Superior Hypophyseal Aneurysm Research Articles

Superior hypophyseal arteries: angiographic re-discovery, comprehensive assessment, and embryologic implications

The superior hypophyseal arteries (SHAs) are well known in anatomical and surgical literature, with a well-established role in supply of the anterior hypophysis and superjacent optic apparatus. However, due to...

Sellar hematoma as a new potential radiological clue for superior hypophyseal artery aneurysm rupture

Background. In cases of spontaneous subarachnoid haemorrhage (SAH) with multiple intracranial aneurysms (MIAs) detected on angiography, some radiological clues assist in determining the site of a ruptured aneurysm which is bleeding is quite beneficial for the selection of the best treatment strategy. Case description. We report a case of a 60 years old patient who presented with spontaneous SAH, sellar hematoma, and three different aneurysms detected in angiography. Although the right Posterior communicating artery (PcomA) aneurysms showed Murphy’s teat on angiography intraoperatively, we discovered that the right superior hypophyseal aneurysm (SHA) was the source of the index bleeding. Both aneurysms were clipped successfully. Conclusion. From the preoperative radiological and intraoperative surgical findings, we propose that sellar hematoma on a non-contrast CT scan is a new potential sign to be correlated with superior hypophyseal artery aneurysm rupture.

Posterior communicating artery aneurysms demonstrate faster interval growth than other growing aneurysms.

Background Posterior communicating artery aneurysms are often associated with a high rupture risk. This study compares the differences in the rate of growth and morphological characteristics between growing posterior communicating artery aneurysms and other types of growing aneurysms. Materials and methods Thirteen patients with growing internal carotid artery aneurysms were scanned using Siemens 64 slice computed tomography scanners. Three patients had ophthalmic aneurysms, three had superior hypophyseal aneurysms and seven had posterior communicating artery aneurysms. Each aneurysm case had three distinct time points, with an average separation time of 1.3 ± 0.6 years. Annual aneurysm dimensional growth, annual volume growth, annual increase in surface area, size ratio, aspect ratio, and non-sphericity index were analysed. Results Posterior communicating artery aneurysms demonstrated significantly higher annual increases in dimensional growth, volume and surface area when compared to other internal carotid artery aneurysms. Posterior communicating artery aneurysms also demonstrated a significantly higher increase in aspect ratio, size ratio and lower non-sphericity index. Discussion Posterior communicating artery aneurysms had significantly greater growth per year when compared to other types of internal carotid artery aneurysms, and had different morphological characteristics.

Posterior circulation cerebral hyperperfusion syndrome after high flow external carotid artery to middle cerebral artery bypass

We present the first report, to our knowledge, in which revascularization of the middle cerebral artery (MCA) with a high flow extracranial-intracranial procedure resulted in symptomatic hyperemia of the posterior circulation. Cerebral hyperperfusion syndrome (CHS) is a poorly understood phenomenon that is classically seen in the distribution of a revascularized artery. A 37-year-old woman presented with a 3month history of cognitive and speech difficulties, persistent headaches, weakness, numbness, and paresthesia which was worse in the right extremities and face. She was found to have bilateral watershed infarcts worse in the left cerebral hemisphere, severe bilateral stenosis of the supraclinoid internal carotid artery, and a small left superior hypophyseal aneurysm. The patient underwent left cerebral hemisphere revascularization with a high flow external carotid artery to MCA bypass with aneurysm trapping. During skin closure, significant changes were seen in her bilateral upper extremity motor-evoked potentials. The patient’s postoperative exam was noted for an intermittent inability to follow commands, bilateral upper extremity weakness, vertical nystagmus, and alogia that all dramatically improved with strict blood pressure control. Postoperative perfusion imaging revealed posterior circulation hyperemia. This patient highlights the potential for hyperemic complications outside the revascularized arterial territory. Strict blood pressure control is recommended in order to prevent and manage hyperemia-associated symptoms. Improving our understanding of CHS may assist in identifying at risk patients and at risk arterial territories in order to optimize CHS prevention and management strategies.

Non-traumatic superior hypophyseal aneurysm with associated pseudoaneurysm presenting with massive epistaxis

Although a common medical problem, epistaxis rarely requires eurosurgical intervention. Bleeding most commonly occurs from iesselbach’s plexus in the anterior septal area and usually resolves ith manual compression, vasoconstrictors, or simple nasal packng. Epistaxis from the posterior nasal cavity is more difficult to anage and if not resolved with conservative measures, sometimes equires endoscopic cauterization or endovascular embolization of he internal maxillary artery (IMA). Rare neurosurgical causes of pistaxis include traumatic and infectious pseudoaneurysms, cavrnous aneurysms, sellar tumors, and dural arteriovenous fistulas. The first case of massive epistaxis caused by an intracranial neurysm was published at a lecture at the Royal College of Sureons of England by Dr. Beadles in 1907 [1]. Since then, there ave been several reports of severe epistaxis from aneurysms r pseudoaneurysms eroding into the paranasal sinuses [2]. The ajority of these reports are extradural pseudoaneurysms of the C4 egment secondary to severe head trauma, particularly with fracures of the skull base [2]. Although extremely rare, non-traumatic neurysms or pseudoaneurysms causing massive epistaxis have lso been reported in the literature. Again, these are generally xtradural aneurysms most commonly of the C4 segment. Known auses include radiation, infection, and aneurysms associated with umors.

Advances in Open Neurovascular Surgery 2007

We have read with great interest the Advances in Stroke 2007 subsection in February’s issue of Stroke and congratulate Dr Fisher for nicely amalgamating articles addressing some of the most pressing advances and shortcomings in stroke management over the past year.1 Although advances in interventional approaches to stroke and neurovascular disease were nicely outlined,1,2 we noticed little emphasis on open neurosurgical approaches. Of particular interest to our cerebrovascular team, reviewing the success of hemicraniectomy for malignant middle cerebral artery infarction1,3 served to support the evidence that we have observed at our institution for this successful intervention for an oftentimes devastating disease. We would, however, like to further highlight more of the exciting advances in open cerebrovascular neurosurgery that have emerged over the past year for stroke and neurovascular diseases. As already acknowledged in your Advances in Stroke 2007 subsection,2 the results of the International Study of Unruptured Intracranial Aneurysms (ISUIA) continued to meet with considerable scrutiny over the past year. Promisingly, advances in both endovascular and neurosurgical approaches to aneurysm treatment continued in 2007. Kassam et al reported the first endoscopic endonasal clipping of a superior hypophyseal aneurysm.4 Kim et al presented a novel approach to the management of fusiform aneurysms, circumferentially cinching a Gore-Tex sling against an already clip-reconstructed parent vessel by clipping the free ends of the sling immediately adjacent to the vessel.5 Krisht et al presented their impressive experience with 50 complex basilar aneurysms managed through a pretemporal, transzygomatic transcavernous approach.6 These aneurysms, unamenable to endovascular coiling, were successfully clipped in 98% of cases with no procedure-related mortality and 6-month follow-up Rankin scores of 0 to 2 in 92% of patients. Given that half of the patients in this series presented …

Clinoid and paraclinoid aneurysms: surgical anatomy, operative techniques, and outcome

Background Paraclinoid or ophthalmic segment aneurysms arise from the internal carotid artery (ICA) between the roof of the cavernous sinus and the origin of the posterior communicating artery. Clinoid aneurysms arise between the proximal and distal carotid dural rings. The complex anatomy of clinoid and paraclinoid ICA aneurysms often makes them difficult to treat by microsurgery. The natural history of these aneurysms varies, based on their location and anatomic relationships. Accurate preoperative assessment of the origin of these aneurysms is therefore a critical aspect of their management. Methods The authors reviewed 35 clinoid and paraclinoid ICA aneurysms operated in 28 patients and classify them according to their anatomic location and angiographic pattern. The operative techniques, surgical outcomes, and indications for surgery are reviewed. Results Based on surgical anatomy and angiographic patterns, the aneurysms were classified into two categories: clinoid segment and paraclinoid (ophthalmic) segment. The clinoid segment aneurysms consisted of medial, lateral and anterior varieties. The paraclinoid aneurysms could be classified topographically into medial, posterior and anterior varieties, or based on the artery of origin into ophthalmic, superior, hypophyseal, and posterior paraclinoid aneurysms. Ophthalmic aneurysms were most common (40%), followed by posterior ICA wall aneurysms (29%), superior hypophyseal aneurysms (14%), and clinoid aneurysms (17%). Twenty patients (71%) had single aneurysms. Of the remaining eight, six had bilateral aneurysms and two had unilateral multiple aneurysms. Of the 35 aneurysms, 32 were clipped satisfactorily, as confirmed by intraoperative or postoperative angiography. One small broad-based aneurysm was wrapped, and two others were treated by trapping and bypass techniques. Three patients who had bilateral aneurysms underwent successful clipping of four contralateral, left-sided aneurysms via a right frontotemporal, transorbital approach. On follow-up (mean, 39 months), 25 patients were in excellent condition (returned to their prior occupation), two were in good condition (independent, but not working), and one died postoperatively of vasospasm. Conclusion Our increased knowledge of anatomy and refinements in operative techniques have greatly improved the surgical treatment of clinoid and paraclinoid aneurysms.

Abstracts of Literature

Abstracts of Literature

Surgery for paraclinoidal carotid artery aneurysms.

Aneurysms arising from the proximal carotid artery between the roof of the cavernous sinus and the origin of the posterior communicating artery pose conceptual and technical surgical problems with regard to acquisition of proximal control and safe intracranial exposure. Over the past 3 1/2 years, 89 patients with paraclinoidal aneurysms have been treated at the University of Texas Southwestern Medical Center. Thirty-nine (44%) of these patients presented with subarachnoid hemorrhage. A total of 149 aneurysms and six arteriovenous malformations have been identified in this patient group such that 38 (43%) of the patients suffered multiple vascular anomalies. Temporary artery occlusion has been employed during operation in 48 cases (54%), permanent carotid artery occlusion in four (4%), and hypothermic circulatory arrest in two (2%). Twenty-two patients harbored giant aneurysms, seven of which had ruptured. Outcome was considered good in 77 patients (86.5%), fair in eight (9%), and poor in three (3%); one patient died. This concentrated experience permitted a practical anatomical grouping of aneurysms into three types: carotid-ophthalmic artery aneurysms with a superior or superomedial projection (44 cases); superior hypophyseal aneurysms with a medial or inferomedial projection (26 cases); and proximal posterior carotid artery wall aneurysms projecting posteriorly or posterolaterally (19 cases). Despite the fact that paraclinoidal aneurysms often disobey the traditional teachings of aneurysm development, having no vessel of origin or clear hemodynamic cause, this practical grouping has allowed individualized and focused operative approaches unique to each aneurysm projection with good visual function and outcome in most patients.