- Email: [email protected]
Microsurgical glue embolectomy of the middle cerebral artery following embolization of a maxillofacial arteriovenous malformation
1733
Case Reports / Journal of Clinical Neuroscience 18 (2011) 1733–1736
Microsurgical glue embolectomy of the middle cerebral artery following embolization of a maxillofacial arteriovenous malformation George M. Ibrahim ⇑, Amal Abou-Hamden, Jai Jai Shiva Shankar, Aditya Bharatha, Karel ter Brugge, Michael Tymianski Division of Neurosurgery and Interventional Neuroradiology, Toronto Western Hospital, 399 Bathurst Street, University of Toronto, Ontario, Canada M5G 1X8
a r t i c l e
i n f o
Article history: Received 1 April 2011 Accepted 5 April 2011
Keywords: AVM Complications Embolectomy Glue Maxillofacial arteriovenous malformation Middle cerebral artery
a b s t r a c t With increasing application of endovascular therapies worldwide, the management of procedure-related complications has become increasingly important. Of particular interest is the surgical management of complications refractory to endovascular recanalization. Here, we present the unique surgical management of an inadvertent intracranial glue embolus following urgent glue embolization of a maxillofacial arteriovenous malformation. This is the first report to document management of this complication. An arteriotomy was performed and the glue, despite being adhered to the vessel intima, was retrieved in its entirety from the middle cerebral artery (MCA). Following the procedure, the patient developed a new thrombus at the previous glue site, likely related to endothelial injury. With post-operative heparin therapy, the patient recovered to baseline neurological state. This report demonstrates that microsurgical arteriotomy and glue embolectomy of the MCA is feasible, safe and may be useful in the management of complications of inadvertent intracranial glue embolization. Ó 2011 Elsevier Ltd. All rights reserved.
1. Introduction Maxillofacial arteriovenous malformations (AVM) are uncommon and may be fatal in the setting of massive oral hemorrhage.1 Although they remain a therapeutic challenge, cure of these lesions with endovascular embolization has been reported. The complications of glue embolization for the treatment of AVM are well-described and include transient and permanent neurological deficits.2 With increasing use of endovascular therapies, management of procedure-related complications is increasingly important. Surgical management of intracranial occlusions refractory to endovascular retrieval is controversial and rarely discussed.3 Here we present a patient with a maxillofacial AVM presenting with massive oral hemorrhage and treated with urgent embolization. This was complicated by glue embolus into the middle cerebral artery (MCA), resulting in ischemia and neurological deficit. An MCA embolectomy was successfully undertaken with clinical improvement. To our knowledge, this is the first report to describe the current management of this complication. 2. Case report A 33-year-old man presented with a left-sided extensive maxillofacial AVM. He had previously undergone several treatments elsewhere. These included injection of alcohol into the AVM, which had resulted in significant right hemiparesis, with a baseline of movement against partial resistance. The patient presented to the emergency department with oral hemorrhage. Emergency embolization of the complex left maxillofacial AVM was therefore carried out. 2.1. Endovascular procedure Under general anaesthetic, the right femoral artery was punctured and a femoral sheath placed. Using a 5-French guiding catheter, the left common carotid artery was selectively catheterized ⇑ Corresponding author. Tel.: +1 416 660 0270; fax: +1 416 603 5298. E-mail address: [email protected] (G.M. Ibrahim).
(Fig. 1A, C). Angiography showed that the AVM was filling from the left ascending pharyngeal artery through multiple collaterals. There was also supply from the left internal carotid artery through collaterals from the petrosal branch segment as well as the left ophthalmic artery. An aneurysm was discovered arising from the left ascending pharyngeal artery. Presuming this was the site of hemorrhage, embolization of the AVM via the left ascending pharyngeal artery was attempted. Using a micro-catheter and micro-guidewire, the left ascending pharyngeal artery was selectively catheterized. A 40% glue mixture was used to embolize the AVM. During the glue injection, a segment of the AVM along with the pseudo-aneurysm filled up with glue. A small lobule of glue adherent to the tip of the microcatheter was dislodged by the tip of the guiding catheter when the micro-catheter was retracted. Control angiography showed occlusion of the left internal carotid artery bifurcation (Fig. 1B, D). Angiography to assess collaterals from the right-sided circulation revealed minimal filling of the left anterior cerebral artery (ACA) and no filling of the left MCA. On repeat angiography of the left internal carotid artery 5 minutes later, the glue had migrated distally into the M1 segment of the left MCA. At this point, endovascular retrieval of the glue embolus was attempted using an alligator device and subsequently a snare without success. At the end of the manipulations, the glue was intentionally pushed further distally towards the left MCA bifurcation in order to facilitate flow towards the M1 perforators. At this point, the patient was awoken from anaesthesia and clinical examination was performed. He was able to move his right upper and lower extremities against gravity. Embolization of the maxillofacial AVM was continued as the patient was actively bleeding from the AVM. The right facial and right lingual artery branches to the AVM were embolized with 500–1000 micron PVA particle mixture. At the end of the procedure, there was significant decrease in the flow through the AVM. Final angiography revealed residual filling of the AVM through multiple collaterals from the right ascending palatine artery, which was reconstituting the left external carotid branches. A total of 12,000 units of heparin were administered and this was not reversed at the end of the procedure.
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Case Reports / Journal of Clinical Neuroscience 18 (2011) 1733–1736
microsurgical technique. The MCA trunk and distal M2 branches were cross-clamped and an incision was made in the M1 bifurcation. The embolus was underneath and was removed piecemeal (Fig. 3). Heparinized saline was irrigated into the vessel. To close the arteriotomy, 10-0 and 9-0 nylon sutures were used and the cross-clamps were removed. Meticulous hemostasis was ensured followed by routine closure.
2.4. Post-operative course Following the procedure, the patient could only move his right side when gravity was eliminated. Imaging revealed an acute insitu thrombus at the site of the previous glue embolus. He was therefore started on heparin 4 hours post-operatively, which continued for another 48 hours. He regained strength in his right upper and lower extremities over the subsequent days nearing his pre-embolization baseline of movement against partial resistance. He was discharged home with family 2 weeks following admission.
3. Discussion
Fig. 1. Catheter angiography of the left common carotid artery (A) pre- and (B) post-embolization antero–posterior views; and (C) pre- and (D) post-embolization lateral views showing the extensive maxillofacial arteriovenous malformation (AVM). Compared to baseline, post-embolization images reveal occlusion of the internal carotid artery bifurcation. There is also decreased filling of the AVM in keeping with the partial palliative embolization.
2.2. Subsequent management Following the procedure, the patient was taken for CT-angiography (Fig. 2) and MRI, which revealed a small focus of restricted diffusion within the left posterior limb of the internal capsule consistent with acute ischemia with a large old infarct in the left MCA territory. He was admitted to the intensive care unit and with induced hypertension, he continued to move his right upper and lower extremities against gravity. Twelve hours from the time of angiography, the patient was found to have right hemiplegia with normalization of the blood pressure. He was therefore brought to the operating room for an MCA embolectomy.
2.3. Operative procedure Following a standard pterional craniotomy, the Sylvian fissure was split down to the middle cerebral artery bifurcation using
To our knowledge, this is the first report of a hemorrhagic maxillofacial AVM treated with palliative partial embolization, which was complicated by glue embolus into the cranial circulation. We demonstrate that MCA embolectomy is feasible and effective at retrieving these emboli, which may not be amenable to endovascular retrieval. Our case is of special interest as glue, being an adhesive agent, is thought to firmly adhere to the wall of the artery. We demonstrate that this adhesive embolic material can be removed by microsurgical embolectomy. Following embolectomy, the patient developed a thrombus at the site of the evacuated glue embolus. While the reason for this is uncertain, it may relate to intimal damage caused by the surgical procedure, or the endovascular attempt at embolus retrieval. With heparin therapy, the patient improved clinically post-operatively to his neurological baseline. Anticoagulation with heparin infusion may well have contributed to this improvement whereas the use of heparin in the setting of a glue embolus would not have been helpful. Open embolectomy for acute MCA occlusion has been described.4,5 Meyer and colleagues5 propose that the best predictor of outcome is the presence of collateral flow on preoperative angiograms. In their series, most emboli were of cardiac or carotid origin and flow was restored in 75% of patients, but only 10% had an excellent outcome. Kakinuma and colleagues6 developed a standardized grading system for assessing collateral flow on cerebral angiography following MCA occlusion. This is based on the time required for conduction (maximal conduction time, MCT) of the contrast media to the insular portion of the MCA from the ACA via leptomeningeal collateral circulation. In the case presented, conduction to the insular portion of the occluded MCA was present in the late arterial phase of the angiogram. This group found that the MCT correlated with infarct size and patient prognosis. With higher grades of MCT, suggestive of poorer collaterals, the authors advocated acute microsurgical revascularization. The current patient’s collateral flow from the ACA was likely a factor contributing to his neurological improvement with induced hypertension and subsequent hemiplegia with normalization of the blood pressure. Occlusion of M1 was found by another group to be an independent risk factor of poor outcome following open embolectomy potentially because of involvement of the lenticulostriate arteries, which are terminal vessels with poor collaterals.4
Case Reports / Journal of Clinical Neuroscience 18 (2011) 1733–1736
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Fig. 2. Axial CT scan (A) pre- and (B) post-contrast showing hyperdensity within the left Sylvian fissure representing embolic glue material within the left middle cerebral artery territory.
Fig. 3. Intraoperative photographs following left pterional craniotomy showing: (A) exposure of the M1–M2 bifurcation following splitting of the left Sylvian fissure; (B) following cross-clamping of the middle cerebral artery trunk and M2 branches, an arteriotomy was fashioned at the bifurcation. Note glue material is found lodged at the bifurcation of the vessels; (C) gentle traction is used to elevate the glue embolus from the vessel wall; and (D) closure of the arteriotomy, removal of clips and reconstitution of flow. (This figure is available in colour at www.sciencedirect.com).
4. Conclusion We present the first report of microsurgical embolectomy following an inadvertent glue embolus into the MCA. Following the procedure, the patient developed an in-situ vessel thrombus, but improved clinically with anticoagulation. Embolectomy is a feasible option for the management of clinically significant embolic material complicating interventional procedures. This is an important tool in the clinician’s armamentarium as the number of endo-
vascular procedures increase, and novel approaches to procedurerelated complications become necessary. References 1. Rodesch G, Soupre V, Vazquez MP, et al. Arteriovenous malformations of the dental arcades. The place of endovascular therapy: results in 12 cases are presented. J Craniomaxillofac Surg 1998;26:306–13. 2. Haw CS, ter Brugge K, Willinsky R, et al. Complications of embolization of arteriovenous malformations of the brain. J Neurosurg 2006;104:226–32.
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Case Reports / Journal of Clinical Neuroscience 18 (2011) 1736–1738
3. Drake B, Redekop G. Middle cerebral artery embolectomy after failed mechanical clot removal. Can J Neurol Sci 2010;37:408–11. 4. Horiuchi T, Nitta J, Ogiwara T, et al. Outcome predictors of open embolectomy in middle cerebral artery occlusion. Neurol Res 2009;31:892–4. 5. Meyer FB, Piepgras DG, Sundt Jr TM, et al. Emergency embolectomy for acute occlusion of the middle cerebral artery. J Neurosurg 1985;62:639–47.
6. Kakinuma K, Ezuka I, Takai N, et al. The simple indicator for revascularization of acute middle cerebral artery occlusion using angiogram and ultra-early embolectomy. Surg Neurol 1999;51:332–41.
doi:10.1016/j.jocn.2011.04.020
Bioresorbable anterior cervical plate device for multi-level degenerative disc disease: Case report with 8-year follow-up Robert G. Whitmore ⇑, Elana S. Tykocinski, Matthew R. Sanborn, William C. Welch Department of Neurosurgery, Hospital of the University of Pennsylvania, 3400 Spruce Street, 3 Silverstein, Philadelphia, PA 19104, USA
a r t i c l e
i n f o
Article history: Received 8 April 2011 Accepted 23 April 2011
Keywords: Anterior cervical decompression and fusion Bioresorbable anterior cervical plate Cervical spondylotic myelopathy
a b s t r a c t Anterior cervical decompression and fusion is most successful when bone graft is combined with stabilizing instrumentation. The use of bioresorbable anterior cervical plates has been reported recently instead of the traditional titanium plate. We report a novel application of a bioresorbable plate in the management of a 69-year-old Caucasian female with multi-level, long-standing cervical spondylotic myelopathy. The patient previously had a failed anterior fusion with allograft and titanium instrumentation, and due to worsening symptoms, she underwent a revision anterior fusion using a bioresorbable cervical plate and a fibular allograft, in conjunction with posterior fusion with metal instrumentation. Successful fusion is visualized on CT imaging at 8-year follow-up. To our knowledge this is the first report of long-term follow-up showing successful fusion with this technology. Ó 2011 Elsevier Ltd. All rights reserved.
1. Introduction
2. Case report
Anterior cervical decompression and fusion (ACDF) is a commonly performed procedure in the treatment of spondylotic myelopathy in the cervical spine.1 While titanium instrumentation has traditionally been employed for this purpose, there have recently been reports of utilizing bioresorbable implants.2–4 The impermanence of the bioresorbable material provides an advantage to titanium. It offers a similar initial stabilizing scaffold until fusion occurs, but it degrades over time, thus obviating the long-term complications associated with permanent metal implants, including implant migration,5,6 compression of anterior soft tissue7 and fusion stress shielding.8 In addition, for patients undergoing revision surgery who will likely require follow up magnetic resonance imaging, a bioresorbable plate offers less artifact and scatter than metal plates.9 Resorbable mesh has been applied as an anterior cervical graft containment device in the surgical management of one- and twolevel disc disease.10–12 Preliminary results from a number of small trials suggest that this technology for anterior fusion may be as effective as traditional titanium plating systems in single-level disease.2,4 However, to our knowledge, bioresorbable anterior cervical plates have not previously been used in the management of spondylotic myelopathy. Here, we report a novel application of a bioresorbable anterior cervical plate for the management of recurrent multi-level cervical spondylotic myelopathy. We show complete resorption of the plate and stable fusion at 8 years follow-up.
We report a 69 year-old female patient with a history of cervical spondylotic myelopathy. Eight months prior to presentation, she underwent a C4 and C5 corpectomy and (C3–6) anterior cervical fusion with a fibular strut allograft and Orion plate instrumentation. Over the next 4 months, the patient deteriorated with increasing upper and lower extremity weakness. Although initial imaging was normal, a MRI performed at this time showed anterior dislodgement of the superior portion of the fibula strut graft at the level of C3. The decision was made to replace the dislodged allograft using a bioresorbable plate and perform decompression and fusion posteriorly. The patient was taken to the operating room and an otolargyngologist assisted with anterior reexposure of vertebral bodies C2 through C7. A new fibular strut allograft was placed in the corpectomy defect. Autograft bone was harvested from the left iliac crest and used to fill the center of the allograft and to fill in space surrounding the strut. The arthrodesis was supplemented with a Macropore Bioresorbable plating system (Medtronic, Minneapolis, MN, USA) and 12 mm screws. The patient was rolled into the prone position. The prior cervical decompression was expanded and instrumented fusion of C3–7 was performed using titanium Axis plating system instrumentation and lateral mass screws. Postoperatively, the patient did well and was sent home in a cervical collar. Her symptoms improved. Routine radiographs performed at 6 weeks demonstrated stable position of the graft and plates. Eight years later, the patient sustained a traumatic fall. A non-contrast CT of the cervical spine was obtained to rule out traumatic injury. Incidentally, the CT
⇑ Corresponding author. Fax: +1 215 349 5534. E-mail address: [email protected] (R.G. Whitmore).
Case Reports / Journal of Clinical Neuroscience 18 (2011) 1733–1736
Microsurgical glue embolectomy of the middle cerebral artery following embolization of a maxillofacial arteriovenous malformation George M. Ibrahim ⇑, Amal Abou-Hamden, Jai Jai Shiva Shankar, Aditya Bharatha, Karel ter Brugge, Michael Tymianski Division of Neurosurgery and Interventional Neuroradiology, Toronto Western Hospital, 399 Bathurst Street, University of Toronto, Ontario, Canada M5G 1X8
a r t i c l e
i n f o
Article history: Received 1 April 2011 Accepted 5 April 2011
Keywords: AVM Complications Embolectomy Glue Maxillofacial arteriovenous malformation Middle cerebral artery
a b s t r a c t With increasing application of endovascular therapies worldwide, the management of procedure-related complications has become increasingly important. Of particular interest is the surgical management of complications refractory to endovascular recanalization. Here, we present the unique surgical management of an inadvertent intracranial glue embolus following urgent glue embolization of a maxillofacial arteriovenous malformation. This is the first report to document management of this complication. An arteriotomy was performed and the glue, despite being adhered to the vessel intima, was retrieved in its entirety from the middle cerebral artery (MCA). Following the procedure, the patient developed a new thrombus at the previous glue site, likely related to endothelial injury. With post-operative heparin therapy, the patient recovered to baseline neurological state. This report demonstrates that microsurgical arteriotomy and glue embolectomy of the MCA is feasible, safe and may be useful in the management of complications of inadvertent intracranial glue embolization. Ó 2011 Elsevier Ltd. All rights reserved.
1. Introduction Maxillofacial arteriovenous malformations (AVM) are uncommon and may be fatal in the setting of massive oral hemorrhage.1 Although they remain a therapeutic challenge, cure of these lesions with endovascular embolization has been reported. The complications of glue embolization for the treatment of AVM are well-described and include transient and permanent neurological deficits.2 With increasing use of endovascular therapies, management of procedure-related complications is increasingly important. Surgical management of intracranial occlusions refractory to endovascular retrieval is controversial and rarely discussed.3 Here we present a patient with a maxillofacial AVM presenting with massive oral hemorrhage and treated with urgent embolization. This was complicated by glue embolus into the middle cerebral artery (MCA), resulting in ischemia and neurological deficit. An MCA embolectomy was successfully undertaken with clinical improvement. To our knowledge, this is the first report to describe the current management of this complication. 2. Case report A 33-year-old man presented with a left-sided extensive maxillofacial AVM. He had previously undergone several treatments elsewhere. These included injection of alcohol into the AVM, which had resulted in significant right hemiparesis, with a baseline of movement against partial resistance. The patient presented to the emergency department with oral hemorrhage. Emergency embolization of the complex left maxillofacial AVM was therefore carried out. 2.1. Endovascular procedure Under general anaesthetic, the right femoral artery was punctured and a femoral sheath placed. Using a 5-French guiding catheter, the left common carotid artery was selectively catheterized ⇑ Corresponding author. Tel.: +1 416 660 0270; fax: +1 416 603 5298. E-mail address: [email protected] (G.M. Ibrahim).
(Fig. 1A, C). Angiography showed that the AVM was filling from the left ascending pharyngeal artery through multiple collaterals. There was also supply from the left internal carotid artery through collaterals from the petrosal branch segment as well as the left ophthalmic artery. An aneurysm was discovered arising from the left ascending pharyngeal artery. Presuming this was the site of hemorrhage, embolization of the AVM via the left ascending pharyngeal artery was attempted. Using a micro-catheter and micro-guidewire, the left ascending pharyngeal artery was selectively catheterized. A 40% glue mixture was used to embolize the AVM. During the glue injection, a segment of the AVM along with the pseudo-aneurysm filled up with glue. A small lobule of glue adherent to the tip of the microcatheter was dislodged by the tip of the guiding catheter when the micro-catheter was retracted. Control angiography showed occlusion of the left internal carotid artery bifurcation (Fig. 1B, D). Angiography to assess collaterals from the right-sided circulation revealed minimal filling of the left anterior cerebral artery (ACA) and no filling of the left MCA. On repeat angiography of the left internal carotid artery 5 minutes later, the glue had migrated distally into the M1 segment of the left MCA. At this point, endovascular retrieval of the glue embolus was attempted using an alligator device and subsequently a snare without success. At the end of the manipulations, the glue was intentionally pushed further distally towards the left MCA bifurcation in order to facilitate flow towards the M1 perforators. At this point, the patient was awoken from anaesthesia and clinical examination was performed. He was able to move his right upper and lower extremities against gravity. Embolization of the maxillofacial AVM was continued as the patient was actively bleeding from the AVM. The right facial and right lingual artery branches to the AVM were embolized with 500–1000 micron PVA particle mixture. At the end of the procedure, there was significant decrease in the flow through the AVM. Final angiography revealed residual filling of the AVM through multiple collaterals from the right ascending palatine artery, which was reconstituting the left external carotid branches. A total of 12,000 units of heparin were administered and this was not reversed at the end of the procedure.
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Case Reports / Journal of Clinical Neuroscience 18 (2011) 1733–1736
microsurgical technique. The MCA trunk and distal M2 branches were cross-clamped and an incision was made in the M1 bifurcation. The embolus was underneath and was removed piecemeal (Fig. 3). Heparinized saline was irrigated into the vessel. To close the arteriotomy, 10-0 and 9-0 nylon sutures were used and the cross-clamps were removed. Meticulous hemostasis was ensured followed by routine closure.
2.4. Post-operative course Following the procedure, the patient could only move his right side when gravity was eliminated. Imaging revealed an acute insitu thrombus at the site of the previous glue embolus. He was therefore started on heparin 4 hours post-operatively, which continued for another 48 hours. He regained strength in his right upper and lower extremities over the subsequent days nearing his pre-embolization baseline of movement against partial resistance. He was discharged home with family 2 weeks following admission.
3. Discussion
Fig. 1. Catheter angiography of the left common carotid artery (A) pre- and (B) post-embolization antero–posterior views; and (C) pre- and (D) post-embolization lateral views showing the extensive maxillofacial arteriovenous malformation (AVM). Compared to baseline, post-embolization images reveal occlusion of the internal carotid artery bifurcation. There is also decreased filling of the AVM in keeping with the partial palliative embolization.
2.2. Subsequent management Following the procedure, the patient was taken for CT-angiography (Fig. 2) and MRI, which revealed a small focus of restricted diffusion within the left posterior limb of the internal capsule consistent with acute ischemia with a large old infarct in the left MCA territory. He was admitted to the intensive care unit and with induced hypertension, he continued to move his right upper and lower extremities against gravity. Twelve hours from the time of angiography, the patient was found to have right hemiplegia with normalization of the blood pressure. He was therefore brought to the operating room for an MCA embolectomy.
2.3. Operative procedure Following a standard pterional craniotomy, the Sylvian fissure was split down to the middle cerebral artery bifurcation using
To our knowledge, this is the first report of a hemorrhagic maxillofacial AVM treated with palliative partial embolization, which was complicated by glue embolus into the cranial circulation. We demonstrate that MCA embolectomy is feasible and effective at retrieving these emboli, which may not be amenable to endovascular retrieval. Our case is of special interest as glue, being an adhesive agent, is thought to firmly adhere to the wall of the artery. We demonstrate that this adhesive embolic material can be removed by microsurgical embolectomy. Following embolectomy, the patient developed a thrombus at the site of the evacuated glue embolus. While the reason for this is uncertain, it may relate to intimal damage caused by the surgical procedure, or the endovascular attempt at embolus retrieval. With heparin therapy, the patient improved clinically post-operatively to his neurological baseline. Anticoagulation with heparin infusion may well have contributed to this improvement whereas the use of heparin in the setting of a glue embolus would not have been helpful. Open embolectomy for acute MCA occlusion has been described.4,5 Meyer and colleagues5 propose that the best predictor of outcome is the presence of collateral flow on preoperative angiograms. In their series, most emboli were of cardiac or carotid origin and flow was restored in 75% of patients, but only 10% had an excellent outcome. Kakinuma and colleagues6 developed a standardized grading system for assessing collateral flow on cerebral angiography following MCA occlusion. This is based on the time required for conduction (maximal conduction time, MCT) of the contrast media to the insular portion of the MCA from the ACA via leptomeningeal collateral circulation. In the case presented, conduction to the insular portion of the occluded MCA was present in the late arterial phase of the angiogram. This group found that the MCT correlated with infarct size and patient prognosis. With higher grades of MCT, suggestive of poorer collaterals, the authors advocated acute microsurgical revascularization. The current patient’s collateral flow from the ACA was likely a factor contributing to his neurological improvement with induced hypertension and subsequent hemiplegia with normalization of the blood pressure. Occlusion of M1 was found by another group to be an independent risk factor of poor outcome following open embolectomy potentially because of involvement of the lenticulostriate arteries, which are terminal vessels with poor collaterals.4
Case Reports / Journal of Clinical Neuroscience 18 (2011) 1733–1736
1735
Fig. 2. Axial CT scan (A) pre- and (B) post-contrast showing hyperdensity within the left Sylvian fissure representing embolic glue material within the left middle cerebral artery territory.
Fig. 3. Intraoperative photographs following left pterional craniotomy showing: (A) exposure of the M1–M2 bifurcation following splitting of the left Sylvian fissure; (B) following cross-clamping of the middle cerebral artery trunk and M2 branches, an arteriotomy was fashioned at the bifurcation. Note glue material is found lodged at the bifurcation of the vessels; (C) gentle traction is used to elevate the glue embolus from the vessel wall; and (D) closure of the arteriotomy, removal of clips and reconstitution of flow. (This figure is available in colour at www.sciencedirect.com).
4. Conclusion We present the first report of microsurgical embolectomy following an inadvertent glue embolus into the MCA. Following the procedure, the patient developed an in-situ vessel thrombus, but improved clinically with anticoagulation. Embolectomy is a feasible option for the management of clinically significant embolic material complicating interventional procedures. This is an important tool in the clinician’s armamentarium as the number of endo-
vascular procedures increase, and novel approaches to procedurerelated complications become necessary. References 1. Rodesch G, Soupre V, Vazquez MP, et al. Arteriovenous malformations of the dental arcades. The place of endovascular therapy: results in 12 cases are presented. J Craniomaxillofac Surg 1998;26:306–13. 2. Haw CS, ter Brugge K, Willinsky R, et al. Complications of embolization of arteriovenous malformations of the brain. J Neurosurg 2006;104:226–32.
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Case Reports / Journal of Clinical Neuroscience 18 (2011) 1736–1738
3. Drake B, Redekop G. Middle cerebral artery embolectomy after failed mechanical clot removal. Can J Neurol Sci 2010;37:408–11. 4. Horiuchi T, Nitta J, Ogiwara T, et al. Outcome predictors of open embolectomy in middle cerebral artery occlusion. Neurol Res 2009;31:892–4. 5. Meyer FB, Piepgras DG, Sundt Jr TM, et al. Emergency embolectomy for acute occlusion of the middle cerebral artery. J Neurosurg 1985;62:639–47.
6. Kakinuma K, Ezuka I, Takai N, et al. The simple indicator for revascularization of acute middle cerebral artery occlusion using angiogram and ultra-early embolectomy. Surg Neurol 1999;51:332–41.
doi:10.1016/j.jocn.2011.04.020
Bioresorbable anterior cervical plate device for multi-level degenerative disc disease: Case report with 8-year follow-up Robert G. Whitmore ⇑, Elana S. Tykocinski, Matthew R. Sanborn, William C. Welch Department of Neurosurgery, Hospital of the University of Pennsylvania, 3400 Spruce Street, 3 Silverstein, Philadelphia, PA 19104, USA
a r t i c l e
i n f o
Article history: Received 8 April 2011 Accepted 23 April 2011
Keywords: Anterior cervical decompression and fusion Bioresorbable anterior cervical plate Cervical spondylotic myelopathy
a b s t r a c t Anterior cervical decompression and fusion is most successful when bone graft is combined with stabilizing instrumentation. The use of bioresorbable anterior cervical plates has been reported recently instead of the traditional titanium plate. We report a novel application of a bioresorbable plate in the management of a 69-year-old Caucasian female with multi-level, long-standing cervical spondylotic myelopathy. The patient previously had a failed anterior fusion with allograft and titanium instrumentation, and due to worsening symptoms, she underwent a revision anterior fusion using a bioresorbable cervical plate and a fibular allograft, in conjunction with posterior fusion with metal instrumentation. Successful fusion is visualized on CT imaging at 8-year follow-up. To our knowledge this is the first report of long-term follow-up showing successful fusion with this technology. Ó 2011 Elsevier Ltd. All rights reserved.
1. Introduction
2. Case report
Anterior cervical decompression and fusion (ACDF) is a commonly performed procedure in the treatment of spondylotic myelopathy in the cervical spine.1 While titanium instrumentation has traditionally been employed for this purpose, there have recently been reports of utilizing bioresorbable implants.2–4 The impermanence of the bioresorbable material provides an advantage to titanium. It offers a similar initial stabilizing scaffold until fusion occurs, but it degrades over time, thus obviating the long-term complications associated with permanent metal implants, including implant migration,5,6 compression of anterior soft tissue7 and fusion stress shielding.8 In addition, for patients undergoing revision surgery who will likely require follow up magnetic resonance imaging, a bioresorbable plate offers less artifact and scatter than metal plates.9 Resorbable mesh has been applied as an anterior cervical graft containment device in the surgical management of one- and twolevel disc disease.10–12 Preliminary results from a number of small trials suggest that this technology for anterior fusion may be as effective as traditional titanium plating systems in single-level disease.2,4 However, to our knowledge, bioresorbable anterior cervical plates have not previously been used in the management of spondylotic myelopathy. Here, we report a novel application of a bioresorbable anterior cervical plate for the management of recurrent multi-level cervical spondylotic myelopathy. We show complete resorption of the plate and stable fusion at 8 years follow-up.
We report a 69 year-old female patient with a history of cervical spondylotic myelopathy. Eight months prior to presentation, she underwent a C4 and C5 corpectomy and (C3–6) anterior cervical fusion with a fibular strut allograft and Orion plate instrumentation. Over the next 4 months, the patient deteriorated with increasing upper and lower extremity weakness. Although initial imaging was normal, a MRI performed at this time showed anterior dislodgement of the superior portion of the fibula strut graft at the level of C3. The decision was made to replace the dislodged allograft using a bioresorbable plate and perform decompression and fusion posteriorly. The patient was taken to the operating room and an otolargyngologist assisted with anterior reexposure of vertebral bodies C2 through C7. A new fibular strut allograft was placed in the corpectomy defect. Autograft bone was harvested from the left iliac crest and used to fill the center of the allograft and to fill in space surrounding the strut. The arthrodesis was supplemented with a Macropore Bioresorbable plating system (Medtronic, Minneapolis, MN, USA) and 12 mm screws. The patient was rolled into the prone position. The prior cervical decompression was expanded and instrumented fusion of C3–7 was performed using titanium Axis plating system instrumentation and lateral mass screws. Postoperatively, the patient did well and was sent home in a cervical collar. Her symptoms improved. Routine radiographs performed at 6 weeks demonstrated stable position of the graft and plates. Eight years later, the patient sustained a traumatic fall. A non-contrast CT of the cervical spine was obtained to rule out traumatic injury. Incidentally, the CT
⇑ Corresponding author. Fax: +1 215 349 5534. E-mail address: [email protected] (R.G. Whitmore).