nearly 30% die. These peripheral "false" aneurysms located within moyamoya and peripheral arteries can be identified on cerebral angiography and may be the origin of the bleeding. A special type of subarachnoid hemorrhage over the cerebral cortex without any evidence of aneurysm and a fair prognosis has been sporadically but repeatedly reported in adult patients, although its pathophysiology still remains to be clarified. These aneurysms occur in three locations52-59: (1) 60% around the circle of Willis, mainly at the vertebrobasilar territory; (2) 20% in peripheral arteries, such as the posterior and anterior choroidal arteries; and (3) 20% in the abnormal moyamoya vasculature as mentioned earlier. The false aneurysms may disappear spontaneously or after revascularization procedures,55 but they might need to be removed surgically because of repeated bleeding. D-F, Results of double staining for cleaved caspase-3 (D, green) and actin (E, red). Cleaved caspase-3 is colocalized with actin, as indicated by the arrows in the merged image (F). The intimal hyperplasia is remarkable (G, the arrow indicates the internal elastic lamina). Caspase-3-dependent apoptosis in middle cerebral arteries in patients with moyamoya disease. Progression from stage 1 to stage 6 has been observed in only a limited number of cases. Perfusion instability detected by measurement of these parameters is supposed to forecast progression of the disease. These parameters can also be used to confirm the effectiveness of surgical revascularization. Acetylsalicylic acid or other antiplatelet drugs are given because studies have revealed that they may have an influence on the progression of vascular stenosis. Examples of microbleeding (arrows) seen on T2-weighted magnetic resonance imaging. B, Multiple microbleeding (along with a trace of past macrohemorrhage on the right side), especially in the left paraventricular region. Compromised hemodynamic reserve verified by H215O positron emission tomography and postoperative improvement in a patient with transient ischemic attacks. A, Impaired hemodynamic reserve on loading with acetazolamide (Diamox), especially in the left hemisphere. Non-Asian experts recommended antiplatelet treatment, whereas Asian experts did not. Currently, there are no clear data indicating definite superiority of either of the methods. The indirect revascularization method is aimed at stimulating the development of new vascular networks and is thought to lead to delayed collateralization, but the extent of revascularization is considered unpredictable, whereas direct revascularization can selectively perfuse ischemic areas immediately but, in so doing, may cause hyperperfusion syndrome as a complication. Common branches used in this technique are the angular, posterior temporal, and posterior parietal arteries. When the entire extent of the frontal branch is dissected, its length is long enough to reach the midline for completion of the anastomotic procedure. Another reason is to facilitate gradual revascularization according to the needs of the ischemic brain so that hyperperfusion secondary to direct revascularization72,73 does not need to be taken into account. This technique involves implanting the temporalis muscle on the lateral brain surface and securing it to the dural edges. The temporalis muscle is considered to be a potential source of collateral circulation over the ischemic brain, and it is appropriately situated anatomically. There are many other variations of procedures consisting of the use of pedicled muscles, galea, periosteum, and the dura mater, combinations of which can be used as novel indirect revascularization methods. For the indirect revascularization method, a rather large craniotomy is recommended in anticipation of a good revascularization. Recently, this technique was employed successfully in three refractory cases of pediatric moyamoya using minimally invasive laparoscopic harvesting of the omentum. Using direct revascularization techniques or combining them with an indirect procedure is considered to be the therapy of choice in adults because indirect methods alone have been reported to be unpredictable or ineffective in achieving adequate revascularization. The two ages at which the incidence is greatest seem to have changed accordingly: the previous higher peak at 5 years of age and the second lower peak at 40 years of age have recently changed to a lower peak at 5 to 9 years and a higher peak at 45 to 49 years. The clinical findings seem to not have changed: mostly ischemia in children and bleeding in adults. However, ischemia and not bleeding seems to be the predominant manifestation in whites, in whom the incidence and prevalence are presumed to be far less and about 10% (in Europe) of those in Japanese reports. The Japan Adult Moyamoya Trial published recently demonstrated that direct bypass surgery also reduced the risk for rebleeding during a follow-up year of 5 years, hence showing the efficacy of direct revascularization in this group of patients. Perioperative Management When revascularization procedures are carried out, appropriate careful general perioperative management is of cardinal importance. Surgery should be scheduled during a period when the patient is in a relatively stable clinical condition without frequent ischemic episodes. Sufficient hydration should be ensured, and the patient should never be allowed to become dehydrated. Normocapnia should be maintained during surgery along with judicious selection of anesthetic agents. Even preoperative evaluation of hemodynamic dysfunction with acetazolamide (Diamox) loading should be carried out with caution and surgery performed (usually after 48 hours) when the hemodynamic and metabolic situation has stabilized. Seventy-five to 80% of cases are thought to have a benign course in terms of life expectancy, with or without surgical treatment. However, limited adaptability to social and school life or impairment of neurological soft signs has been reported. Recently, the effectiveness of direct bypass in preventing rebleeding over a follow-up period of 5 years could be demonstrated in the Japan Adult Moyamoya Trial. The relevance of hemodynamic factors in perioperative complications in childhood moyamoya disease. Long-term follow-up study after extracranial-intracranial bypass surgery for anterior circulation ischemia in childhood moyamoya disease. Radiological findings, clinical course, and outcome in asymptomatic moyamoya disease: results of multicenter survey in Japan. Cerebral hemodynamics and metabolism in adult moyamoya disease: comparison of angiographic collateral circulation. Cerebrovascular "moyamoya" disease: disease showing abnormal net-like vessels in base of brain. Spontaneous occlusion of the circle of Willis: a disease apparently confined to Japanese. Expression of vascular endothelial growth factor in dura mater of patients with moyamoya disease. A co-operative study: clinical characteristic of 334 Korean patients with moyamoya disease treated at neurosurgical institutes (1976-1994). Fukui M, Members of Research Committee on Spontaneous Occlusion of the Circle of Willis (Moyamoya Disease) of the Ministry of Health and Welfare, Japan. Guidelines for the diagnosis and treatment of spontaneous occlusion of the circle of Willis ("moyamoya" disease). Epidemiological features of moyamoya disease in Japan: findings from a nationwide survey. Prevalence and clinicoepidemiological features of moyamoya disease in Japan: findings from a nationwide epidemiological survey. Radiological findings, clinical course, and outcome in asymptomatic moyamoya disease: results of multicenter survey in Japan, for the Research Committee on Moyamoya Disease in Japan. Autopsy of a case with an anomalous hemangioma of the internal carotid artery at the skull base. Distribution of thrombotic lesions in the cerebral arteries in spontaneous occlusion of the circle of Willis: cerebrovascular moyamoya disease. Smooth muscle cell proliferation and localization of macrophages and T cells in the occlusive intracranial major arteries in moyamoya disease. Involvement of the external carotid arteries in moyamoya disease: neuroradiological evaluation of 66 patients. Possible role of fibroblastic growth factor in the pathogenesis of moyamoya disease. Increased expression of hepatocyte growth factor in cerebrospinal fluid and intracranial artery in moyamoya disease. Expression of hypoxia-inducing factor-1 alpha and endoglin in intimal hyperplasia of the middle cerebral artery of patients with moyamoya disease. Annual Report of the Research Committee on Spontaneous Occlusion of the Circle of Willis (Moyamoya Disease) 1990 [in Japanese, English abstract]. Inheritance pattern of familial moyamoya disease: autosomal dominant mode and genomic imprinting. Analysis of filing data bank of 1500 cases of spontaneous occlusion of the circle of Willis and follow-up study of 200 cases for more than 5 years. Potential hazard of intracranial bleeding and cerebral ischemia in patients with moyamoya disease. Annual Report of the Research Committee on Spontaneous Occlusion of the Circe of Willis (Moyamoya Disease) 1995. A source of haemorrhage in adult patients with moyamoya disease: the significance of tributaries from the choroidal artery. Lipohyalinosis and miliary microaneurysms causing hemorrhage in a patient with moyamoya disease: a clinicopathological study. A case of moyamoya disease with repeated intraventricular hemorrhage due to ruptured pseudoaneurysm. Moyamoya disease presenting with subarachnoid hemorrhage localized over the frontal cortex: case report. Association of middle cerebral anomalies with saccular aneurysms and moyamoya disease. Differences between intracranial aneurysms associated with moyamoya disease and usual saccular aneurysms (Part 1). Second report: collateral routes to forebrain via ethmoidal sinus and superior nasal meatus. The presence of multiple microbleeds as a predictor of subsequent cerebral hemorrhage in patients with moyamoya disease. Severe haemodynamic stress in selected subtypes of patients with moyamoya disease: a positron emission tomography study. Cerebral circulation and oxygen metabolism in moyamoya disease of ischemic type in children. Temporary neurologic deterioration due to cerebral hyperperfusion after superficial 73. Paper presented at: the 36th Annual Meeting of the American Association of Neurological Surgeons; 1968; Chicago. Arterial extracranial intracranial anastomosis: Technical and clinical aspects: results. Direct revascularization to the anterior cerebral artery territory in patients with moyamoya disease. Cerebral vascularization using omental transplantation for childhood moyamoya disease. Less invasive pedicled omental-cranial transposition in pediatric patients with moyamoya disease and failed prior revascularization. Metabolic changes after H215O-positron emission tomography with acetazolamide in a patient with moyamoya disease: case report and review of previous cases.

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Once approximately half of the incision is complete symptoms rheumatic fever cheap 4 mg reminyl mastercard, another stitch is placed at the proximal arteriotomy and run distally (Video 366-14) medicine 100 years ago purchase 8 mg reminyl otc. Once the closure has proceeded to within two stitches of completion treatment trends discount reminyl line, the systolic blood pressure is lowered to less than 150 mm Hg symptoms zoloft withdrawal reminyl 4 mg lowest price. A specimen cup is placed over the arteriotomy defect to prevent pulsatile blood from splashing the surgeons treatment naive definition buy reminyl with a visa. The vessel loop is then removed from the superior thyroid artery to allow continuous backbleeding while the final Prolene stitch is placed and the two ends are tied (Video 366-15) medicine 6 year cheap 8 mg reminyl with amex. The suture line is then inspected for leaks, which can often be managed within minutes by digital pressure, warm saline irrigation, and patience. In cases of persistent bleeding, a single 7-0 Prolene suture can be placed across the hole to achieve hemostasis. Confirmation of flow is achieved with a sterile, nondisposable handheld Doppler probe (Video 366-17). In a series of 141 consecutive endarterectomies performed by the senior author, 137 arteriotomies were repaired primarily. A major disadvantage of using an autogenous vein patch, as opposed to a synthetic patch, is the additional cross-clamp time required to harvest a vein, most commonly the saphenous vein. Advantages of the vein patch, as opposed to its synthetic counterpart, include a lower risk of infection and bleeding through the suture hole. Vein patches also provide resistance against thrombosis by providing an endothelial cell surface upon placement of the vessel. Polytetrafluoroethylene and Dacron patches are the most commonly used synthetic materials for patch angioplasty. The Dacron patches were easily deformed and less likely to produce needle hole bleeding. The patch thickness is very amenable to passing needles during closure of the arteriotomy. The distal end of the patch is trimmed to a "V" shape to match the arteriotomy apex. The stitch is placed through the apex of the patch, then through the apex of the arteriotomy, and tied. A running stitch is then used to close whatever wall is easiest with a forehand stitch first. Precision must be used when throwing the first several stitches to ensure the patch and native intima are lining up appropriately. The patch is sutured as described earlier, going first from the graft to the native vessel wall. At this point the patch is trimmed and the suture is advanced around onto the opposite side. Care must be taken to ensure that the full thickness of the common carotid wall is included in each stitch. By lifting the patch toward the suture line, it can be inspected from inside the vessel lumen to ensure uniformity. At this point, the second arm of the needle is taken from the distal apex and brought proximally. However, prior to complete closure the shunt is clamped with two mosquito hemostats and cut between them, and then each end is removed serially with replacement of the vessel clamps. Complete closure of the arteriotomy then proceeds quickly to avoid cerebral ischemia. The final result after endarterectomy, primary angioplasty, and restoration of flow. Primary closure of the arteriotomy is achieved in the overwhelming majority of patients using a 6-0 Prolene suture. Patients are evaluated with bedside neurological examinations hourly immediately after surgery and then every 2 hours thereafter. Radiographic evidence of hypoperfusion is managed with hypertension or gentle heparin anticoagulation. If occlusion of the endarterectomy site is seen, the patient is taken for cerebral angiography to attempt direct clot lysis and, if this is unsuccessful, is returned to the operating room to directly repair the occlusion. Although we have not had to do this at our institution, the carotid surgeon should be prepared for any and all postoperative courses. A postoperative neck hematoma can result in a neurosurgical and anesthesia emergency. Many authors, who cite a failure to adequately evacuate clot and decompress the airway without the appropriate instruments and the risk for further, uncontrollable bleeding, discourage opening the wound at the bedside in the intensive care unit. The goal in this situation should be a rapid return to the operating room, a controlled intubation, and expeditious surgical exploration. The otolaryngology team should be notified to come to the operating room in the event an emergency tracheostomy needs to be placed. In rare instances, a Hemashield Dacron patch angioplasty is performed to restore adequate flow in the internal carotid artery. In addition, a combination of Floseal hemostatic matrix applied diffusely in the wound and manual pressure with gauze assists in achieving hemostasis. Given that patients are maintained on antiplatelet agents postoperatively, and that postoperative hematomas can result in sudden and severe airway compromise, hemostasis is of utmost priority. Jackson-Pratt drains are not commonly used at our institution; however, they can serve as a protective measure in patients with a deep neck or who are otherwise at higher risk for postoperative bleeding. Postoperative Care All patients go to the postanesthesia care unit immediately after surgery. Routine postoperative cardiac evaluation with cardiac enzyme monitoring and electrocardiography is avoided unless recommended by the cardiologist who evaluated the patient preoperatively or indicated by the presence of clinical signs or symptoms. An arterial line is maintained overnight and systolic blood pressure is maintained below 150 mm Hg to avoid cerebral hyperperfusion injuries and hematoma formation. Failure to maintain normotension with intermittent intravenous beta blockers or vasodilators results in the initiation of a continuous nicardipine infusion titrated to the systolic blood pressure goal. Higher dose aspirin is reserved for patients with significant cardiac history, and clopidogrel (Plavix) is avoided perioperatively for risk of bleeding complications. Patients are started on a liquid or soft diet the night of surgery, ambulate the night of surgery, and are routinely discharged from the hospital the day after surgery. This is supported by several well-constructed and implemented randomized, controlled studies. Although there is variability among the surgical nuances, individual surgeon and center data in regard to perioperative morbidity and mortality should be critically evaluated prior to deciding if a patient would benefit from endarterectomy at a morbidity rate that is less than that of nonoperative or endovascular management. Carotid artery stenting compared with endarterectomy in patients with symptomatic carotid stenosis (International Carotid Stenting Study): an interim analysis of a randomised controlled trial. Asymptomatic internal carotid artery stenosis and cerebrovascular risk stratification. Endarterectomy for symptomatic carotid stenosis in relation to clinical subgroups and timing of surgery. Heart disease and stroke statistics-2013 update: a report from the American Heart Association. Causes and severity of ischemic stroke in patients with internal carotid artery stenosis. Stroke epidemiology: advancing our understanding of disease mechanism and therapy. The angiographic diagnosis of spontaneous thrombosis of the internal and common carotid arteries. Morbidity and mortality of carotid endarterectomy under local anesthesia: a retrospective study. Insidious thrombotic occlusion of cervical carotid arteries, treated by arterial graft: a case report. Partial internal carotid artery occlusion treated by primary resection and vein graft; report of a case. Surgical considerations of occlusive disease of the innominate, carotid, subclavian, and vertebral arteries. The performance of endarterectomy for disease of the extracranial arteries of the head. Dramatic changes in the performance of endarterectomy for diseases of the extracranial arteries of the head. Relation between prepublication release of clinical trial results and the practice of carotid endarterectomy. Evaluation and management of transient ischemic attack and minor cerebral infarction. Carotid Doppler ultrasound criteria for internal carotid artery stenosis based on residual lumen diameter calculated from en bloc carotid endarterectomy specimens. Comparison of Doppler ultrasonography with arteriography of the carotid artery bifurcation. Relative roles of magnetic resonance angiography and computed tomographic angiography in evaluation of symptomatic carotid stenosis: a critically appraised topic. Investigating individual subjects and screening populations for asymptomatic carotid stenosis can be harmful. Prevalence of asymptomatic carotid artery stenosis according to age and sex: systematic review and metaregression analysis. Analysis of pooled data from the randomized controlled trials of endarterectomy for symptomatic carotid stenosis. Risk of stroke early after transient ischaemic attack: a systematic review and meta-analysis. Early risk of recurrence by subtype of ischemic stroke in population-based incidence studies. Low risk of ipsilateral stroke in patients with asymptomatic carotid stenosis on best medical treatment: a prospective, population-based study. Medical (nonsurgical) intervention alone is now best for prevention of stroke associated with asymptomatic severe carotid stenosis: results of a systematic review and analysis. Selective versus routine intraoperative shunting during carotid endarterectomy: a multivariate outcome analysis. Endarterectomy versus Stenting in Patients with Symptomatic Severe Carotid Stenosis. Carotid endarterectomy under local and/or regional anesthesia has less risk of myocardial infarction compared to general anesthesia: an analysis of National Surgical Quality Improvement Program database. The differences in electroencephalographic changes in patients undergoing carotid endarterectomies while under local versus general anesthesia. Incidence of cranial nerve injuries after carotid eversion endarterectomy with a transverse skin incision under regional anaesthesia. Mandibular subluxation for distal cervical exposure of the internal carotid artery. Exposure of the cervical internal carotid artery: surgical steps to the cranial base and morphometric study. Routine shunting is a safe and reliable method of cerebral protection during carotid endarterectomy. Distal cervical carotid dissection after carotid endarterectomy: a complication of indwelling shunt Electrophysiological monitoring for selective shunting during carotid endarterectomy. Predictors of shunt during carotid endarterectomy with routine electroencephalography monitoring. Carotid endarterectomy saphenous vein patch rupture revisited: selective use on the basis of vein diameter. A prospective, randomized study of saphenous vein patching versus synthetic patching during carotid endarterectomy. Carotid endarterectomy: comparison of complications between transverse and longitudinal incision. Cranial and cervical nerve injuries after carotid endarterectomy: a prospective study. Carotid recurrent stenosis and risk of ipsilateral stroke: a systematic review of the literature. Siddiqui Atherosclerotic disease in the carotid arteries is thought to be the cause of ischemic strokes in approximately 15% of cases. Soon there was a push toward implementing this technique for treatment of atherosclerotic disease. However, the risk of iatrogenic dissections (5%-8%) and distal embolic complications (8%-10%) was inordinately high. The first attempts were simple distal occlusion of the internal carotid artery via a balloon parked in series to the more proximal stent delivery system, followed by aspiration of blood and debris after angioplasty. Nevertheless, the results from carotid angioplasty remained dismal, principally because of the high rates of recurrent stenosis and procedural complications. Parallel development of coronary and peripheral vascular stents eventually resulted in the trial of a stent at the carotid bifurcation with inherent jailing of the external carotid artery in 1990. Because approximately 795,000 new or recurrent strokes occur annually in the United States, carotid artery disease is a major cause of disability and mortality. Through large clinical trials (North American Symptomatic Carotid Endarterectomy Trial, Asymptomatic Carotid Atherosclerosis Study, Asymptomatic Carotid Surgery Trial, European Carotid Surgery Trial), treatment of this pathologic condition has been shown to decrease the rate of stroke in comparison with medical management alone. The revolution that has ensued has included the development of a wide variety of balloons for angioplasty, stents designed specifically for carotid anatomy, and an array of "distal" embolic protection devices. More recently, "proximal" protection has been developed through flow arrest or flow reversal from the internal carotid artery into the arterial guide sheath, which is also the conduit for the deployment of devices across the carotid bifurcation. Studies have demonstrated rates of perioperative stroke and death to range from 0%13 to 11. The investigators of the Asymptomatic Carotid Stenosis and Risk of Stroke "natural history" study followed up with 1115 patients with asymptomatic internal carotid artery stenosis who were treated with medical therapy alone; significant differences with respect to stroke and death risk were identified in patient subgroups.

Revascularization of collaterals for hemodynamic stroke: insight on pathophysiology from the carotid occlusion surgery study symptoms inner ear infection generic 4 mg reminyl otc. Intracranial angioplasty & stenting for cerebral atherosclerosis: a position statement of the American Society of Interventional and Therapeutic Neuroradiology medicine plus buy reminyl 4 mg fast delivery, Society of Interventional Radiology symptoms gallbladder problems discount reminyl online amex, and the American Society of Neuroradiology symptoms hypoglycemia reminyl 8mg fast delivery. Stroke recurrences in patients with symptomatic vs asymptomatic middle cerebral artery disease medicine abuse safe 8mg reminyl. Tandem bypass: occipital artery to posterior inferior cerebellar artery side-to-side anastomosis and occipital artery to anterior inferior cerebellar artery end-to-side anastomosis-a case report medications given for migraines buy 4mg reminyl with mastercard. An anatomic mathematical measurement to find an adequate recipient M4 branch for superficial temporal artery to middle cerebral artery bypass surgery. The cut flow index: an intraoperative predictor of the success of extracranial-intracranial bypass for occlusive cerebrovascular disease. Construction of a new posterior communicating artery in a patient with poor posterior fossa circulation: technical case report. Direct endarterectomy of the middle cerebral artery for treatment of symptomatic stenosis: case report. Microsurgical endarterectomy of the intracranial vertebral artery for vertebrobasilar transient ischemic attacks. A novel, self-expanding, nitinol stent in medically refractory intracranial atherosclerotic stenoses: the Wingspan study. Can a patent extracranial-intracranial bypass provoke the conversion of an intracranial arterial stenosis to a symptomatic occlusion Time to initiation of medical or interventional treatment is critical in delivering potentially lifesaving therapy for ischemic stroke patients. Additionally, mechanical thrombectomy is not without complications, including both symptomatic and asymptomatic intracranial hemorrhage, distal clot embolization, and vascular dissection. As newer devices are introduced, these rates continue to decline and the time to revascularization, rates of revascularization, and clinical outcome at 90 days continue to improve. Neurointerventional treatments are very promising, and it is likely that newer generations of these devices will continue to improve the safety and efficacy of thrombectomy. One explanation for this is that, although the study was designed to detect a difference in recanalization rate, it had insufficient power to detect differences in clinical outcome or mortality. The device is a flexible, corkscrew-shaped nitinol wire delivered through a microcatheter distal to the occluded segment of the vessel. When it is deployed, it expands to engage the thrombus, which is then pulled into the balloon guide catheter with proximal flow arrest or under suction. However, in the early course of the study, there was concern for hemorrhagic conversion with clinical deterioration. Aspiration can be achieved with either a small-size syringe or Penumbra aspiration pump. Aspiration in combination with direct contact of the catheter against the thrombus engages the clot, evidenced by absence of flow in the aspiration catheter. Aspiration is held for 20 to 30 seconds to verify clot engagement, then the catheter is retracted, pulling the thrombus out with it. These work through a hybrid of older thrombectomy techniques along with newer developments in clot removal. Stent retrievers are generally recommended to be deployed under proximal flow arrest with a balloon guide catheter, although many practitioners do not utilize proximal flow arrest. A microcatheter is passed through the thrombus to deliver a nitinol stent, which applies a radial force throughout the length of the clot. The stent is deployed, causing radial displacement of the thrombus against the blood vessel and finally collapse into the stent retriever. The stent is then retrieved, often under continuous aspiration with a large syringe or vacuum device. The Trevo device has a vertically oriented strut system that allows for efficient clot integration, whereas the Solitaire device has a circumferential overlapping design allowing for several contact points with the thrombus during engagement of the clot. The Trevo 2 trial was an open-label randomized, controlled trial of the Trevo device versus the Merci device in patients treated less than 8 hours from symptom onset. Revascularization was achieved in 73% of patients with a median time of thrombectomy of 80 minutes. The Penumbra System, approved for use in 2008, is composed of a reperfusion catheter and a "separator" wire with an oliveshaped tip used to disrupt thrombus during active aspiration. During the study, 656 patients were randomized in a 2-to-1 treatment-control ratio. However, the study was stopped early due to futility because the treatment arm showed rates of safety and efficacy similar to those in the control arm. However, recent studies suggest that these time parameters can be extended in appropriately selected patients. Appropriate selection includes demonstrated mismatch on perfusion imaging, which indicates parenchymal tissue that is at risk, but not infarcted despite the time from symptom onset. These patients showed rates of reperfusion, good functional outcome, mortality, and symptomatic intracranial hemorrhage similar to those of patients treated within 8 hours. A total of 502 patients were enrolled, with 233 receiving intra-arterial mechanical thrombectomy or thrombolysis in addition to standard of care and 269 receiving standard of care alone. The vast majority (190 of 233, or 82%) of the intra-arterial treatment group received intra-arterial stent retriever therapy for mechanical thrombectomy. This study, which was stopped early because of demonstration of efficacy, enrolled 316 adults, with 165 in the intra-arterial therapy group, of whom 130 received intra-arterial stent retriever therapy, and with 151 in the standard-of-care only group. Patients in the treatment group were treated with a retrievable stent within 6 hours of symptom onset in addition to intravenous alteplase, compared to intravenous alteplase alone in the control group. Similar to the other studies, the ischemic strokes were limited to those with confirmed proximal anterior circulation occlusions and an absence of a large ischemic core on imaging. Several changes in these newer trials-modern, more effective clot removal; a faster time to treatment; and requirement of neuroimaging evidence of large-vessel proximal stroke with salvageable tissue-have addressed these issues. Clear benefit for the role of intra-arterial thrombectomy has been shown for patients with large-vessel, anterior circulation ischemic strokes and salvageable brain tissue with small infarct volumes treated with great attention to door-totreatment times. The neurointerventionalist can now safely, decisively, and effectively treat stroke with the advent of the latest thrombectomy devices. Therefore, the acute management of stroke will need to undergo a shift in response in order to ensure that patients are evaluated and transported to hospitals with these capabilities. The Penumbra Pivotal Stroke Trial: safety and effectiveness of a new generation of mechanical devices for clot removal in intracranial large vessel occlusive disease. The Penumbra System: a mechanical device for the treatment of acute stroke due to thromboembolism. Penumbra System: a novel mechanical thrombectomy device for large-vessel occlusions in acute stroke. The Penumbra system for mechanical thrombectomy in endovascular acute ischemic stroke therapy. Direct thrombus retrieval using the reperfusion catheter of the Penumbra System: forced-suction thrombectomy in acute ischemic stroke. Initial experience with the Penumbra Stroke System for recanalization of large vessel occlusions in acute ischemic stroke. Recanalization of large intracranial vessels using the Penumbra System: a single-center experience. First experience with a new device for mechanical thrombectomy in acute basilar artery occlusion. Rescue, combined, and standalone thrombectomy in the management of large vessel occlusion stroke using the Solitaire device: a prospective 50-patient singlecenter study: timing, safety, and efficacy. Comparison of stent-retriever devices versus the Merci retriever for endovascular treatment of acute stroke. Early experience with stent retrievers and comparison with previous-generation mechanical thrombectomy devices for acute ischemic stroke. Trevo System: single-center experience with a novel mechanical thrombectomy device. Retrievable stent thrombectomy in the treatment of acute ischemic stroke: analysis of a revolutionizing treatment technique. Stentrievers versus other endovascular treatment methods for acute stroke: comparison of procedural results and their relationship to outcomes. Treatment of acute vertebrobasilar occlusion using thrombectomy with stent retrievers: initial experience with 18 patients. Selecting endovascular treatment strategy according to the location of intracranial occlusion in acute stroke. The clinical findings are mainly cerebral ischemia in children and cerebral hemorrhage in Asian adults, but presumably also mainly ischemia in white adults. Its etiology is still unknown despite the accumulation of new molecular biologic and genetic information. Biopsy of the superior laryngeal artery revealed a slight proliferative change in the intima and media. The authors considered the occlusion to be due to congenital hypoplasia causing insufficient collateral circulation to the brain. Since its initial discovery some 50 years ago, the clinical features of the disease have become clearer. It has been hypothesized that in the setting of arterial stenosis-occlusion, hypoxic regions of the brain induce deep collateral flow by the dilation of tortuous perforating arteries, namely the moyamoya vasculature. This revascularization phenomenon is thought to be orchestrated by the expression of various angiogenic signaling cascades. Perioperative factors related to the development of ischemic complications in patients with moyamoya disease. Study design for a prospective randomized trial of extracranial-intracranial bypass surgery for adults with moyamoya disease and hemorrhagic onset- the Japan Adult Moyamoya Trial Group. Effects of extracranial-intracranial bypass for patients with hemorrhagic moyamoya disease. It was first described by Ribes in the early 19th century,1 who reported the case of a 45-year-old man with systemic malignancy and thrombosis of the superior sagittal sinus demonstrated at autopsy. Cavernous and transverse sinus thromboses are most frequently associated with infections such as sinusitis, otitis, and mastoiditis. In chronic forms, gram-negative rods and fungi such as Aspergillus species are most commonly isolated. The risk is much higher in women using oral contraceptives who also have the prothrombin gene mutation. Most of these conditions involve alterations in the physical properties of the vasculature, the chemical properties of blood coagulation, or the hemodynamic properties of blood flow. The spectrum ranges from varying degrees of cerebral edema to massive hemorrhage and bilateral cerebral infarcts. Vascular injury and compression owing to trauma or mass lesions cause local endothelial damage and altered hemodynamics. In the largest study of cerebral venous thrombosis, acquired prothrombotic condition was present in 34% of patients. Ehler and Courville36 found 16 cases of superior sagittal sinus thrombosis in a series of 12,500 autopsies. The most common locations for venous sinus thrombosis are the superior sagittal sinus and the transverse sinus. In the largest series of cerebral venous sinus thrombosis in the literature, superior sagittal sinus involvement was seen in 62% of patients, transverse sinus in 41% to 45% of patients, straight sinus in 18% of patients, and cavernous sinus in 1. When the thrombosis involves the deep venous system, the patient can exhibit akinetic mutism, coma, or decerebration. Cortical vein thrombosis without sinus involvement can present as a stroke syndrome. For example, a patient with visual alterations should be seen by an ophthalmologist. In all cases, imaging of the venous system is a cornerstone of diagnostic imaging work-up. Sometimes a dense triangle, also known as the delta sign, is seen as the thrombus occupies the superior sagittal sinus. The thrombus can be visualized directly, and cortical lesions, such as edema and hemorrhagic infarct, can be detected. T2- and T2*-weighted images are particularly helpful in early diagnosis,62 and susceptibility weighted imaging sequences for detecting hemorrhage. Papilledema is seen in approximately 50% of patients, and confusion, agitation, and other mental status changes occur in approximately 25% of patients. Although an acute presentation can mimic acute ischemic stroke, subacute presentations are more common. In 70% of patients, the complaints are present for days to weeks, and the symptoms can be fluctuating or progressive. The clinical presentation also varies according to the site and extent of thrombosis. When thrombosis is limited to the superior sagittal sinus or transverse sinus, the most frequent pattern of presentation is isolated intracranial hypertension. A number of patients with thrombosis are initially thought to have pseudotumor or idiopathic intracranial hypertension. If the thrombosis extends to the cortical veins, focal deficits and seizures can occur. False-positive identification can occur when sinuses are congenitally absent or hypoplastic. Falsenegative identification can occur when the signal of methemoglobin mimics that of flowing blood, when loss of signal occurs secondary to magnetic susceptibility artifact, or when the patient cannot cooperate and the study is technically poor.