Microsurgery For Aneurysms Research Articles

Traitement des anévrismes intracrâniens grade 0 : étude rétrospective portant sur 79 patients

Aim Without precise international recommendations, despite the advances of the ISUAA study, the superiority of microsurgery or endovascular treatment for unruptured intracranial aneurysm (UIA) over the natural history of this disease has not been proved. In this context, the authors evaluate their experience with the aim of assessing the results and risks of the different therapeutics and comparing them with the natural risk of this disease. Material and method From January 1993 to July 2000, 79 patients harboring 110 UIAs were treated. These patients were divided retrospectively into two groups. Group A included 45 operated patients. Group B included 37 patients treated with endovascular coiling. The therapeutic choice was not randomized and was approved by a multidisciplinary neurovascular staff. Results The two populations were homogeneous in terms of age and sex. In group A, 12 patients presented early complications (26.6 %), with one death. In group B, 15.6 % of the patients presented an ischemic complication. After 1 year of follow-up, morbidity was 11.4 % in group A and 4.8 % for group B. Angiography found a partial recanalization in 12.5 % of the operated patients and in 33 % of the patients treated with endovascular coiling. Discussion Many factors are involved in the therapeutic decision: UIA location and size and individual risks. Progress in both surgery and interventional neuroradiology has led to good results conforming with the data reported in the literature but does not demonstrate the superiority of one technique over another.

Vascular neurosurgery since the International Subarachnoid Aneurysm Trial

Vascular neurosurgery since the International Subarachnoid Aneurysm Trial

Microsurgery for intracranial aneurysm:analysis of 438 cases

To summarize the experience of surgical therapy in a series of 438 patients with intracranial aneurysms. A retrospective analysis was made on the clinical data of 438 patients, in terms of the perioperative management, timing of surgery, surgical skills, and The HUNT-HESS grade. 438 patients with 476 aneurysms underwent microsurgery, in which 450 aneurysms were clipped, 14 were wrapped, 8 were isolated,4 were cut. 32 aneurysms were ruptured (6.72%) during the operation. The relation between Hunt-Hess scale and mortality is significant postpone operation (> or =7 d) has got a better curative effect than the early. Microsurgical treatment is a confirmed effective method with intracranial aneurysms. The higher of HUNT-HESS grade will result to the worse clinical outcome.

前交通動脈瘤手術における３Ｄ‐ａｎｇｉｏｇｒａｐｈｙの有用性

Obtaining detailed anatomical information is crucial before aneurysm microsurgery. The anterior cerebral communicating artery complex (AcoC) is particularly complicated compared to other parts. The anatomical structure of the AcoC is sometimes difficult to understand using conventional angiography. We evaluated the advantages of 3-dimensional digital angiography (3D-DA) for aneurysm microsurgery on the anterior cerebral communicating artery. Subjects comprised 10 men and 5 women (mean age, 61 years; range, 33-79 years) who underwent surgery in our hospital between November 2002 and October 2005. Twelve aneurysms were ruptured, and 3 aneurysms were unruptured. We compared 3D-DA images and surgical findings to assess aneurysmal morphology and relationships to neighboring vessels. We also examined both the presence and visualization of variations on AcoC. In all cases, surgical findings corresponded well to 3D-DA images. Variations on AcoC included fenestration (n=3), azygos (n=1) and aplasia or hypoplasia of the A1 segment of a unilateral anterior cerebral artery (n=9), and these were all well-visualized in 3D-DA. In addition, 3D-DA was also useful for aneurysms with 2 domes for selection of surgical approach, and provided assessment of not only aneurysmal morphology, but also variations of AcoC. This tool provided useful information for the selection of operation approach and intraoperative manipulations by using it together with 2-dimensional digital substraction angiography.

Early-mid-phase microsurgery for ruptured cerebral anterior circulating aneurysm

To evaluate clinical strategy and effect of early-mid-phase microsurgery for ruptured cerebral anterior circulating aneurysm. Seventy-five patients presenting with anterior circulating aneurysmal subarachnoid hemorrhage (SAH) underwent early-mid-phase (within 3 days or 3-10 days) microsurgical clipping at Huashan Hospital between January 2001 and August 2004. Glasgow outcome scale (GOS) was conducted to evaluate patients' outcomes. Of 81 intracranial aneurysms, 77 lesions were clipped successfully, and 4 were wrapped. Good outcome was achieved in 53 cases, mild disability in 9 cases, severe disability in 7 cases, persistent vegetative state in 3 cases, and 3 patients (4%) died after surgery. The difference of GOS was statistically significant between patients in Hunt and Hess Grade I-III and Grade IV-V. However, there was no significant difference between early surgery and metaphase surgery. Early-mid-phase microsurgery for ruptured cerebral anterior circulating aneurysm is considered the feasible opinion.

Magnetic resonance angiography image guidance for the microsurgical clipping of intracranial aneurysms: a report of two cases

To describe the integration of magnetic resonance angiography (MRA) in neuronavigation procedures for microsurgery of intracranial aneurysms. MRA was combined with standard magnetic resonance image (MRI) acquisition in the image-guided planning for the microsurgical clipping of a saccular aneurysm in two patients (one 3-mm large middle cerebral artery and one 8-mm large pericallosal artery aneurysm, diagnosed by catheter angiography in both patients) using two different neurosurgical navigation systems. Conventional 3-D T1-weighted MRI with gadolinium and MRA pulse sequences were acquired in frameless stereotactic conditions the day before surgery and thereafter registered, allowing the definition a minimally invasive straight trajectory to the aneurysm neck. MRA-guided neurosurgery allowed a direct approach to the aneurysms at their proper location, reducing the invasiveness of the approach by tailoring the bone opening and reducing the duration and extension of brain retraction. The technique also avoided unnecessary dissection and exposure of the main trunks and collateral vessels. The aneurysms were successfully eradicated without complication. Integration of MRA in the planning and neuronavigation procedure for intracranial aneurysms may minimize the morbidity related to the surgical approach. This technique may be applicable more routinely using standard neuronavigation equipment.

Use of elective temporary clips in preventing intraoperative cerebral aneurysm rupture

Objective: To review the result of microsurgical treatment for cerebral aneurysms at Princess Margaret Hospital, Hong Kong, SAR, with the focus on the use of elective temporary clipping (ETC) in reducing intraoperative aneurysm rupture (IOR).Methods: All clinical notes and operation records of patients who had undergone aneurysm‐clipping microsurgery from July 1996 to November 2002 were reviewed.Results: In the past 6 years, 148 patients with 150 aneurysms had undergone microsurgical clipping operations. The overall usage rate of ETC was only 25% (38 out of 150) in the present surgical series. Elective temporary clipping was most frequently applied (40%) in treating anterior communicating artery aneurysm. The overall IOR rate was 26% without ETC, versus 8% with ETC, with 18% absolute risk reduction (95% confident interval: 3.2%−28.2%) and 70% relative risk reduction, respectively. The numbers needed for treatment was 5.55. The benefit of ETC was most prominently observed in treating anterior communicating artery aneurysm in which the IOR rate was reduced from 42 to 12%, with 30% absolute risk reduction. Among cases of IOR that occurred without prior elective temporary clip application, the mortality rate was 20.7%. For IOR patients with prior elective temporary clip application, there was no mortality.Conclusion: The present study demonstrates that ETC had led to a significant overall reduction in IOR rate and ETC was associated with better clinical outcome. We encourage and recommend the use of ETC in preventing IOR during aneurysm microsurgery. A prospective study will be conducted on the same topic in our hospitals.

Nuances of middle cerebral artery aneurysm microsurgery.

Middle cerebral artery aneurysms, a common source of subarachnoid hemorrhage, occur predominantly at the main bifurcation of the middle cerebral artery. Microsurgical clipping is the most effective treatment of these aneurysms because of their peripheral location, wide necks, and straightforward surgical anatomy. Despite the moderate technical requirements of this type of surgery, patients with ruptured aneurysms often have poor outcomes because of the high incidence of intracerebral hematomas. Although several different surgical approaches can be used, we favor a lateral-to-medial transsylvian approach for most aneurysms. This description of our surgical technique stresses minimizing retraction to avoid injury to the brain and preparing broad-based middle cerebral artery aneurysms for clipping. Management of outcomes when using these techniques also is presented.

Nuances of Middle Cerebral Artery Aneurysm Microsurgery

Nuances of Middle Cerebral Artery Aneurysm Microsurgery

Endoscope-assisted microsurgery for cerebral aneurysms.

We performed endoscope-assisted microsurgery for 64 patients with cerebral aneurysms from June 1998 to January 1999. Two patients were treated under picture-in-picture imaging using a surgical microscope connected with an endoscopic-image display system. The study included 34 patients with incidental discovery: 3 IC oph, aneurysm, 1 from cavernous (C3) portion, 8 at ICPC, 1 from infundibular dilatation, 2 at IC bifurcation, 6 at AcoA, 1 at A1A2, 8 at MCA, 1 at P1, 1 from basilar tip, 1 at AICA, 1 at VA and 1 from PICA. The study also included 30 patients with subarachnoid hemorrhage: 5 ICPC, 2 from anterior choroidal, 1 from IC infundibular dilatation, 10 from AcoA, 2 from A2A3, 7 from MCA, 2 from basilar tip and 1 from PICA. They were classified into gr. 1 for 2, gr. 2 for 8, gr. 3 for 10, gr. 4 for 7, and gr. 5 for 3 cases.

Endoscope-assisted microsurgery for cerebral aneurysms.

A total of 66 patients with intracranial aneurysms were endoscopically assisted treated during a 3 years period. Among those were five individuals with giant aneurysms and 27 patients with aneurysms of the posterior circulation. The endoscope was used only for checking the anatomical structures surround the aneurysms in 16 cases. In 43 patients the aneurysm sac was also dissected under endoscopical control. Even the clipping procedure was performed in seven cases exclusively under endoscopical observation. Only one prematural rupture occurred intraoperatively during preparation of a basilar tip aneurysm. Postoperatively three individuals with aneurysms located in the posterior circulation were temporarily neurologically impaired, and one patient with a basilar tip aneurysm suffered from a surgical related hemiparesis. The use of an endoscope in aneurysm surgery improves the visualization of the aneurysm itself and the surrounding anatomical structures. This minimizes the retraction of the nervous structures and leads to a reduced morbidity.

Paraclinoid Aneurysms-Management Update

Microsurgery of aneurysms that arise in the paraclinoid region remains a formidable challenge to most neurosurgeons. The intricate anatomy related to the internal carotid artery at the site where it leaves the base of the skull to enter the subarachnoid space is responsible for most of the drawbacks of aneurysm surgery in that area.The planning of the operative strategy requires that one considers some major issues involved with the management of paraclinoid aneurysms, i.e., those related to the anatomical relationships of the paraclinoid area, the characteristics of the aneurysm itself, the choice of the best surgical approach, the site for proximal control of arterial bleeding, and the possibilities for either the improvement or for the arrest of visual deterioration.

神経内視鏡による観察を併用した顕微鏡下脳動脈瘤手術

Introduction of microsurgery for cerebral aneurysms markedly improved the operative outcome. However, the microsurgically blind portion hidden behind unretractable structures such as a major artery, cranial nerves, aneurysm sack and tentorium, has remained a problem. An endoscope was applied for microsurgical operation of cerebral aneurysm to minimize the blind area under the microscope.We used a rigid form endoscope (CODMAN Gaab Neuroendoscope System with 30°, 70°and 120°angled telescope) to visualize the microsurgically blind portion in 10 patients with cerebral aneurysms. Application of endoscope was useful to reduce the risk of careless surgical injury by avoiding the extensive brain retraction in all patients. We report here on four patients. In 1 patient with high positioned basilar top aneurysm (Case 1), the aneurysm could not be visualized through pterional route, and after confirmation of the aneurysm by endoscope, neck clipping was performed through orbitozygomatic route. For bilateral internal carotid artery (IC) aneurysms (Case 2), after clipping of the left IC-posteior communicating artery (PcomA) aneurysm, the IC aneurysms on the right side could be inspected endoscopically through the prechiasmatic cistern. In another patient (Case 3), during endoscopic observation for left IC-PcomA aneurysm, IC-anterior choroidal artery aneurysm that had not been identified by angiography was detected. In the remaining patient (Case 4), an endoscope was used to confirm correct neck clipping for a vertebral artery-posterior inferior cerebellar artery aneurysm attached to the seventh and eighth cranial nerves.Though instruments of solid form endoscope entail some inconvenience for endoscopic surgery, the image is markedly clearer than that of the fiberoptic endoscope. Endoscopy seems to be useful for minimizing the surgical trauma in microsurgical operation for cerebral aneurysm.

P250 Facilitation of motor evoked potentials in spinal cord monitoring during spine surgery

Temporary arterial occlusion (TAO) is valuable for minimizing intraoperative rupture risk during intracranial aneurysm microsurgery; however, it may be associated with ischemic injury. This study aims to identify surgical and intraoperative neurophysiologic monitoring factors that predict perioperative stroke risk after TAO.We performed a retrospective chart review of 177 intracranial aneurysm surgeries at our institution in which TAO was performed before placement of a permanent clip under monitoring with somatosensory evoked potentials (SSEPs) and electroencephalography. Perioperative stroke was defined as a new-onset neurologic deficit that developed within 24 hours postoperatively that was correlated with hypodensity on postoperative computed tomography.Ten (6%) patients developed perioperative stroke in the vascular territory of TAO. SSEP changes were observed in 50% (5/10) of patients with perioperative stroke and in 14% (24/167) of patients without stroke (P = 0.003). Mean maximum single-episode TAO duration for patients who developed perioperative stroke was 12.6 minutes (95% confidence interval 8.1–17.1) and TAO duration for patients without stroke was 8.0 minutes (95% confidence interval 7.3–8.7; P = 0.026). In patients with SSEP changes, risk of stroke was particularly elevated with unruptured aneurysms (P = 0.013) compared with patients with ruptured aneurysms. Temporary clip location, number of occlusive episodes, onset and duration of intraoperative neurophysiologic monitoring changes, and rupture status were not predictive of perioperative stroke.SSEP changes and increased single-episode TAO duration are independently associated with increased perioperative stroke risk. SSEP changes are most predictive for perioperative stroke in unruptured cases.

Anatomical and technical aspects of the contralateral approach for multiple aneurysms

Microsurgery of multiple aneurysms is still a controversial subject. In order to avoid the risk of rebleeding and the consequent increase in morbidity in such cases all aneurysms or at least as many aneurysms as possible should be treated in the first operative procedure. To reach that goal aneurysms located on the contralateral side should also be considered for clipping during the first operation. Between 1984 and 1994 a series of 51 patients harboring multiple aneurysms of which 55 aneurysms were located on the contralateral side of the craniotomy were operated at our institution. No mortality or morbidity could be directly ascribed to the aneurysm that was clipped contralaterally. Based on that series we have described the anatomical features, technical aspects and surgical difficulties of approaching bilateral aneurysms through the same craniotomy.

PS-7-6 Influence of cooling on somatosensory evoked potentials in subjects with multiple sclerosis

Temporary arterial occlusion (TAO) is valuable for minimizing intraoperative rupture risk during intracranial aneurysm microsurgery; however, it may be associated with ischemic injury. This study aims to identify surgical and intraoperative neurophysiologic monitoring factors that predict perioperative stroke risk after TAO.We performed a retrospective chart review of 177 intracranial aneurysm surgeries at our institution in which TAO was performed before placement of a permanent clip under monitoring with somatosensory evoked potentials (SSEPs) and electroencephalography. Perioperative stroke was defined as a new-onset neurologic deficit that developed within 24 hours postoperatively that was correlated with hypodensity on postoperative computed tomography.Ten (6%) patients developed perioperative stroke in the vascular territory of TAO. SSEP changes were observed in 50% (5/10) of patients with perioperative stroke and in 14% (24/167) of patients without stroke (P = 0.003). Mean maximum single-episode TAO duration for patients who developed perioperative stroke was 12.6 minutes (95% confidence interval 8.1–17.1) and TAO duration for patients without stroke was 8.0 minutes (95% confidence interval 7.3–8.7; P = 0.026). In patients with SSEP changes, risk of stroke was particularly elevated with unruptured aneurysms (P = 0.013) compared with patients with ruptured aneurysms. Temporary clip location, number of occlusive episodes, onset and duration of intraoperative neurophysiologic monitoring changes, and rupture status were not predictive of perioperative stroke.SSEP changes and increased single-episode TAO duration are independently associated with increased perioperative stroke risk. SSEP changes are most predictive for perioperative stroke in unruptured cases.

Combined transsylvian-subtemporal exposure of cerebral aneurysms involving the basilar apex.

The surgical repair of cerebral aneurysms involving the apex of the basilar artery continues to undergo refinement and evolution. The inherent difficulty in accessing the basilar apex as well as the complexities of the microanatomy render this area a notoriously hazardous and technically challenging region in which to perform microsurgical clipping of cerebral aneurysms. Several operative approaches have been described and are constantly undergoing a state of evolution in the hopes of optimizing the exposure of the distal basilar artery and minimizing the inherent risks of surgery. The consistent decline in operative morbidity has paralleled improved understanding of the microvascular anatomy, both in this region and along the various corridors of approach. No single operative approach is universally superior, considering the wide variability of individual patient anatomy and vascular configurations. Each approach has strengths, weaknesses, and potential complications that must be considered in the though process of planning an operative attack on a basilar apex aneurysm. Intimate familiarity with the microvasculature and the microsurgical anatomy of the region is an imperative prerequisite for the application of any surgical approach to this region. This paper outlines a detailed review of the microsurgical anatomy that is pertinent to microsurgery of aneurysms in this region, and describes an approach referred to as the combined transsylvian-subtemporal approach. We have found this operative approach particularly useful in aneurysm surgery of the basilar apex but do not mean to imply that this single approach is suitable for all surgeons or all patients.(ABSTRACT TRUNCATED AT 250 WORDS)

Microsurgery of cerebral aneurysms. By Zentaro Ito Amsterdam, Elsevier Biomedical Press BV, 1986 299 pp, illustrated, $222.25

Annals of NeurologyVolume 22, Issue 2 p. 286-286 Books Microsurgery of cerebral aneurysms. By Zentaro Ito Amsterdam, Elsevier Biomedical Press BV, 1986 299 pp, illustrated, $222.25 Fred Plum, Fred Plum MDSearch for more papers by this author Fred Plum, Fred Plum MDSearch for more papers by this author First published: August 1987 https://doi.org/10.1002/ana.410220228AboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinked InRedditWechat No abstract is available for this article. Volume22, Issue2August 1987Pages 286-286 RelatedInformation

Microsurgery of Cerebral Aneurysms. An Atlas

Microsurgery of Cerebral Aneurysms. An Atlas

Microsurgical treatment of intracranial aneurysm in the elderly.

Microsurgery for supratentorial aneurysm was performed in 19 patients over the age of 65 with good results in 74%. Mortality and complications are discussed in the light of the preoperative neurological status and general condition. The indications for surgery are outlined.