Abstract – EANSICH2011

Adalimumab is Neuroprotective in Experimental Peripheral Nerve Injury: An Electronmicroscopic and Biochemical Study

Introduction:Despite all clinical and experimental studies on peripheral nerve injury, optimum results for neural healing couldn't be accomplished. Neuroinflammation is an important mechanism that develops as a consequence of microvascular stasis-edema and agents against these mechanisms may enhance neural healing. Adalimumab exerts its effect through TNF-a which is secreted from immune response cells like macrophages or lymphocytes. Thus decline in levels of TNF-a may improve cellular injury mediated through these immune response cells. TNF-a was proved to have important role in apoptosis and demyelinization process and blockage of its activity may improve neural healing. Here we investigate probable neuroprotective influence of adalimumab in rat PNI model with biochemical and electron microscopic methods.

Study-design:Forty adult Wistar albino rats were divided into sham, sciatic nerve trauma, low dose adalimumab and high dose adalimumab groups at random. Six rats from each group were reserved for biochemical and remaining 4 rats for electron microscopy. Neural injury was induced with clip compression and adalimumab was injected simultaneously. Rats were sacrificed after 2 weeks of adalimumab treatment..

Results-conclusion:Nerve tissue lipid peroxidation values were found to be significantly decreased both in low and high dose adalimumab treatment groups when compared with rats subjected to sciatic nerve trauma only. This statistical result denotes to its positive influence on neural healing. Furthermore, this effect was found to be proportional with dose increments of adalimumab. The results of this study showed that adalimumab is an effective neuroprotective agent for neural healing particularly in the early phase.

Distal Superior Cerebellar Artery Aneurysm Operated Via Cerebellopontine Route

Introduction:Superior cerebellar artery(SCA) supplies cerebellar hemisphere, interpeduncular fossa, cerebral peduncles, superior and inferior colliculi. Aneurysms of distal SCA segments are rare. There is scarce clinical, endovascular and surgical experience regarding these aneurysms. Selective coiling of the regarding aneurysm for endovascular intervention and cerebellopontine approach for surgical treatment are usual therapeutic choices. Intimate association of the aneurysms at this localization with cranial nerves 3, 4 and 6 worsens the conflict between endovascular and conventional surgical choices.

Study-design:56-year-old male patient presented with severe headache and imbalance that progressed to clouding of consciousness and GCS of 12 without prominent lateralized weakness. CT showed subarachnoid hemorrhage and cerebral angiography demonstrated two separate aneurysms on distal portion of left SCA. The patient was operated through left suboccipital craniotomy and the aneurysms were clipped distal to pedincular perforators of SCA with two straight clips. Postoperative course was uneventful and neurological examination was completely normal after 2 weeks. There was no remnant of aneurysms on cerebral angiogram 3 months after the operation.

Results-conclusion:SCA aneurysms form 1% of cerebral and 10% of vertebrobasilar system aneurysms. SCA aneurysms were reported to be most common at SCA(cisternal segment) origin and distal cortical segment aneurysms are extremely rare. Aneurysms of the distal segment is frequently associated with other aneurysms which make the situation much more challenging. To our knowledge, multiple aneurysms of distal cortical segment were not previously reported. The aneurysms were successfully clipped via cerebellopontine approach..

Giant Middle Cerebral Artery Aneurysm Presenting with Acute Stroke

Introduction:Giant aneurysms are defined as aneurysms greater than 2.5 cm in size and they are rare. They constitute 5 to 7 percent of all intracranial aneurysms. ICA(%21), MCA(%16), ACoA and ACA(%12) are the most prominent sites. Despite their huge size, only one third of giant aneurysms present with subarachnoid hemorrhage. Here we report an operated giant MCA aneurysm presenting with severe subarachnoid hemorrhage, hematoma, ischemia and herniation.

Study-design:55-year-old male patient presented with sudden severe headache, vomiting, loss of consciousness and hemiplegia with a GCS of 7. Left temporal huge lesion with a size of 6x8 cm, marked shift and hemorrhagic components with severe perilesional edema was noted on CT. Pterional craniotomy with wide necrotic cerebral tissues were performed and a hard huge mass was noted under cerebral cortex. There was no bleeding after puncture and it was easily removed without bleeding after isolation and clippage from M2 branch. The patient gained consciousness at the postoperative period. At the 9th month of operation, the patient was able to walk with little support and marked aphasia. Cerebral angiography showed occlusion after M1 with marked collateral branches from ACA.

Results-conclusion:Incidental giant aneurysms presenting with ischemic stroke and severe intracerebral hemorrhage are usually mortal in one third of the cases. The mortality rate without treatment was 68% within 2 years due to subarachnoid hemorrhage. Risk of rupture is increased in huge lesions therefore treatment is mandatory.

Fibromuscular Dysplasia Associated with Carotid Artery Agenesis

Introduction:Fibromuscular dysplasia(FMD) is a non-atherosclerotic, non-inflammatory and segmental vascular disease that effects medium-sized arteries of middle-aged women. Hypertension and cigarette smoking were proposed as the most amenable reasons. Renal and carotid arteries were most commonly involved. In about onefourth of patients more than one vascular territory is involved. Here we report a patient with vertebrobasilar artery junction FMD associated with ipsilateral agenesis of internal carotid artery(ICA).

Case report:60-year-old male patient presented with severe headache, vertigo, blurring of vision, nausea, rightsided facial numbness and tingling. Neurological examination showed right-gaze paresis, right facial hyposthesia and bilateral horizontal nystagmus. Cranial CT and MRI revealed fusiform dilatation and luminal thrombus within left vertebrobasilar junction including proximal one third of the basilar artery. Cerebral angiography confirmed MRI findings and also revealed left internal carotid artery agenesis. The patient was conservatively treated with daily oral intake of 600 mg acetylsalicylic acid without any intervention.

Results-conclusion:IFMD causes alternating mural thinning and thickening, which appears as irregular succession of dilatations and stenoses on angiography and cerebrovascular symptoms may be related to critical stenosis or occlusions of major arteries, rupture of intracranial aneurysm, carotid artery dissection, or cerebral embolism originating from intravascular thrombi in stenotic regions. Association of FMD with agenesis of ICA was not reported until now in the literature. The patient reported here should be treated more cautiously since basilar system supplies a wider cerebral cortex. Theoretical risks involve dissection, stenosis-related ischemic stroke and subarachnoid hemorrhage.

Trigeminal Neuralgia Caused by Ectatic Basilar Artery

Introduction:Trigeminal nerve root entry zone compression due to an arterial or venous loop is a common cause of trigeminal neuralgia. Ectatic basilar artery, persistant trigeminal artery variant and giant vertebrobasilar loop are most commonly reported uncommon vascular reasons. Ectatic vertebral and basilar arteries were reported to compress the root entry zone of cranial nerve 5 in less than 2% of cases with trigeminal neuralgia. It was also reported as a cause of trigeminal neuralgia in re-do microvascular decompression. The anatomical intimacy is also defined to be an uncommon cause of trigeminal neuralgia on MR, MRA screening and anatomical studies.

Case report:This 47-year-old man presented with a 9-year history of left sided facial hypoesthesia and trigeminal pain. Difficulty in speech and unbearable pain while eating with exacerbation upon cold exposure were prominent. Carbamazepine and similar drugs as well as Radiofrequency coagulation all failed in symptom control and the patient was referred for surgical intervention with MRI diagnosis of basilar artery shift towards cerebellopontine fissure. Basilar artery was isolated from the trigeminal nerve with meticulous surgical dissection and teflon. At the postoperative period, the patient experiences significant relief of pain and independent of oral intake.

Conclusion:Microvascular decompression is widely used for trigeminal neuralgia. Surgical treatment involves repositioning the tortuous vertebrobasilar artery by pulling it toward the dura mater of the clivus using a synthetic vascular slip, vascular tape, teflon, autologous muscle or silicone sheath.

True Aneurysm of the Thyrocervical Trunk Associated with Intracranial Aneurysms

Introduction:True aneurysm of the thyrocervical trunk is uncommon. Less than 20 cases were reported. Association of thyrocervical trunk aneurysm with intracranial aneurysm was not emphasized previously. Surgical or endovascular therapies are both successful with a favor towards endovascular management. Due to high risk of rupture, treatment is mandatory.

Case report:54-year-old male patient presented with sudden syncope and severe headache which started a week before his admission. Hypertension and cigarette smoking were prominent findings of past medical history. CT showed subarachnoid hemorrhage. Cerebral angiography demonstrated right MCA bifurcation(5x9mm in size), left MCA bifurcation(4x5mm in size) and left inferior trunk bifurcation(3x2mm). A separate aneurysm was noted on left thyrocervical trunk which is 7x9mm in size. The patient was operated with bilateral pterional craniotomies and allaneurysms were clipped at the same operation. The patient experienced meningitis and treated with wide spectrum antibiotics for 2 weeks..

Conclusion:Association of inferior thyroid artery origin aneurysm with intracranial aneurysms is quite rare. Subclavian artery catheterization poses a significant risk for rupture during intracranial aneurysm surgery and it should be avoided. Alternative methods for central venous catheterization should be considered. Inadvertent rupture of aneurysm at the thyrocervical trunk may lead to severe bleeding and hemothorax which may result in death..

3D Angiographic Visualization of Cerebral Aneurysms and Arteriovenous Malformations: A Beneficial Tool for Operative Planning

Introduction:3D Angiography(3DA) applies to arteriovenous malformation(AVM)s and aneurysms which aids in both surgical and endovascular planning of operations. The details of the lesion vasculature, origin of arteries-veins that supply-drain the lesion may be evaluated preoperatively. Vascular dynamics of AVM-aneurysm may also be evaluated on dynamic runs for further planning.

Study design:The study group includes 87 patients with cerebral aneurysms (57 presented with subarachnoid hemorrhage and 3DA performed in 63), and 7 patients with AVMs(3 presented with hemorrhage, 3DA performed in all)(between 2008-2010). 3DA was performed for each patient before surgery. The patients were further analyzed for age, aneurysm-nidus size and localization, origin-feeder-drainage, perioperative hemorrhage, complication at the hospital stay. Peroperative mortality and morbidity was calculated for each patient. 5 patients died at the perioperative period, 13 experienced perioperative aneurysmal bleeding and 5 patients experienced serious morbidity among aneurysm group. There was no mortality in AVM group (1 minor morbidity) and no need for blood transfusion in any operation.

Results-conclusion:Complex aneurysms and AVMs may turn out to be simpler ones if spatial anatomic localization of the aneurysm, its bleb, neck, diameter, can be understood preoperatively, e.g. understanding spatial localization of the aneurysm bleb, major drainage or feeding site of AVM. Operative morbidity and mortality was almost identical with pre-3DA period for aneurysms with a slight improvement but major improvement was noted for AVM surgery. This precise anatomical data from 3D angiographic studies gives the surgeons a strong self confidence during surgical steps of AVM and aneurysm surgery.

Propriospinal Myoclonus Induced with Intraarterial Contrast Material: A Technical Pitfall of Spinal Angiography

Introduction:Spinal myoclonus is a rare form of myoclonus characterized by focal involuntary contractions that are usually associated with neoplastic, infectious, traumatic, and degenerative spinal cord lesions. Association with spinal arteriovenous malformations(AVMs) is rare. Diagnostic spinal angiography is a standard technique for the diagnosis of spinal AVMs.

Study design:55-year-old male presented with symptoms of bilateral leg pain, weakness, paresthesia, migratory involuntary myoclonic jerks on bilateral lower extremity. Bilateral myoclonus was not periodical or exacerbated with any stimuli. Neurological examination revealed paraparesis and plantar response was bilaterally negative with marked hypoesthesia below T12. Spasticity on the left lower extremity and moderate atrophy on the right lower extremity muscular groups were also noted. Thoracal MRI demonstrated tortuosity of spinal cord vasculature on posterior spinal cord.Intercostal arteries between T6 -12 and first three lumbar arteries were bilaterally catheterized with 5F Simmons 1 and Cobra catheters during spinal angiography. Spinal AVM extending from T8 to T11 levels was visualized. The patient experienced myoclonic jerks almost at every injection of contrast material to each intercostal or lumbar artery lasting for a few seconds. The patient was unable to control these involuntary jerks induced with contrast.

Conclusion:ntravenous contrast injection may induce myoclonic jerks during diagnostic procedures like enhanced CT scan. These jerks were characterized to appear simultaneously with every intercostal injection. They obscure the quality of images further during spinal angiography together with respiratory artifacts. Therefore, we advocate deep sedation or general anesthesia during spinal angiographies of such patients to obtain better images.

Aneurysm Size is Smaller in Ruptured Aneurysms

Introduction:The prevalence of unruptured intracranial aneurysm in general population is around 2% and they are usually small. The prediction of exact rupture risk constitutes main object of ISUIA and risk of hemorrhage for aneurysms less than 7 mm in size was given as 0% within 5 years. There is a considerable data pointing that the majority of bleeding aneurysms are small in size. This conflict gave some researchers to conduct another interesting recent study the result of which showed that the aneurysms do not shrink before they rupture..

Study design:We conducted a clinical survey on patients with diagnosis of cerebral aneurysms. Patients admitted to our center between 2008-2010 were divided into two as ruptured (subarachnoid hemorrhage(SAH)) and unruptured.

Results-conclusion:53 of 87 aneurysms were ruptured. Hypertension was present in 30/53 of ruptured and 11/34 of unruptured group. Cigarette use was prominent in 11/53 of ruptured and 7/34 of unruptured group. Average aneurysm size was 6.68mm for ruptured and 8.54mm for unruptured cases. 13/53 aneurysms were £4mm in ruptured group and 1/34 in unruptured group. Aneurysms between 5-7mm constitute 21/53 of ruptured and 11/34 of unruptured group, between 8-10mm 16/53 and 14/34, ³10mm 4/53 and 9/34 of ruptured and unruptured group respectively. Distribution of ruptured aneurysms: ACA(13/53 cases), MCA(23/53 cases), ICA (17/53 cases) whereas distribution of unruptured aneurysms were: ACA(15/34 cases), MCA(16/34 cases), ICA (3/34 cases). 19 patients have WFNS score of 3 or worse. Patients with aneurysms smaller than 4mm constitute a significant group of ruptured aneurysms.