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   Table of Contents - Current issue
Coverpage
January-June 2020
Volume 8 | Issue 1
Page Nos. 1-70

Online since Thursday, October 1, 2020

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EDITORIAL  

From the editor's desk Highly accessed article p. 1
Jaspreet Singh Dil
DOI:10.4103/jcvs.jcvs_12_20  
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INVITED EDITORIAL Top

Cerebrovascular complications of COVID-19 p. 2
NK Venkataramana
DOI:10.4103/jcvs.jcvs_13_20  
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ORIGINAL ARTICLES Top

Long-term follow-up of large and giant intracranial aneurysms managed by endovascular techniques: Experience from a tertiary care neurosurgery institute in India Highly accessed article p. 5
Gautam Dutta, Divya Mahajan, Daljit Singh, Anita Jagetia, Hukum Singh, Arvind Kumar Srivastava
DOI:10.4103/jcvs.jcvs_18_20  
Introduction: We present our experience of managing large and giant intracranial aneurysms by conventional endovascular techniques. We discuss the long-term clinical and angiographic outcome of coiling of these aneurysms. Materials and Methods: We assessed a prospectively maintained database of patients with large and giant intracranial aneurysms managed by the endovascular techniques from January 2010 to December 2014. In 412 patients with 468 aneurysms managed during this period, 58 patients with 60 aneurysms were identified as either large or giant. Each patient's records were reviewed with regard to size, location and morphology of the aneurysms, Hunt and Hess grade, occlusion and coiling/recoiling rates. Clinical outcome was assessed using the modified Rankin Scale (mRS) score with score of 0–2 and 3–6 taken as favourable and unfavourable outcome, respectively. Results: Overall complication rate was 13.8%, and no intraprocedural death was seen. Angiographic and clinical follow-up was available for 49 patients with 49 aneurysms at an average of 28.7 months. Recanalisation rate was 26.5% in this study and of them 38.5% required retreatment. Favourable mRS score (0–2) was seen in 82.6% of ruptured aneurysms and 92.3% in unruptured aneurysms. Conclusion: Coiling of large and giant aneurysms is a safe and viable option with a very good clinical outcome in the long run. However, long-term clinical and angiographic follow-up is necessary as angiographic results immediately after the procedure may be deceptive.
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Arteriovenous fistulae of the neuraxis: An institutional experience p. 10
Sibhi Ganapathy, Swaroop Gopal, Paritosh Pandey
DOI:10.4103/jcvs.jcvs_4_20  
Introduction: Arteriovenous fistulae (AVF) are rare lesions. Patients typically present with slowly progressive myelopathy that is often mistaken for degenerative cervical or lumbar stenosis. Cranial presentations are even more innocuous ranging from seizures to tinnitus. The purpose of this study is to present a series of cases to aid in the assessment, diagnosis and treatment of this unusual pathology. Case Series: We present 11 cases of AVFs treated at our centre over an 4-year period. Seventy percent of patients were male. The mean age of presentation was 62.6 years. The most common lesion was a dural AVF emanating from the craniovertebral junction with single feeder. All patients underwent either microsurgical correction or endovascular embolization as the primary procedure. Eight patients showed improvement following treatment as graded by the Nurick system. Two patients failed to improve. None of the patients worsened. One patient had a cortical venous thrombosis after embolization that resolved well with anticoagulants. Conclusion: The successful treatment of AVF requires a detailed understanding of clinical presentation and imaging findings to allow for precise treatment. Owing to the rarity of the condition, clinicians must continue to share their experiences to advance our knowledge.
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Surgery for anterior communicating artery aneurysms: Lessons learnt p. 19
Jaspreet Singh Dil, Sumeet Narang, Harpreet Kaur, A Raja
DOI:10.4103/jcvs.jcvs_8_20  
Background: Anterior communicating artery (ACoA) aneurysms are one of the most common cerebral aneurysms encountered by neurovascular surgeons. They are surgically complex and sensitive and the scope for dialogue and exchange towards development are never over rated. Aims and objectives: The authors seek to discuss and emphasize on key lessons learnt from the observations from ACoA aneurysms treated by micro-vascular clipping. Materials and Methods: Hospital based retrospective observational study of 237 cases of ACoA aneurysms admitted to the study hospital and treated by micro-vascular clipping. Conclusion: The lessons learnt are broadly under the headings: exposure, intracranial pressure, gyrus rectus resection, vascular anatomy, perforator preservation, temporary clipping, damage control, lamina terminalis fenestration, team play, cognitive and morbidity assessment, and timing of surgery.
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Acute neurovascular care in the COVID era: Safety and resilience p. 24
Srinivasan Paramasivam, Harihara Sudan, Dinesh Babu, N V Vinoth Kumar
DOI:10.4103/jcvs.jcvs_5_20  
Introduction: Since the outbreak of the coronavirus pandemic, much has changed in the protocol for management of healthcare setups and patients presenting with any illness including neurological and neurosurgical emergencies. Patients are themselves deterred from visiting a hospital in an emergency, and healthcare workers require stringent precautions and plans to prevent the spread of the virus to themselves and others, without compromising on the care that is to be provided. Aims and objectives: To outline the importance of identifying neurological emergencies requiring urgent intervention even in the time of a pandemic, and methods to effectively manage patients without compromising on safety and infection prevention measures. Materials: Guidelines reviewed from existing literature and retrospective analysis of management protocol and care delivered in a neurovascular unit during the COVID-19 pandemic.. Conclusion: Acute neurovascular care should not be compromised upon even during a pandemic, but neither should the safety of healthcare workers. Safety guidelines and protocols require strict adherence.
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REVIEW ARTICLES Top

The association of bacterial infection with intracranial aneurysm disease p. 29
Mikko Pyysalo, Tanja Pessi, Joona Hallikainen, Juhana Frösen
DOI:10.4103/jcvs.jcvs_20_20  
The human body abounds in micro-organisms that maintain the vital balance of the internal ecosystem. Though it is well known that several benefit the human body while others are linked to disease, how the microbiota affects the pathology of intra-cranial aneurysms is an interesting arena that still requires exploration. Studies have suggested possible association between the excess of bacteria, such as those causing gingivitis, as well the deficit of bacteria, such as loss of gut flora due to antibiotics, to intracranial aneurysms and their subsequent behavior. The authors review existing literature on the subject and outline the scope for further research on the subject.
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Management strategies for cerebral arteriovenous malformation - An institutional experience p. 32
Kasinathan Sudhakar, Abderrahmane Cheikh, Yashiro Yamada, Takao Teranishi, Tsukasa Kawase, Yoko Kato
DOI:10.4103/jcvs.jcvs_6_20  
Background: Cerebral Arteriovenous Malformation represent a particularly challenging subset of lesions, given their overall low incidence and the high frequency with which some form of multimodality monitoring may be required for complete obliteration. Materials and Methods: We report retrospective analysis of 9 cases with unruptured cerebral arteriovenous malformation who got admitted in the Banbuntane Hotokokai Hospital, Fujita Health University, and Nagoya, Japan .from the year 2014 to 2017.surgical treatment was appropriate craniotomy and resection based on the location of the arteriovenous malformation with multimodality monitoring with Dual Image Video Angiography, Motor Evoked Potential, and FLOW 800. We studied the following factors: Sex, Age, Arteriovenous Malformation size, Location, occurrence of Intracranial Hemorrhage, Seizure type, Duration of Seizure history, Treatment modality, and Arteriovenous Malformation obliteration. We tested for statistical associations between these factors and seizure presentation and outcomes with Clinical follow-up. Outcome was compared with modified Rankin Scale Results: Out of 9 cases operated for intracranial arteriovenous malformation 5 patients were female and 4 were male. Age [ Mean 39.4 + 16.7] of the patients ranged from 20 to 66 , 5 patients were 25 - 40 and 2 were > 65 and < 25 each.6 patients were Spetzler - Martin Grade 2 ,1 patient was Spetzler - Martin Grade 4,Grade 3 and Grade 5. 3 patients were draining into superficial venous system and 2 patient were asymptomatic and incidentally diagnosed during screening procedure. There is no Mortality in this study.1 patient underwent Gamma Knife stereotactic radiosurgery. Conclusion: The increasing use of advance imaging techniques will increase the incidence of asymptomatic arteriovenous malformations. Non-ruptured arteriovenous malformation Spetzler Martin Grade 1 or Spetzler Martin Grade 2 have a good outcome for microsurgery [modified Rankin Scale and complete obliteration and there is better outcome with microsurgery.
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A giant anterior inferior cerebellar artery aneurysm in the guise of a cerebellopontine angle tumour: A case report and review of literature p. 40
Sumeet Narang, Ganesh Kumar Manoharan, Jaspreet Singh Dil, A Raja
DOI:10.4103/jcvs.jcvs_3_20  
Giant intracranial aneurysms, and aneurysms in the posterior circulation of the brain, are each rare entity when considered separately. It is more uncommon to find both coexisting. Aneurysms usually present when they rupture and haemorrhage, and for one to present with non-haemorrhagic symptoms, is rarer. The authors present an unusual case of a giant aneurysm of the anterior inferior cerebellar artery masquerading as a cerebellopontine angle tumour with cerebellar signs. The patient was treated with a retromastoid suboccipital craniectomy and microsurgical clipping and excision, with excellent results. A PubMed search of existing literature was carried out and reviewed and has been discussed.
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Middle meningeal artery embolization in the management of chronic subdural haematoma: A case report and review of literature p. 45
Srinivasan Paramasivam, Harihara Sudan
DOI:10.4103/jcvs.jcvs_7_20  
Chronic subdural hematoma (cSDH) is a common cranial neurosurgical condition with morbidity and mortality ranging from 2% to 5%. Conventional treatment includes conservative and surgical evacuation. Minimally invasive middle meningeal artery (MMA) embolisation is emerging as a potential treatment option. We report our case successfully managed by MMA embolization and review the literature. cSDH development and progression is related to the cycle of chronic inflammation and angiogenesis following the original hemorrhage due to trivial trauma. Due to growth factor, stimulation-initiating angiogenesis leading to growth of leaky blood vessels causing microhaemorrhages resulting in the progressive enlargement of subdural collection as the physiologic absorption capability is outpaced by the rate of collection. Strategies for the management of cSDH are aimed at interrupting the vicious cycle of its development and tilting the balance toward reabsorption of haemorrhage. Conservative management, medical treatment and surgical treatments are conventional treatment options with surgical evacuation considered as the gold standard option. However, challenges include recurrence and reversal of anti-platelets and anti-coagulants and its associated risk of ischaemic complications. cSDH being a pathology of meninges deriving blood the dura causing microhaemorrhages, it is prudent to seal off the vessels to tilt the balance towards resorption. MMA embolisation as a treatment option has been used with significant published data. It may be used as a stand-alone therapy in minimally symptomatic patients. Technical success rate is high both with polyviny alcohol and liquid embolic agents. Recurrence rate is consistently low in spite of significant patients having antiplatelets and anti-coagulants on board. It eliminates the ischemic complication due to stoppage of antiplatelets and anticoagulants. MMA embolization is also emerging as an adjunct to surgically evacuated cSDH that is considered high risk for recurrence.
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‘Mickey mouse head aneurysms’ – Kissing aneurysms of the distal anterior cerebral artery: A case report and review of literature p. 50
Sachin Chemate, K Chandrasekar, C V Shankar Ganesh, Chetana Govindaraju, M Balamurugan
DOI:10.4103/jcvs.jcvs_9_20  
When two or more adjacent intracranial aneurysms, arise from the same or different arteries, with separate origins and partially adherent walls, they are referred to as 'kissing aneurysms'. These are rare aneurysms. Among different locations of kissing aneurysms reported in the literature, kissing aneurysms of bilateral distal anterior cerebral arteries (DACAs), two different aneurysms situated symmetrically on opposite DACA are very rare. A 69-year-old woman with multiple comorbidities was admitted with anterior interhemispheric bleed. Magnetic resonance angiography and digital subtraction angiography (DSA) showed ruptured bilateral DACA aneurysms in mirror position to each other forming a Mickey mouse head appearance. The patient was managed surgically by craniotomy and clipping of both aneurysms. Kissing aneurysms of bilateral DACA aneurysms are very rare. DSA is essential to be useful for pre-operative diagnosis and planning. The basic principle of securing the parent artery proximally and clipping the neck after meticulous dissection should be followed.
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‘Mickey mouse head aneurysms’ – Kissing aneurysms of the distal anterior cerebral artery: A case report and review of literature p. 50
Sachin Chemate, K Chandrasekar, C V Shankar Ganesh, Chetana Govindaraju, M Balamurugan
DOI:10.4103/jcvs.jcvs_9_20  
When two or more adjacent intracranial aneurysms, arise from the same or different arteries, with separate origins and partially adherent walls, they are referred to as 'kissing aneurysms'. These are rare aneurysms. Among different locations of kissing aneurysms reported in the literature, kissing aneurysms of bilateral distal anterior cerebral arteries (DACAs), two different aneurysms situated symmetrically on opposite DACA are very rare. A 69-year-old woman with multiple comorbidities was admitted with anterior interhemispheric bleed. Magnetic resonance angiography and digital subtraction angiography (DSA) showed ruptured bilateral DACA aneurysms in mirror position to each other forming a Mickey mouse head appearance. The patient was managed surgically by craniotomy and clipping of both aneurysms. Kissing aneurysms of bilateral DACA aneurysms are very rare. DSA is essential to be useful for pre-operative diagnosis and planning. The basic principle of securing the parent artery proximally and clipping the neck after meticulous dissection should be followed.
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EXPERT COMMENTARY Top

Musings about surgery for intra-cranial arterio-venous malformations p. 55
A Raja
DOI:10.4103/jcvs.jcvs_15_20  
Introduction: Neurosurgery has evolved with the times and as with all things with a rich history, there is much to be learnt from experience and much to be re-iterated in the present. Aims and objectives: To reinforce the key basic points in AVM surgery, for the benefit of all neurosurgeons operating on AVMs. Materials: Based on personal experience from over he author recollects integral points and principles of the surgical management of intra-cranial arterio-venous malformations (AVMs), highlighting the basic elements such as planning, exposure, equipment use, intra-operative identification, and safe approach, execution and hemostasis. Conclusion: The success of AVM surgery depends highly on methodical planning and precise execution.
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CASE REPORTS Top

Bilateral subdural haematomas secondary to spontaneous intracranial hypotension-A dilemma in management p. 58
Girish R Menon, Sandesh Onkarappa, RT Sanjeev, Saurabh Beedkar, Rajesh P Nair
DOI:10.4103/jcvs.jcvs_19_20  
We present a case of bilateral subdural haematomas secondary to spontaneous intracranial hypotension. The diagnostic features and the management issues are discussed.
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Pitfalls in diagnosis: Acute hypodense posterior fossa subarachnoid haemorrhage on computed tomography scan – An unusual entity p. 61
Gautam Dutta, Daljit Singh, Anita Jagetia, Arvind Kumar Srivastava
DOI:10.4103/jcvs.jcvs_22_20  
Acute subarachnoid haemorrhage (SAH) generally appears hyperdense on computed tomography (CT) scan. However, in some rare circumstances, it may appear hypodense which can pose a diagnostic problem and compromise patient care. We report the case of a 32-year-old man who had presented with acute posterior fossa SAH. A cranial CT scan revealed a hypodense posterior fossa lesion mimicking cerebellar infarct. Surgical intervention confirmed that it was an acute bleed in the subarachnoid space. Treating physicians should be cautious in interpreting CT images as that can sometimes be misleading leading to misdiagnosis and incorrect treatment choices.
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Stent-assisted aneurysm coiling of a complex A1–A2 aneurysm: A technically demanding but useful procedure in complex intracranial aneurysms p. 64
Swaroop Gopal, Sibhi Ganapathy
DOI:10.4103/jcvs.jcvs_2_20  
Intracranial aneurysms are a subject of controversy. Anterior circulation aneurysms are usually considered surgical territory, yet endovascular prowess can affect good results with minimal morbidity and comparable long-term results. We present a complex anterior cerebral artery aneurysm that would require either a bypass or a complex vessel reconstructive procedure. Instead, we proceeded to perform a stent-assisted coiling trapping the coils inside the aneurysm through a covered stent, thereby ensuring vascular continuity and complete aneurysm control. A brief review of the literature is also added to put this report in perspective.
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A rare case of internal carotid artery trifurcation and an aneurysm associated with it p. 68
Harshal Agrawal, Joy Varghese, M Balamurugan
DOI:10.4103/jcvs.jcvs_21_20  
Existing literature is devoid of data on true trifurcations of the internal carotid artery (ICA). The authors present a rare case of trifurcation of the ICA, discovered during the evaluation of a patient with subarachnoid haemorrhage, and discuss the surgical implications of the anomaly.
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