Wrapping

Wrapping

Wrapping or coating the aneurysm: although this should never be the goal of surgery, situations may arise in which there is little else that can be done (e.g. Fusiform Aneurysm on the Basilar Artery Trunk, aneurysms with significant branches arising from the dome, or part of the neck within the cavernous sinus)

a) Norman McOmish Dott published in 1933 the first method used to surgically treat an aneurysm with muscle 1) (the patient described died from rebleeding)

b) In 1958 Gillingham popularized wrapping with cotton or muslin 2). An analysis of 60 patients showed that 8.5% rebled in ≤ 6 mos, and the annual rebleeding rate was 1.5% thereafter 3) (similar to the natural history)

c) Wrapping with plastic resin or other polymer: maybe slightly better than muscle or gauze 4).

One study with long follow-up found no protection from rebleeding during the first month, but thereafter the risk was slightly lower than the natural history 5). Other studies show no difference from the natural course 6).

d) Teflon and fibrin glue 7)

AUTOGENOUS FASCIA AND A CYANOACRYLATE 8).


In 1990 Fujiwara et al. published the long term result of the treatment of 29 intracranial ruptured aneurysms by wrapping with or without coating. These patients were followed for a mean period of 11 years. The outcome of all patients was as follows; 19 were categorized as good, 2 were severely disabled, on the Glasgow Outcome Scale (GOS), and 8 died. The rebleeding occurred in 5 patients within 3 years after surgery, and all died. There was an overall rate of 17% of rebleeding in our series, which is much higher than the rebleeding rate after aneurysm treatment by clipping of the neck but lower than the usual rebleeding rate in conservatively treated cases. In conclusion, the wrapping as a choice of treatment of ruptured aneurysms is not a safe alternative to the direct operative occlusion of the aneurysmal sack 9).


see also wrap-clipping.

References

1)

Dott NM. Intracranial Aneurysms: Cerebral Arteriography, Surgical Treatment. Trans Med Chir Soc Edin. 1933; 40:219–234
2)

Gillingham FJ. The Management of Ruptured Intracranial Aneurysms. Hunterian Lecture. Ann R Coll Surg Engl. 1958; 23:89–117
3)

Todd NV, Tocher JL, Jones PA, et al. Outcome Following Aneurysm Wrapping: A 10-Year Follow-Up Review of Clipped and Wrapped Aneurysms. J Neurosurg. 1989; 70:841–846
4) , 5)

Cossu M, Pau A, Turtas S, et al. Subsequent Bleeding from Ruptured Intracranial Aneurysms Treated by Wrapping or Coating: A Review of the Long-Term Results in 47 Cases. Neurosurgery. 1993; 32:344–347
6)

Minakawa T, Koike T, Fujii Y, et al. Long Term Results of Ruptured Aneurysms Treated by Coating. Neurosurgery. 1987; 21:660–663
7)

Pellissou-Guyotat J, Deruty R, Mottolese C, et al. The Use of Teflon as Wrapping Material in Aneurysm Surgery. Neurol Res. 1994; 16:224–227
8)

COE JE, BONDURANT CP Jr. LATE THROMBOSIS FOLLOWING THE USE OF AUTOGENOUS FASCIA AND A CYANOACRYLATE (EASTMAN 910 MONOMER) FOR THE WRAPPING OF AN INTRACRANIAL ANEURYSM. J Neurosurg. 1964 Oct;21:884-6. PubMed PMID: 14213489.
9)

Fujiwara S, Fujii K, Nishio S, Fukui M. Long-term results of wrapping of intracranial ruptured aneurysms. Acta Neurochir (Wien). 1990;103(1-2):27-9. PubMed PMID: 2360463.

Magnetic resonance neurography first description

Magnetic resonance neurography (MRN) is the direct imaging of nerves in the body by optimizing selectivity for unique MRI water properties of nerves. It is a modification of magnetic resonance imaging. This technique yields a detailed image of a nerve from the resonance signal that arises from in the nerve itself rather than from surrounding tissues or from fat in the nerve lining. Because of the intraneural source of the image signal, the image provides a medically useful set of information about the internal state of the nerve such as the presence of irritation, nerve swelling (edema), compression, pinch or injury. Standard magnetic resonance images can show the outline of some nerves in portions of their courses but do not show the intrinsic signal from nerve water. Magnetic resonance neurography is used to evaluate major nerve compressions such as those affecting the sciatic nerve (e.g. piriformis syndrome), the brachial plexus nerves (e.g. thoracic outlet syndrome), the pudendal nerve, or virtually any named nerve in the body. A related technique for imaging neural tracts in the brain and spinal cord is called magnetic resonance tractography or diffusion tensor imaging.

History

We have made cross-sectional image “neurograms” in which peripheral nerve has a greater signal intensity than that of other tissue. Neurographic images of the rabbit forelimb were obtained using a spin-echo magnetic resonance imaging (MRI) technique that combines fat suppression and diffusion weighting. After fat suppression the nerve shows up in relative isolation and is brighter than the surrounding tissue due to its longer T2 relaxation time of approximately 50 ms compared to approximately 27 ms for muscle. The addition of pulsed gradients for diffusion weighting of the MR signal further enhances the intensity of the nerve signal relative to that of surrounding muscle tissue. The greater diffusional anisotropy of nerve tissue (D parallel/D perpendicular = 3.1) compared to that of muscle (D parallel/D perpendicular = 1.9) allows further enhancement of the nerve by a subtraction of two diffusion-weighted images, one with the gradients oriented parallel and one with the gradients oriented perpendicular to the nerve orientation. We show that by manipulation of the MRI parameters, either echo time or pulsed gradient strength, the nerves can be made to show up as the most intense feature. This verifies the feasibility of generating three-dimensional “neurographic” images, analogous to angiograms, but which demonstrate the peripheral nerve tracts in apparent isolation 1).
1) Howe FA, Filler AG, Bell BA, Griffiths JR. Magnetic resonance neurography.Magn Reson Med. 1992 Dec;28(2):328-38. PubMed PMID: 1461131.

Update: Neurocysticercosis

Twenty-six patients with cysticercosis of the brain parenchyma were treated with the antihelmintic agent praziquantel (50 mg per kilogram of body weight daily for 15 days). During treatment a strong inflammatory reaction occurred, as evidenced by increased protein and cells in the cerebrospinal fluid. This finding correlated with headache, exacerbation of neurologic symptoms, and edema and inflammation around cystic lesions. After three months of treatment all patients had improved clinically, and 13 (50 per cent) were asymptomatic. The total number of cysts on CT scans had decreased from 152 at the beginning of treatment to 51, and the mean diameter of cysts was reduced by 72 per cent. CT scans showed improvement in 25 of the 26 patients, with total remission of all cysts in nine. Seventeen control patients followed with CT studies for a mean of 9 +/- 2 months had no spontaneous remission of lesions, and in many cases the scans showed worsening during the observation period. Our results indicate that praziquantel is effective in cysticercosis of the brain parenchyma.


Sotelo J, Escobedo F, Rodriguez-Carbajal J, Torres B, Rubio-Donnadieu F. Therapy of parenchymal brain cysticercosis with praziquantel. N Engl J Med. 1984 Apr 19;310(16):1001-7. PubMed PMID: 6708975.

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