Microsurgical Treatment Of Aneurysms Research Articles

Current State of Microsurgical Treatment of Aneurysms of the Ophthalmic Segment of the Internal Carotid Artery

Current State of Microsurgical Treatment of Aneurysms of the Ophthalmic Segment of the Internal Carotid Artery

The Correlation Between the Intraoperative Employment of Indocyanine Green Videoangiography and Incidences of Residual Aneurysm and Parent Vessel Trauma: A Retrospective Analysis from a Single Centre

Abstract Background Mitigating residual cerebral aneurysm and parent artery trauma during the microsurgical treatment of aneurysms, specifically clipping, is of paramount importance to enhance patient outcomes. This study examines the effectiveness of intraoperative indocyanine green-videoangiography as a strategic tool to attenuate these surgical complications. Materials and Methods We conducted a retrospective analysis of patient medical records who underwent cerebral aneurysm surgery in our institution from January 2012 to July 2018. The characteristic variables were juxtaposed between cohorts who had undergone intraoperative ICG-VA and those who had not, employing the independent-samples Student’s t-test and Chi-square test for statistical comparison. The Sindou grading system was utilized to categorize aneurysm remnants, while injury to the parent artery was determined jointly by a neurosurgeon and a neuroradiologist. Logistic regression models were utilized to investigate the correlation between intraoperative ICG-VA usage and the presence of aneurysm remnants and parent artery injury. Results A total of 127 patients, harboring 131 aneurysms, underwent surgical treatment. Among these patients, 55 had intraoperative ICG-VA utilized. The occurrence rates of residual aneurysm and parent artery injury were documented at 30.5% and 6.9%, respectively. With regards to the Sindou grade I–III aneurysm remnants, interpreted as favorable outcomes, such results were observed in 14 (82.4%) patients in the non-ICG-VA group and 21 (91.3%) patients in the ICG-VA group, with no significant difference discerned between the two groups (p = 0.406; odds ratio [OR], 2.250; 95% confidence interval [CI], 0.332–15.236). Without parent artery injury, there were 64 (88.9%) patients in the non-ICG-VA group and 58 (98.3%) patients in the ICG-VA group, presenting a significant difference (p = 0.038; OR, 10.793; 95% CI, 1.134–102.691). Conclusions The utilization of intraoperative ICG-VA during microsurgical aneurysm clipping could notably decrease the incidence of parent artery injury. Nonetheless, when considering the presence of aneurysm remnants, the expertise of the neurosurgeon may play a more influential role compared to the use of ICG-VA.

Microsurgical Treatment of Cerebral Aneurysms

Despite advances in endovascular techniques, microsurgery continues to play an important role in the treatment of cerebral aneurysms. This article reviews the history of surgical treatment of intracranial aneurysms and the evolving role of microsurgery in the endovascular era. Although endovascular tools and techniques have changed significantly since the placement of the first Guglielmi coils in 1990, with the development of endoluminal flow-diverting stents and now endosaccular flow-diverting devices, microsurgical treatment of aneurysms has also continued to evolve. Since the first treatment with Hunterian ligation by Horsley in the 1800s, surgical treatment of intracranial aneurysms has advanced significantly beginning with the introduction of the microscope and microsurgical techniques in the 1950s. More recent advances in microsurgical treatment of aneurysms include microsurgical adjuncts, such as indocyanine green angiography, adenosine, and the exoscope, as well as tailored craniotomies, retractorless surgery, and novel bypass constructs for complex aneurysms. Microsurgery continues to play an important role in the endovascular era.

External Ventricular Drainage in Patients With Acute Aneurysmal Subarachnoid Hemorrhage After Microsurgical Clipping: Our 2006-2018 Experience and a Literature Review.

IntroductionThe placement of an external ventricular drain (EVD) is widely practiced in neurosurgery for various diseases and conditions accompanied by impaired cerebrospinal fluid (CSF) circulation, intracranial hypertension (ICHyp), intraventricular hemorrhage (IVH), and hydrocephalus. Specialists have been using this method in patients with acute aneurysmal subarachnoid hemorrhage (aSAH) for more than 50 years. Extensive experience gained at the Burdenko Neurosurgical Center (BNC) in Moscow, the Russian Federation, in the surgical treatment of patients with acute aSAH enabled us to describe the results of using an EVD in patients after microsurgery. The objective of the research was to assess the effectiveness and safety of the EVD and clarify the indications for the microsurgical treatment of aneurysms in patients with acute SAH.Materials and methodsFrom 2006 until the end of 2018, 645 patients registered in the BNC database underwent microsurgery for acute (0-21 days) aSAH. During the case study, we assessed the severity of hemorrhage according to the Fisher scale, the condition of patients on the Hunt-Hess (H-H) scale during surgery, the time of placement of EVD (before, during, and after surgery), and the duration of EVD. The number of patients with parenchymal intracranial pressure (ICP) transducers was assessed by the degree of correlation of ICP data through the EVD and parenchymal ICP transducer. One of the aims of the research was to compare the frequency of using EVD and decompressive craniectomy (DCH). The incidence of EVD-associated meningitis was analyzed. The need for a ventriculoperitoneal shunt (VPS) in patients after using EVD was also assessed. Overall outcomes were assessed using a modified Rankin scale (mRS) at the time of patient discharge. Exclusion criteria were as follows: patients aged less than 18 years and the lack of assessed data. Patients undergoing endovascular and conservative treatments also were excluded.ResultsAmong the patients enrolled in the study, 22% (n=142) had EVD. Among these, 99 cases (69.7%) had EVD installed in the operating room just before the start of the surgical intervention. In some cases, ventriculostomy was performed on a delayed basis (16.3%). A satisfactory outcome (mRS scores of 1 and 2) was observed in 24.7% (n=35). Moderate and profound disability at the time of discharge was noted in 55.7% (n=79). Vegetative outcome at discharge was noted in 8.4% (n=12), and mortality occurred in 12.3% (n=15).ConclusionEVD ensures effective monitoring and reduction of ICP. EVD is associated with a relatively low risk of infectious, liquorodynamic, and hemorrhagic complications and does not worsen outcomes when used in patients with aSAH. We propose that all patients in the acute stage of SAH with H-H severity of III-V should receive EVD immediately before surgery.

Abstract WP33: Early Lessons Learned From the WEB Device: Feasibility, Technique and Complications—A Real Life Experience

Introduction: Wide-neck bifurcation cerebral aneurysms have always posed a treatment challenge and have historically required either clip ligation, or stent vs. balloon-assisted coil embolization. This predicament led to the development of the newly FDA-approved Woven EndoBridge (WEB) aneurysm embolization system (Sequent Medical Inc, Aliso Viejo, CA) Which is a self-expanding mesh that achieves intrasaccular flow disruption and does not require antithrombotic medications. In this study, we report our experience with the first 64 consecutive aneurysms treated via WEB embolization at two high-volume institutions. Methods: We reviewed our first 61 consecutive patients with 64 cerebral aneurysms who underwent WEB embolization from February-August 2019. We collected data on patient demographics and clinical presentation, aneurysm characteristics, device and procedural details, and functional outcomes. Results: A total of 64 aneurysms were included in our study. Fifteen patients (24.1%) presented with acutely ruptured aneurysm while the rest were unruptured. The majority of patients (82.8%) required only one attempt for successful device deployment, while a stent was necessary as an adjunct treatment in 4 patients (6.3%) due to WEB herniation. Two patients had residual aneurysm that had to undergo additional treatment; one of them underwent second WEB embolization and one underwent clip ligation. One patient with a PICA aneurysm had device dislodgment with injury to the parent vessel—Onyx and coils were used to deconstruct the vertebral artery. Conclusions: The advent of the WEB device has significantly impacted the surgical decision-making for the treatment of bifurcation, wide-neck aneurysms. We discuss in detail the lessons learned from patient selection, device size selection, technique, and complications from two institutions with high-volume endovascular and microsurgical aneurysm treatment experience.

Early Lessons Learned From the WEB Device: Feasibility, Technique and Complications—A Real-Life Experience

Abstract INTRODUCTION Wide-neck bifurcation cerebral aneurysms have always posed a treatment challenge and have historically required either clip ligation, or stent vs balloon-assisted coil embolization. This predicament led to the development of the newly FDA-approved Woven EndoBridge (WEB) Aneurysm Embolization System (Sequent Medical Inc, Aliso Viejo, California), which is a self-expanding mesh that achieves intrasaccular flow disruption and does not require antithrombotic medications. In this study, we report our experience with the first 29 consecutive aneurysms treated via WEB embolization at 2 high-volume institutions. METHODS We reviewed our first 27 consecutive patients with 29 cerebral aneurysms who underwent WEB embolization from February to April 2019. We collected data on patient demographics and clinical presentation, aneurysm characteristics, device and procedural details, and functional outcomes. RESULTS A total of 29 aneurysms were included in our study. Seven patients (24.1%) presented with acutely ruptured aneurysm while the rest were unruptured. The majority of patients (82.8%) required only 1 attempt for successful device deployment, while a stent was necessary as an adjunct treatment in 4 patients (13.7%) due to WEB herniation. Two patients had residual aneurysm that had to undergo additional treatment; one of them underwent second WEB embolization and one underwent clip ligation. One patient with a PICA aneurysm had device dislodgment with injury to the parent vessel Onyx and coils were used to deconstruct the vertebral artery. CONCLUSION The advent of the WEB device has significantly impacted the surgical decision-making for the treatment of bifurcation, wide-neck aneurysms. We discuss in detail the lessons learned from patient selection, device size selection, technique, and complications from 2 institutions with a high-volume endovascular and microsurgical aneurysm treatment experience.

Microsurgical treatment of aneurysms of vertebral and posterior-lower cerebellar arteries: surgical approaches, exclusion options, treatment results

The experience of microsurgical treatment of 67 patients with VA and PICA aneurysms in N.N. Burdenko National Medical Research Center for Neurosurgery of the RF Ministry of Health from 2012 to 2017 is presented. Most patients underwent reconstructive microsurgical interventions: clipping of the aneurysm neck in 42 (62.7%) patients and complex clipping with the formation of arterial opening - in 10 (14.9%). Exclusion of the aneurysm together with the carrier artery (trapping, proximal clipping) was performed on 10 (14.9%) patients. In 5 (7.5%) patients, deconstruction of the carrier artery of the aneurysm was performed after creating local anastomoses. The radical exclusion of aneurysms in the studied group was 95.5%. Postoperative dysfunction of the caudal group of cranial nerves was detected in 11 (16.4%) patients. There were no lethal outcomes, or cases with vegetative status outcomes. Microsurgical intervention is an effective way to treat VA and PICA aneurysms, subject to the principles of patient selection based on existing treatment algorithms as well as adherence to an interdisciplinary approach.

Microsurgical Treatment of Cerebral Aneurysms After Previous Endovascular Therapy: Single-Center Series and Systematic Review

Since its introduction in the early 1990s, endovascular treatment of cerebral aneurysms has had a steady upward trend and is the primary mode of treatment for most intracranial aneurysms. Concurrently, the need for retreatment of aneurysms after previous endovascular treatment has continued to increase, some of which can only be treated with microsurgical techniques. The factors that dictate outcomes in this group of patients are incompletely understood. To study factors contributing to patient outcomes after microsurgical treatment of aneurysms with previous endovascular treatment. The records of the senior author (D.L.B.) since 2002 were retrospectively reviewed for aneurysms treated after previous endovascular treatment. Demographics, treatment details, and imaging were reviewed for all patients. A systematic review of the literature on microsurgical treatment of aneurysms previously treated by endovascular therapy was also conducted. A total of 91 patients were identified from the retrospective review. Mean age at the time of initial treatment was 49 ± 12.68 years. Most patients initially presented with subarachnoid hemorrhage before initial endovascular treatment, with only 11 patients (12%) presenting with incidentally discovered lesions. Modified Rankin Scale score at discharge after initial treatment was good (0-3) in 81.4% of cases. Functional outcomes at the last known follow-up showed a modified Rankin Scale score of 0-3 in 77 patients (84.6%). Only aneurysm neck size was found to be a significant predictor of surgical complications (Wald χ2= 10.79; P= 0.0010) with an odds ratio of 2.32 (95% confidence interval, 1.40-3.83) for a 2-mm increase in neck size. Systematic review identified 37 studies who were used to pool data on 370 patients. Although type of surgery was identified as a predictor of poor outcomes, this was significantly confounded by Hunt and Hess grade in the systematic review. Favorable outcomes can be obtained even for highly complex cerebral aneurysms that have failed endovascular treatment at high-volume cerebrovascular centers. Initial presentation grade and aneurysm size are important predictors of final patient outcomes.

Training Young Neurosurgeons in Open Microsurgical Aneurysm Treatment.

National and international trends continue to show greater emphasis on endovascular techniques for the treatment of cerebrovascular disease. The cerebrovascular neurosurgeon however must be adequately equipped to treat these patients via both open and endovascular techniques.The decline in open cerebrovascular cases for aneurysm clipping has forced many trainees to pursue open cerebrovascular fellowships to increase case volume. An alternative strategy has been employed at our institution, which is early identification of subspecialty focus with resident driven self-selection of open cerebrovascular cases.This has allowed recent graduates to obtain enfolded endovascular training and a significant number of open cerebrovascular cases in order to obtain competence and exposure.We advocate for further self-selection paradigms supplemented with simulation training in order to obviate the need for extended post-residency fellowships.Las tendencias nacionales e internacionales continúan mostrando un mayor énfasis en las técnicas endovasculares para el tratamiento de la enfermedad cerebrovascular. Sin embargo, el neurocirujano cerebrovascular debe estar adecuadamente equipado para tratar a estos pacientes mediante técnicas tanto abiertas como endovasculares.La disminución de los casos cerebrovasculares abiertos por clipaje de aneurismas ha obligado a muchos alumnos a buscar becas cerebrovasculares abiertas para aumentar el volumen de casos. Se ha empleado una estrategia alternativa en nuestra institución, que es la identificación temprana del enfoque de subespecialidad con la autoselección impulsada por el residente de casos cerebrovasculares abiertos.Esto ha permitido a los recién graduados obtener una formación endovascular completa y un número significativo de casos cerebrovasculares abiertos para obtener competencia y exposición.Abogamos por nuevos paradigmas de autoselección complementados con capacitación en simulación para evitar la necesidad de becas extendidas posteriores a la residencia.

Use of a surgical rehearsal platform and improvement in aneurysm clipping measures: results of a prospective, randomized trial.

OBJECTIVE The field of neurosurgery is constantly undergoing improvements and advances, both in technique and technology. Cerebrovascular neurosurgery is no exception, with endovascular treatments changing the treatment paradigm. Clipping of aneurysms is still necessary, however, and advances are still being made to improve patient outcomes within the microsurgical treatment of aneurysms. Surgical rehearsal platforms are surgical simulators that offer the opportunity to rehearse a procedure prior to entering the operative suite. This study is designed to determine whether use of a surgical rehearsal platform in aneurysm surgery is helpful in decreasing aneurysm dissection time and clip manipulation of the aneurysm. METHODS The authors conducted a blinded, prospective, randomized study comparing key effort and time variables in aneurysm clip ligation surgery with and without preoperative use of the SuRgical Planner (SRP) surgical rehearsal platform. Initially, 40 patients were randomly assigned to either of two groups: one in which surgery was performed after use of the SRP (SRP group) and one in which surgery was performed without use of the SRP (control group). All operations were videotaped. After exclusion of 6 patients from the SRP group and 9 from the control group, a total of 25 surgical cases were analyzed by a reviewer blinded to group assignment. The videos were analyzed for total microsurgical time, number of clips used, and number of clip placement attempts. Means and standard deviations (SDs) were calculated and compared between groups. RESULTS The mean (± SD) amount of operative time per clip used was 920 ± 770 seconds in the SRP group and 1294 ± 678 seconds in the control group (p = 0.05). In addition, the mean values for the number of clip attempts, total operative time, ratio of clip attempts to clips used, and time per clip attempt were all lower in the SRP group, although the between-group differences were not statistically significant. CONCLUSIONS Preoperative rehearsal with SRP increased efficiency and safety in aneurysm microsurgery as demonstrated by the statistically significant improvement in time per clip used. Although the rest of the outcomes did not demonstrate statistically significant between-group differences, the fact that the SRP group showed improvement in mean values for all measures studied suggests that preoperative rehearsal may increase the efficiency and safety of aneurysm microsurgery. Future studies aimed at improving patient outcome and safety during surgical clipping of aneurysms will be needed to keep pace with the quickly advancing endovascular field.

Intraoperative Three-Dimensional Angiography Increases the Diagnostic Yield for Detection of Neck Remnant during Microsurgical Aneurysm Occlusion

Aims: Intraoperative digital subtraction angiography (DSA) has been demonstrated to improve occlusion rates during microsurgical aneurysm treatment. Whether the addition of three-dimensional DSA (3D DSA) with immediate image reconstruction further enhances surgical outcome has not been investigated so far. Methods: A retrospective analysis was performed for patients undergoing microsurgical aneurysm occlusion in the hybrid OR between March 2011 and October 2014. The rate of intraoperatively detected neck remnant and clip repositioning was recorded. For verification, a delayed reevaluation was performed with two blinded neuroradiologists, who were asked to assess the surgical results based on 2D DSA in anteroposterior, lateral, and oblique views. In a second step, 3D DSA reconstructions were presented for analysis. Results: Of 142 patients (100 female, 42 male, mean age 56.1 years), 82 received intraoperative 3D DSA. Neck remnant was detected in 19 patients (23.2%). Surgical strategy and clip repositioning were performed in six patients (7.2%) just based on 3D DSA diagnostic, which were not detected in 2D views. Conclusion: Based on our preliminary observations, 3D DSA increases the diagnostic yield for intraoperative assessment of neck remnant in aneurysm surgery. 3D DSA might become a gold standard in hybrid neurovascular procedures to improve surgical results and patient's outcome. However, a prospective study has still to be performed.

E-045 Separating the Wheat from the Chaff: Completion Angiography Following Complex Aneurysm Repair Using Low-Dose Volume of Interest Plus Metal Artefact Reduction Imaging

IntroductionFollowing complex endovascular or microsurgical treatment of aneurysms, volumetric assessment of the surgical outcome in the angiography suite can be challenging due to device resolution and metallic artefact. We investigated...

Supraorbital keyhole approach for microsurgical treatment of aneurysms in the aterior circulation

To study the method with endoscope-assisted microsurgical technique through the supraorbital keyhole approach to treat aneurysms in the anterior circulation. According to preoperative diagnostic imagings, to work out of the individual operation planning. Skin incision was made in the eyebrow, and the diameter of supraorbital craniotomy was about 2 cm, endoscope-assisted microsurgical technique was used to clip aneurysm. The technique was used in the most recent 12 consecutive patients. Five different kinds of aneurysms in the anterior circulation were clipped through this method and 12 patients were cured. One patient, intraoperative accidental aneurysm rupture occurred. There were no approach-related complications. This endoscope-assisted microsurgical technique via supraorbital keyhole approach is a safe, minimal invasive and effective way for the treatment of aneurysms in the anterior circulation, and there is more sufficient operating space.

The small frontolateral approach for the microsurgical treatment of intracranial aneurysms.

The authors describe a new approach (the Small Frontolateral Approach) for the elective microsurgical treatment of aneurysms of the rostral part of the circle of Willis, including those arising from the carotid siphon. This approach provides the advantage of permitting an easy, direct and "protective" attack to such aneurysms through a small and merely osteoplastic craniotomy.